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background the number of refugees and other displaced individuals in mid of 2022 was estimated to be approximately 103 million many migrants asylum seekers and refugees find their final destination is not what they expected they may spend months or years in conditions frequently fall short of basic humanitarian standards even in the european union the legal and socioeconomic status varies greatly however many are at a higher risk of inadequate healthcare due to their unsettled or transitory status the european centre for disease prevention and control has reported that migrants in europe have disproportionately been affected by the coronavirus disease pandemic in terms of health and social impacts thus covid19 has exposed and exacerbated many preexisting health inequalities within communities and between populations due to overcrowding lack of access to clean water and sanitation and inadequate medical care there is a high risk of transmission of the sarscov2 virus furthermore certain migrant groups have several factors contributing to low vaccine uptake and may experience access barriers adult and adolescent migrants may not receive the recommended regular vaccinations and are not immediately included in catchup vaccination efforts in various european countries the covid19 pandemic may increase the vulnerability of refugees and asylum seekers and the lack of covid19 health information strategies for culturally and linguistically diverse groups reduces awareness of prevention measures a variety of risk factors and comorbidities associated with covid19 have exacerbated health disparities and contributed to the increase of disease burden according to kabir et al the governments goals and decisions during the epidemic prioritized its inhabitants putting the population of refugees at serious risk most nations have closed their borders in an effort to stem the spread of covid19 and this has allowed them to take legally dubious stern steps toward refugees and migrants in the absence of official status in a host country migrants often live on the fringes of society without adequate access to basic needs in order to enhance migrants welfare and immunization programs and tactics including the covid19 vaccination it is crucial to study how covid 19 affects migrants physical and mental health as well as the obstacles that prevent certain migrants from getting the vaccination they need the following research questions directed the review of the literature what is known about how covid19 affects the physical and mental health of refugees asylum seekers undocumented immigrants and internally displaced persons what is known about the barriers influencing access to treatment or prevention of refugees asylum seekers undocumented immigrants and internally displaced persons during the covid19 pandemic methodology the scattered and fragmented nature of the literature made conducting a systematic review impossible the subject is also comparatively understudied and cuts across several approaches and disciplines the aim of this study is to map the current research on this subject that has been done using scholarly publications including qualitative quantitative and mixed methodologies studies the criteria used for inclusion and exclusion of studies are listed in table 1 in view of the nature of the task and the researchs current state a scoping review was considered appropriate the study follows the prisma 2020 guidelines for scoping reviews the search was conducted using pubmedmedline cinahl scopus and sciencedirect and the key search terms were defined using a peo strategy the following peo components were used during the search population refugees asylum seekers undocumented migrants and internally displaced persons exposure covid19 infection or vaccination outcome health and wellbeing and barriers to manage references look for duplicates and eliminate them endnote 92 was used as a citation management tool in order to keep the precise numbers retrieved from each database the references were exported to the software the screening was conducted using the rayyan tool and the references were exported to rayyan after deduplication according to the inclusion and exclusion criteria two reviewers independently examined the references titles and abstracts and a third reviewer settled any disagreements we looked for pertinent references in the complete texts of the articles the titleabstract screening step for the fulltext publications was conducted using the same methods as in the titleabstract screening author title publication year the country where the study was performed study design and sample were gathered from the publications using a customized data charting form recommended by arksey and omalley the four databases yielded a total of 4991 articles following the removal of duplicates and title scanning 329 articles were selected for screening additionally 271 studies were disregarded because they failed to present results particular to refugees or asylum seekers independently of the 58 articles which were retrieved fully only 24 met all the inclusion and exclusion criteria the articles included were coded thematically and classified according to major themes and subthemes in this review the terms of migrants asylum seekers refugees internally displaced persons and undocumented migrants are used as adopted by the international organization of migration researchers can use critical analysis to focus their attention on the articles that are most pertinent to the research issue and that can substantiate their assertions with reliable evidence or to steer them toward highlevel research that is directly useful to their practice in the current study the mixed methods appraisal tool was utilized see this tool makes evaluating qualitative quantitative and mixedmethods research easier than alternative tools results study findings are broadly categorized into two major research themes the impact of covid19 on asylum seekers refugees internally displaced persons and undocumented migrants health and wellbeing and the key barriers to covid19 treatment and prophylaxis studies were conducted in a variety of locations in total 13 studies were carried out in highincome countries and 11 in lowto middleincome countries there is a diversity of research designs in the studies that were included there are a total of five qualitative research studies five mixed methods studies while 14 studies adopted a quantitative research design see summary table health and wellbeing of asylum seekers refugees internally displaced persons and undocumented migrants under covid19 prevalence of covid19 in the target population the prevalence of covid19 among the target population has been reported in four studies turunen et al report that despite prior preventative steps being implemented the number of asylum seekers presenting with covid19 in april 2020 at a receiving facility in espoo finland rose in the screening of the entire population 37 percent tested positive and were isolated the local public health authority quarantined the other asylum seekers who tested negative for 14 days to prevent further spread after the quarantine was lifted no widespread transmission of covid19 was detected suggesting that comprehensive quarantine and isolation measures likely contained the outbreak during the first 9 months of the epidemic in greece a retrospective analysis of national surveillance data was carried out to detect covid19 outbreaks and estimate incidence among asylum seekers and refugees residing in the camps there were 25 covid19 outbreaks found in refugee and asylum seeker institutions the studys findings showed that due to their less favorable living conditions refugees and asylum seekers in receiving facilities had a 253 times greater risk of covid19 infection than the general population inclusion exclusion • studies that focus on refugees asylum seekers and undocumented immigrants internally displaced persons of all ages in low middleand highincome countries • studies that report healthrelated information • studies that focus on drivers barriers or challenges • peerreviewed articles • primary research articles • articles published from december 2019 to october 2022 • studies not published in english economic factors influencing health and overall wellbeing some studies recognized an indirect impact of covid19 on asylum seekers refugees internally displaced persons and undocumented migrants overall wellbeing in a study from burkina faso for instance the authors compared the living conditions of idps before and after the authorities imposed a lockdown they found that 85 of the idps surveyed had no incomegenerating activities during the lockdown and the remaining 15 who continued to work reported that their activities had been significantly scaled down for the vast majority of them their living situations which were already considered to be challenging under normal circumstances continued to deteriorate idps were also prohibited from leaving the camps or areas where they were housed to look for better living circumstances or to go back home in a study among among us bhutanese and burmese refugees comparing those with and without infection with severe acute respiratory syndrome coronavirus it was found that essential workers were more likely to contract the disease and spread it to their families besides higher exposure and less worker protection the findings should be considered in light of the fact that refugees are less likely to have access to public and occupational health information in their preferred language further poverty may make people more vulnerable such as refuges without the means to obtain personal vehicles being dependent on crowded public transport similarly in a qualitative study exploring the challenges of afghan refugee women in the face of covid19 in iran lebni et al found that challenges related to access to information resources about covid19 family challenges socioeconomic challenges health issues all contributed to women being vulnerable to covid19 infection impact on mental health according to three studies among refugees and asylum seekers with the aim of assessing the relationship between covid19 related fear and stressors and mental health it was found that depression anxiety and stress in relation to the fear of being infected and associated consequences were moderate to high in one of the studies among 274 syrian refuges in canada severe anxiety depression and stress were associated with the fear of contracting covid19 in a study among 656 refugees and asylum seekers living in australia liddell et al found that worries about contracting or spreading the potentially deadly covid19 virus were associated with health anxiety and posttraumatic stress disorder in general fear related to the future such as worries about the application process predicted health anxiety social difficulties such as having to stay at home or not being able to engage in social activities were associated with depression however the strongest predictor of negative mental health outcomes was related to covid19 being a reminder of previous difficult life events mental health challenges have also been associated with other factors including a lack of access to resources inadequate health information perceived discrimination by host country actors and poor social support studies show that low social support and a lack of knowledge about the steps that needs to be taken to lower the prevalence of stress depression and anxiety are related for example in the study by sharifesfahani et al there was a positive association between a persons sense of belonging to canada and stress and anxiety measures the lower once sense of belonging to canada the higher levels of stress and anxiety a situation likely to have been exacerbated by isolation and a lack of social support during the pandemic impact on specific groups the prevalence of physical and mental health problems across specific groups such as adolescents has been recognized jones et al investigated the extent to which the pandemic has compounded preexisting social inequalities among adolescents in jordan and reported that 193 of the adolescents in the sample presented with symptoms of moderateto severe depression 9 months into the pandemic and had small signs of improvement additionally the pandemic had caused significant service and economic disruptions that had a wide range of diverse implications on teenage wellbeing gugliemi et al found that among rohingya teenagers of both sexes in bangladesh the pandemic has increased food insecurity educational and economic marginalization threats to ones bodily integrity and a decline in reported health status ceccon and moscardino found that young adult asylum seekers in italy suffered more psychological and physical stress throughout the pandemic the increased stress was related to worries about family in their home country fear of ones health and concerns due to delays in processing asylum applications during the lockdown many experienced a sense of hopelessness as they were without employment and faced significant uncertainty another specific group paid attention to are pregnant women due to among others concerns about contracting the disease lebni et al noted that afghan refugee women did not seek support for pregnancy and childbirth similarly a qualitative study from kenya found that during the pandemic preferences for home births rose and healthcare professionals saw delays in seeking care as well as an overall decline in the use of maternal health care services due to a fear of contracting covid19 barriers influencing access to treatment or prevention lack of access to information regarding covid19 according to different studies refugees may not have access to the latest and most accurate information regarding the pandemic and the information are not always provided in a language they can understand budak and bostan found that 30 percent of syrian refugees lacked information about selfprotection during the pandemic this was attributed to limited access to digital tools and difficulty in communicating with healthcare workers in their study on afghan women in iran lebni et al found that a lack of information regarding covid19 resulted in a resistance to explore treatment and preventative alternatives further most of the afghan women were illiterate or had low literacy levels making it difficult to access various information about covid19 in a study from sweden it was found that the shift from faceto face encounters within health care for refugees to more digital assessment influenced access to health care among those not fluent in swedish the use of translators was found to be more complicated and the quality of the translation decreased often due to excessive background noise further the shift to digital tools created new barriers not only due to language barriers or lack of technical knowledge but also due to structural barriers such as using such tools requiring a swedish bank id often inaccessible to refugees in sweden lack of access to necessary resources studies indicate that refugees in a variety of contexts have been prevented from accessing treatment or prevention eg unable or being delayed in getting important medical appointments during the pandemic or experiencing limited access to health services and or human aid in the form of food water and shelter also personal protective equipment such as masks and gloves are found to be restricted in typical refuge settlements an important factor in the effort of preventing the spread of covid19 among the refugee population according to a modeling study by truelove et al ineffective control of the viral spread of covid19 through refugee camps or settlements can result in excessive stress on healthcare systems particularly in a highpopulation density refugee settlement further in their modeling research gilman et al claim that the situation is made worse by the difficulty to segment camps to separate covid19positive individuals as well as by the restricted availability of face masks even though a study from kenya found that fear of contracting covid19 was one of the main reasons for the decline in the use of maternal health care services among refugees financial obstacles like the inability to afford masks for antenatal visits and a general lack of refugeesinclusive health care were also identified as significant barriers in a qualitative study among refugee women in california united states exploring the receptiveness for virtual platforms to access information and engage in discussions about reproductive frontiers in public health 06 frontiersinorg health it was found that literacy language proficiency and access to and experience with digital technology highly influenced the womens engagement and actual possibilities to navigate this type of digital support the study also identified cultural barriers including the need for allfemale support in virtual settings to preserve confidentiality and modesty vaccine hesitancy barriers studies show that there are several factors that contribute to vaccine hesitancy the lack of knowledge about how the vaccine will protect the individual and information on its administration is one of the key aspects highlighted according to different studies lack of formal education and lack of trust are important barriers to vaccine hesitancy furthermore three different studies among refugees in lebanon iran and the usa show that misinformation spread through social media can interfere with judgments regarding vaccinations it seems like refugees often prefer social media tools because they are more suited to their language and literacy skills and because refugee camps often lack access to organized information however due to algorithmic effects such preferences may generate or worsen vaccination reluctance and lead to serious misconceptions studies show that concerns regarding the effectiveness and safety of the vaccine contribute to vaccine hesitancy for instance a survey of 3173 syrians in lebanon found that 31 percent of the refugees did not want the vaccination and 7 percent were undecided concerns about the vaccine being too new and insufficiently tested the desire for precautionary measures and the idea that the vaccination is not essential were given as justifications further studies among refugees living in the united kingdom and the united states showed a widespread concern about the adverse effects of the vaccine and its implications for safety in a study among 812 undocumented migrants in geneva baltimore milano and paris it was revealed that 77 of the respondents approved of vaccination generally but 56 disapproved of the covid19 vaccination specifically participants mainly searched for information through traditional or social media sources as well as community networks sources that may have influenced peoples reluctance for example getting information through social media in milano and community networks in paris were negatively associated with demand for vaccination furthermore participants who believed that covid19 vaccination would be unavailable to undocumented migrants cited lack of health insurance or card as the main barrier to access other reasons associated with vaccine hesitancy are attributed to confusion over the registration process language andor communication barriers and limited trust in the health care system according to liddell et al and shaw et al logistical challenges in accessing vaccine centers such as transportation barriers also contribute to vaccine hesitancy among refugees in general the findings in the above studies indicate a general fear related to the effects of the covid19 vaccine combined with factors such as lack of access communication barriers fear of the vaccine being religiously prohibited and a general lack of trust in health authorities potentially reflecting prior experiences with persecution and lack of protection by authorities in their home countries discussion a pandemic or epidemic may result in disproportionately high mortality rates for marginalized groups as observed in previous pandemics and epidemics as part of this scoping review only one study in greece compared covid19 infection rates among refugees and the general population and found a higher prevalence of infection among refugees an ecdc report indicates that some migrant communities are disproportionately represented in covid19 cases hospitalizations and deaths in denmark norway and sweden for example covid19 cases have had higher proportions of migrants than expected given their numbers in population the modeling studies evaluated in this research indicate that crowded conditions and delays in accessing medical care are additional risk factors prior research has shown a lack of access to preventative health support for migrant populations and ethnic minorities who bear a disproportionately high burden when it comes to infectious diseases it is necessary to conduct more populationbased epidemiological studies to evaluate the degree of inequity in access to healthcare between refugees and the general population the first research question was to identify the impact of the pandemic on the physical and mental health of asylum seekers refugees internally displaced persons and undocumented migrants based on an analysis of the mental health impact of the pandemic anxiety and depression have been identified as common outcomes however the reasons for the negative impact on mental health should be investigated further the researchers in this review argue that refugees are likely to experience trauma due to fleeing war violence persecution and discrimination they also face additional challenges of stress and fear of contracting covid19 or losing their livelihoods as well as isolation and loneliness during lockdowns which has exacerbated mental health issues although job securityrelated stress is evident among individuals in general this is particularly prevalent among refugees and asylum seekers as their limited previous experience lack of recommendations and inability to accredit qualifications create additional challenges there is a greater concern about job insecurity in lowand middleincome countries for example ozer et al in their analysis of internally displaced persons in burkina faso and palattiyil et al in their assessment of refugees in kenya have shown that forcibly displaced people face additional challenges in terms of food security and mobility this literature review argues that food security challenges and dependency on host countries exacerbate physical health problems additionally refugees have limited access to public health services for example syrian refugees in jordan cannot access health facilities without providing identification documents this review argues that inability to create sectoring and effective social distancing could also be attributed to physical health problems as many refugees reside in densely populated camps with inadequate health infrastructure making physical distancing very difficult additionally the lack of access to clean water face masks and other personal protective equipment makes refugees more vulnerable to covid19 a key challenge facing refugees is the ability to access suitable and affordable housing the researchers of this review argue that the pandemic has exacerbated the economic challenges that refugees face on a daily basis lockdowns whether total or partial have prevented refugees from earning their daily income particularly since many refugees lack stable employment opportunities it might also be difficult for refugees to obtain adequate treatment if they are infected with covid19 due to the decrease in their income it is crucial to remember that whether immigrants have the legal right to work depends on their legal status including whether they are refugees or asylum seekers for people who do not have the right to work covid19 and the associated lockdown has made matters worse as a second research question we aimed to identify the key barriers that hamper access this study recognizes that inadequate access to valid information is a key barrier during the pandemic access to digital sources was a key driver of information according to budak and bostan the digital gap and social media driven misinformation produced major social inequalities contributing to the rise of the information access barrier it has been shown in previous research that information asymmetry continues to affect the refugee population according to different studies the most frequent sources of information include social media traditional media and informal networks of communication eg through other refugees additionally emmer et al contend that because refugees are seen as being in transition host nations seldom give access to information a high priority thus rumors and misinformation may be spread and reinforced through different sources healthcare workers acknowledge that refugees and asylum seekers lack access to resources that could enable them to receive support a systematic review indicates several barriers such as lack of trust in the host healthcare system communication or language barriers and a lack of access to integrated and migration friendly services furter the availability of vaccinations and acceptance might not coincide studies show that vaccine hesitancy may be attributed to a variety of factors structural factors such as poverty related barriers difficult registration processes in the host country language andor communication barriers digital tools demanding digital competencies lack of health insurance personal documentation and national bank ids as well as personal barriers such as a general fear related to the effects of the covid19 vaccine fear of the vaccine being religiously prohibited and limited trust in authorities andor the health care system probably reflecting prior experiences with persecution and lack of protection by authorities in the refugees home countries given that refugees asylum seekers or internally displaced persons have previously suffered because of crisis occurrences the worry is probably not unwarranted in the light of crisis situations authorities may treat refugees discriminatory and brutally including by repressing them australia appear to be striving to guarantee that everyone has access to vaccinations but they will not be successful unless they take effective steps to allay the concerns of persecution that many refugees experience further access to vaccinations and reluctance to receive them are related to refugees financial capacity to pay for them due to exorbitant unit prices vaccination availability is a challenge in many poor nations including kenya in such cases it is crucial to take into account the host nations capacity to meet the requirements of both refugees and its own asylum applicants the factors influencing covid19 vaccination hesitancy among the age group have not been explored however we hypothesize that the factors may be similar to those previously mentioned for other vulnerable populations there is a need to further investigate these factors among children to develop targeted strategies to address vaccine hesitancy one additional factor that may contribute to vaccination reluctance in children might be the perception of a lower risk associated with covid19 infection in this age group strengths and limitations this scoping review is notable for its inclusion of asylum seekers refugees undocumented migrants and internally displaced persons in addition this study has the advantage of adopting an explicit methodology that can be replicated to the last detail over the next few years covid19related research will continue to evolve with more studies exploring similar topics providing specific methodology and details can enhance the search process and build upon the findings of this review it is imperative to acknowledge some limitations of the selected studies the majority of studies are crosssectional in nature evaluating evidence at a specific point in time the variations in evolving covid19 strains and shifts in vaccine policy and vaccine research can change the observed outcomes of this study it is vital that longitudinal cohort studies are carried out to ascertain the longterm implications of the covid19 pandemic though the researchers intended to include all health and wellbeingrelated asylum seekers refugees internally displaced persons and undocumented migrants outcomes targeted research on specific health issues was not evident it is important to acknowledge that most of the included quantitative studies have a small sample size thus the findings should be interpreted carefully as part of this study a thematic analysis approach was used to summarize the results it would be desirable to conduct a metaanalysis to assess the epidemiological implications associated with refugeelevel exposure and treatment support during the pandemic in the future the findings of this review have several implications for strengthening routine public health response to the covid19 pandemic as well as the needs of the asylum seekers refugees undocumented migrants and internally displaced persons covid19 has starkly demonstrated the imperative embedded in the notion that preventing the spread of pandemics and subsequent health and economic disruptions requires recognizing that everyone should not be left behind public health responses must be inclusive of all populations in order to ensure more resilient and responsive health systems for all in the event that the health and wellbeing needs remain unmet poorly addressed or of low priority the host countries will remain vulnerable asylum seekers refugees undocumented migrants and internally displaced persons should be involved in the development of tailored and evidencebased vaccination strategies to address specific barriers frontiers in public health 08 frontiersinorg and perceptions regarding vaccinations with specific focus to covid19 additionally it will be crucial to communicate public health messages to gain the trust of the target populations and combat the spread of misinformation as highlighted by the rollout of the covid19 vaccine effectively and unambiguously conclusion as covid19 has shown refugees asylum seekers undocumented migrants and internally displaced persons are facing a dilemma as a result of poverty lack of support and a pandemic the lack of economic opportunities and housing options negatively impacts their physical health there are a moderate to a high level of mental health challenges facing them these challenges are further aggravated by a lack of resources a lack of information and a lack of adjustments in the healthcare system it is necessary to address vaccine hesitancy in order to prevent any future outbreaks of covid19 there is a need for future research to identify key facilitators that can help overcome these barriers this study includes studies focusing on refugees living in high income countries as well as studies from lowmiddle income countries as a result the refugees undocumented migrants asylum seekers and internally displaced persons experiences can differ and to obtain a contextually relevant picture of the state of their health and wellbeing during the pandemic future literature reviews could compare evidence in high income countries and lowmiddle income countries 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 supplementary material the supplementary material for this article can be found online at full supplementarymaterial

objectives the objective of this scoping review was to identify what is known about the impact of covid19 on the physical and mental wellbeing of refugees asylum seekers undocumented migrants and internally displaced persons the aim was also to identify barriers influencing access to treatment or preventionthe search was conducted using pubmedmedline cinahl scopus and sciencedirect a mixed methods appraisal tool was used to assess methodological rigor the study findings were synthesized using a thematic analysis approach results and discussion this review comprised 24 studies and were conducted utilizing a mixed method approach incorporating both quantitative and qualitative methodologies two major themes were identified related to the impact of covid19 on the health and wellbeing of refugees asylum seekers undocumented migrants and internally displaced persons and the key barriers influencing access to treatment or prevention of covid19 they often have barriers to accessing healthcare due to their legal status language barriers and limited resources the pandemic has further strained already limited health resources making it even more challenging for these populations to receive healthcare this review reveals that refugees and asylum seekers in receiving facilities face a higher risk of covid19 infection than the general population due to their less favorable living conditions the various health impacts stem from a lack of access to accurate information about the pandemic misinformation and the exacerbation of preexisting mental health issues caused by heightened stress anxiety and uncertainty fear of deportation among undocumented migrants and overcrowding camps and detention facilities that increase exposure risk social distancing measures are difficult to implement in these settings and inadequate sanitation hygiene and a lack of personal protective equipment further compound the problem moreover the pandemic has had significant economic consequences for these populations many of them rely on informal or precarious employment which has been disproportionately affected by the pandemic job losses and reduced working hours and limited access to social protection can lead to increased poverty and food insecurity children faced specific challenges such as disruptions to education additionally interruptions in support services for pregnant women some pregnant women have avoided seeking maternity care due to fears of

introduction regional sustainable development groups have become more prevalent in recent years due to the growing concerns with regards to climate change these sustainable development groups bring together a mix of government and industry members to examine sustainable development issues that affect the region these issues can include climate change adaptation biodiversity and urban planning across local government borders the groups collaborate to develop policies and practical applications on sustainable development that meet regional needs these groups bring a local focus to the issues with local knowledge and expertise they can cross boundaries between business and government offering opportunities for collaboration on projects foster the sharing of knowledge and broaden the understanding and views of those organisations involved at the same time joint collaboration at the regional level brings about a number of difficulties in transferring knowledge and establishing cooperation these groups include mixed membership between multiple government business nonprofit and educational organisations with potentially differing agendas that can be more complicated than found in other interorganisational groups groups that focus on regional sustainable development need to address economic social and environmental issues as well as governmental political agendas this means that members can have a greater difficulty developing a mutual understanding a key requirement in successful knowledge sharing furthermore knowledge developed by the group needs to cross boundaries from the group to multiple external bodies such boundary crossing to differing external bodies requires group strategies to allow successful knowledge transfer in this study we aim at developing a better understanding of knowledge sharing in such interorganisational groups the research question at the core of this study is  how knowledge is shared in interorganisational groups that focus on regional sustainable development title in order to answer this question the paper examines in detail a regional sustainable development group made up of industry and government members more specific questions related to the context of our study include  how knowledge sharing occurs within the group  how the broad knowledge domain can influence knowledge sharing  how the need to span boundaries between the group and external organisations impacts knowledge sharing a case study research has been conducted with data collected via questionnaires observations and indepth interviews the analysis included investigation of knowledge networks within the group group structure and activities and the ways the group deals with the issues of multiple agendas multiple knowledge bases of mixed membership and the need to transfer knowledge to participating organisations the rest of the paper is structured as follows section 2 outlines the literature on governmentindustry collaboration in sustainable development and the issues with knowledge sharing in these partnerships section 3 describes the methodological approach to the research including outlining the case study group and research design utilised section 4 reports on the results found and section 5 summarises the implications of these findings with regards to the research question and future directions of the research 2 issues of knowledge sharing in interorganisational regional sustainable development literature review a regional perspective is very important for sustainable development individuals organisations and communities may independently appreciate and practice values of sustainable development however real substantial outcomes can be achieved only when all those efforts are coordinated and based on a shared vision of the region as an integral natural ecosystem and human built environment a successful triple bottom line approach where economic success for business enterprises can be created by meeting environmental and social objectives largely depends on creating and managing effective collaborative partnerships among the stakeholders their commitment to a shared vision and a deliberate effort to build a broadbased longterm support among constituency the response of these issues has been the development of interorganisational groups that combine the resources and knowledge of both government and business organisations within a region these groups are well positioned to recognise regional needs for sustainability and develop practical applications to address those needs their key advantage is that actors are embedded in the regional context and have specific knowledge of the issues that are important to the region the issues of knowledge communication in regional industrygovernment interorganisational collaboration are described in section 21 the challenges of sharing knowledge in governmentindustry collaborations are reviewed in section 22 the templates for industrygovernment sustainable collaboration as discussed in the literature are outlined in section 23 author knowledge sharing in industrygovernment sustainable development groups paquette and wiseman highlight industrygovernment collaboration as an opportunity for wider access to knowledge and ideas from sources that are beyond the participating individual organisations boundaries having broader membership allows members of industrygovernment groups to explore different ways of thinking about the environmental issues they confront this is in contrast to the boundaries and constraints the individuals face within their own organisations such as business interests and budgetary responsibilities additionally members are able to embrace the bigger picture of the region rather than just the specific issue faced by their individual organisations by being able to examine the complexities of the regional impacts and the options available an interorganisational group are able to make decisions that include informed social and environmental considerations while maintaining economic improvement a good example of this occurred in the monroe 2020 project where a problem with sceneryobscuring billboards was overcome through a combined examination across the whole of the region that allowed for continued signage without obscuring the scenery along highways a number of studies have highlighted that knowledge sharing between members of a regional interorganisational network often occurs at several levels the top level involves full group participation interaction at this level provides opportunities to bring together all the members to share knowledge from outside experts collaboratively address and resolve mutual issues with regards to sustainable development and provide an opportunity for facetoface interaction that can aid in building trust between members and network development for individual knowledge sharing in some networks this top level may not have a strong operational focus but it is a means to organise and develop working groups to deal with specific issues as occurred in the monroe 2020 group examined by manring et al the second or middle level involves the formation of projectdriven or issuedriven subgroups between particular members in response to needs and opportunities and these subgroups only last as long as the purpose they serve the third or lowest level involves informal linkages between individual members that evolve as they attempt to understand and clarify particular issues manring and moore describe the example of knowledge sharing in such a multilevel network in the case of a textile industry sustainable development network the network was bubbling with small groups clusters and coalitions focusing on their specialist aspects of the overall toxicity problem these subgroups or bubbles of concentrated knowledge sharing formed the middle level of the network and they knew little about the intricacies of each others operations and did not trust each other however by being part of the whole network level they were able to make connections to information sources and retain those sources and the links as long as needed another good example of how multiple levels affects knowledge sharing is given in a study on informal network negotiations between biotech firms tang found that executives regard informal knowledge transfer as the key to determining which organisations to develop formal contractual agreements with title challenges for knowledge sharing in industrygovernment collaboration industrygovernment collaborations on sustainable development while providing potential for effective knowledge sharing are also faced with some complexities that are reflected in the knowledge sharing literature one of the issues faced by industrygovernment collaborations involve the different and sometimes competing views of members due to the broad mix of membership with different knowledge bases thought worlds and priorities of the organisations they represent while the need to develop a shared understanding of sustainable development is vital and a mutual understanding is essential for effective knowledge sharing collaborations in practice achieving consensus may be difficult and may require tailored knowledge sharing approaches interorganisational regional collaborations need to deal with high complexity of the knowledge sharing process and a broader range of stakeholders contributing to the knowledge sharing industry participants are generally focused on economic gains while industry members may have a social or environmental reason for participating they still factor economic improvement as key in sustainable development implementation in contrast governmental participants may include economic agendas but the main focus is generally on the social aspect for the community and region further these interorganisational groups need to communicate knowledge not only across boundaries between different members within the group but also between the group and external organisations carlile classified such interorganisational knowledge sharing as crossing syntactic semantic and pragmatic boundaries the syntactic boundary involves the development of a common lexicon as an interorganisational group involving members from government and industry the use of terminology can differ and requires the development of a mutual language to aid in understanding and knowledge transfer between the members from the different organisations the semantic boundary deals with the consideration of differing agendas and perspectives government and industry perspectives on issues such as climate change carbon taxes and the economic issues behind sustainable development adaptation can be very different the aim of the group is to create shared meanings by interpretation of organisational perspectives on a group level the pragmatic boundary recognises the differences in practices of the actors involved in knowledge development there may be consequences of knowledge transfer or the need to adapt the knowledge for transfer these consequences or need for adaptation of the knowledge can generate additional costs that must be considered in the knowledge transfer process and timeframes industrygovernment groups on sustainable development must deal with the political issues of the government members the changing political aspects of government can add a high level of uncertainty to the relationship regional interorganisational groups need to meet local political agendas to ensure the successful uptake and application of knowledge provided by the group to external government author bodies this requires consideration of how knowledge should be represented and also when it should be presented to the external government organisations in summary the key aspects for knowledge sharing in an industrygovernment sustainable interorganisational group include having a wide focus that includes regional environmental economic and social aspects a broad knowledge domain and wide access to knowledge due to the mixed membership a high level of complexity with both governmental and industry agendas affecting knowledge sharing the need to transfer knowledge across differing boundaries both within the group and externally and a level of uncertainty due to the political aspects of the governmental members templates for industrygovernment sustainable development collaboration interorganisational collaboration may adopt different governance structures which consequently affect the way knowledge is shared this method utilises a joint venture agreement to develop a specific tool for sustainable development between the government and sme participants an example of this template was the development of a geographic information system that outlines regional land use in the monroe 2020 project examined by manring et al the second template is sustainable business development where there is a joint venture between several companies and the local government to develop a new and ongoing business enterprise that can be found in some ecotourism ventures again in this model a formal joint venture agreement is established between the government and smes but in contrast to the first template it is to create an ongoing business enterprise where all members achieve benefit the formal joint ventures outlined in the above two templates can place limits on the knowledge sharing that occurs in formal collaborations with industry the relationship is defined by contractual boundaries that reduce the risk for the industry partners towards loss of competitive advantage these boundaries can reduce the potential for knowledge sharing and knowledge creation the third template is community development aimed at the sustainable growth of the entire local andor regional community projects in this template include the development of regional growth agreements or shared welfare strategies in this partnership smes have less participation in the development of the programmes and are utilised only to provide a service or support but generally do not make decisions there is no formalised joint venture defining participation a fourth template is the interorganisational network that acts as a network of affiliates some characteristics of the ion template are shifting structures in an ad hoc alliance where members collaborate on projects based on their skill and expertise there is no single title leader different members take the leadership role of the group dependent on their expertise ions also involve multilevel interaction and knowledge sharing as described in section 21 due to the less formal approach to collaboration in templates three and four there can be more scope for knowledge sharing as the defining boundaries found in the joint venture templates dont exist however the knowledge shared can be impacted by the political issues that affect government collaboration as outlined in section 22 each of these templates is focused on sustainability however both the corporate environmental management and the sustainable business development templates also contain a high level of economic focus and structured approach to the relationship and the goal of the project undertaken with the community development and ion templates the focus is more on the community and regional outcomes both also operate with less structure having no joint venture agreement the gaps the research on industrygovernment interorganisational collaboration is growing but there are still a number of gaps particularly in the area of knowledge sharing as we have seen interorganisational groups may interact and share knowledge at different structural levels in their operations however there is little discussion about how the knowledge at the different levels flows between the levels or influences the knowledge sharing at different levels additionally there needs to be more insight into how the different levels of interaction aids members in their knowledge sharing contribution there is evidence in the literature of the advantages when members can see the big picture and access a broad knowledge domain through governmentindustry collaboration however the focus is on those benefits at the group level there is also a need for further insights of how the mixed membership of these interorganisational groups can contribute at the individual level in particular the personal network development for members through their association lastly there is little research around boundary spanning problems of communicating group knowledge to external organisations there is much literature on boundary spanning with emphasis on the roles of knowledge brokers who aid in communicating knowledge to improve knowledge transfer and acceptance however there is limited research on external boundary spanning with regards to the mix of industry and government external bodies particularly when dealing with the multiple agendas and translation of useful knowledge into relevant contexts our research looks into these gaps of knowledge sharing by examining an interorganisational sustainable development group that involves a mix of government and industry members methodology this research is a case study based on an environmental interorganisational group the research question at the core of this study is how the knowledge sharing takes place in a author regional sustainable development interorganisational group specifically we are interested in how the broad knowledge domain of the group influences knowledge sharing how the knowledge sharing at different levels within the group occurs and how the need to span boundaries between the group and external organisations impacts knowledge sharing this research was undertaken utilising multiple methods and included analysis of the knowledge networks formed within the group examination of the group activities and of the individuals perceptions within the group a mixed approach for study allowed for the collection of different data during the phases of the research and to develop a richer understanding of the knowledge sharing issues faced by mixed interorganisational sustainable development groups additionally the multiple methods for data collection and analysis allowed for validation of the results by being able to confirm or test results against the other sources case study background the case study focuses on an environmental group established in 2002 as a subgroup of a regional alliance between five municipal councils and a number of independent organisations in regional australia based on documents provided by the group chairman the purpose of the alliance is  to develop a platform for the region to be able to communicate with all levels of government using one voice  facilitate multiagency collaboration and sharing of information and resources  to promote crossborder collaboration between the municipalities with a focus on big picture regional issues the environmental subgroup is one of several subgroups formed through the regional alliance which focus on areas such as regional economy transport health and wellbeing and the environment the environmental group has approximately 30 members at this time the membership includes representatives from the council and council officers of each local government municipality there are also members from state government departments and agencies that have a focus on sustainable development including such organisations as the department of primary industries the environmental protection agency and sustainability victoria additionally there are several members from industries and private citizens with experience in the field of sustainable development the industry members are from sme organisations within the region the purpose of the environmental group is to provide a forum for participating interest groups to discuss important regional environmental issues with a view to developing strategies and project plans to address them the group runs according to an established terms of reference which includes  share information on current and planned programs so that synergies between them can be identified and promote collaborative approaches  facilitate a common position on important regional environmental issues title  support the creation of working groups to provide specific advice deliver projects and undertake targeted activities undertakings developed by the environmental group are presented to the board of directors by the environmental groups chairman and the alliance ceo these projects are then voted on by board members to determine if they should be allocated a status of priority project priority projects are then promoted by the board of directors to the state and federal governments for future funding allocations for the purpose of this study the alliance is considered one of the external bodies that the sustainable development group reports to over a period of ten months we have observed the groups operational meetings we have also completed nine interviews and 20 questionnaires including interviewing key members such as the group chairman and the alliance ceo other interviewees have included representatives from local councils government departments and smes the group was selected as the case study because it is a regional interorganisational sustainable development group that has a structure similar to the ion template outlined in section 23 the group includes a mixed membership of government and enterprise and has a large scale regional sustainable development focus data collection data was collected through three primary means 1 questionnaire of the majority of group members to obtain an overall understanding of knowledge sharing within the group 2 indepth interviews from a sample of members to obtain deeper insights of why members participate in these sustainable development groups and what benefits they receive through participation and 3 direct observations of group meetings to gain an understanding of the internal workings of the group and each members roles a more detailed explanation of the three methods follows the purpose of the preliminary questionnaire was to collect network data on who the members of the group feel are the experts on specific types of knowledge and who they talk to outside of the group the questions utilised were adapted from research by giuliani who used social network analysis to examine cluster knowledge networks developed by individual members of the clusters in the italian and chilean wine production industries similar to guilianis research we wanted to examine who among the group are the most knowledgeable in different areas the only changes to giulianis questions where to suit our sustainable development context and knowledge areas this allowed us to develop a knowledge map on specific knowledge areas dealt within the group from an initial analysis of group meeting agendas four knowledge areas were identified group operation matters regional and sustainable development policies practical applications leading to regional sustainable development and funding related matters the knowledge map was developed by asking questions such as which members of the group have the most knowledge about issues of sustainable development policy which members of the group have the most knowledge about sustainable development practical applications author these questions aid in establishing the network of contacts members have developed with each other for informal sharing of knowledge on the main issues that they are dealing with in sustainable development to improve the accuracy of responses in the questionnaire we utilised a free choice approach to the questions allowing participants to name as many or as few as they wished we also chose a rostered recall approach rather than free recall in the listing of names in the group participants were provided with a list of the group members names to aid as a prompt to who was part of the group as the case study has membership changes and not all members can attend every meeting provision of a roster of names aided participants in naming the members they felt best suited to each question the indepth interview utilised semistructured focused questions to allow us to talk to individual members about the group and who they communicate with the questions were adapted from tang on knowledge sharing in interorganisational collaborations in the biotech industry tangs questions looked at why members of the interorganisational group would participate in knowledge sharing and what they received from that participation these questions resonated with our research to understand why members would participate in interorganisational sustainable development knowledge sharing particularly industry members that risk the loss of competitive advantage through participation we adapted tangs questions on why members would collaborate and what they would discuss adjusting them for our sustainable development context these questions allowed us to see why an organisation has agreed to be a part of this knowledge sharing group as well as what the group actually discusses additionally we examined whether the participant communicated specifically on certain types of knowledge and whether that was done inside or outside group events direct observation of group meetings allowed us to acquire knowledge on the patterns of social interaction in their natural environment specifically we were able to observe how the group communicates as a whole the group structure what knowledge was being shared and how the members interact through observation of the group meetings we are able to build an understanding of the types of issues discussed within the group the interactions between members and the projects undertaken additionally direct observation can give a different perspective to what the participants themselves think may be happening observation also allowed us to develop a connection with members of the group and to build familiarity and trust that aided in carrying out the interviews a summation of the data collection methods can be seen in table 1 showing their relation to the analysis method and purpose of enquiry title data analysis data analysis involved social network analysis based on the questionnaire data complimented by content analysis of interview data and observational field notes the main purpose of social network analysis is to examine the relationships between actors one aspect is its use in determining the relational ties between actors as channels for transfer or flow of resources in this case the resource is knowledge the questions specifically address the issue of who each member considers to be the most knowledgeable with regards to the specific knowledge type data collected was directional indicating who members talk to rather than the assumption of reciprocal communication network maps were developed to analyse the interaction between members of the group at the personal network level these network maps provided insights into which members of the group were most actively sought for their knowledge on sustainable development analytical tests such as centrality were utilised to see the prominence of members in the network members with a high centrality degree are in contact with many other actors within the network centrality can be further defined by directional relationships where indegree indicates that a member is approached by other members and outdegree indicates the relationship where a member approaches other members a high indegree indicates that these are members that are approached often by other actors within the network and are recognized as a major source of knowledge thus centrality analysis made it possible to highlight which members were most sought for their knowledge the interview instrument allowed us to do three things  build up an understanding of why members seek out specific group members for discussion and sharing knowledge  develop an understanding of how the group members share knowledge at the group and informal network levels  we also developed insight into the group structure how the group operates and how it has evolved over time microanalysis was applied to interview data in order to identify major themes issues and concepts that shape knowledge sharing activities and relationships within the group additionally data from individual interviews was crosschecked to verify the roles of key experts in the knowledge network as interview data can be individualistic and focused on the individual participant the responses from the participants can be limited somewhat to their recall and their priorities to understand how the group shares knowledge to counter the possibility of not getting a full understanding of the issues discussed we used observational data collected from group meetings field notes from observations were analysed to develop an understanding of synergies within the group and the members interactions we also utilised observational data to validate our findings from the interviews and social network analysis a summation of the data analysis methods in relation to the data collected and the purpose of enquiry can be found in table 1 below examination of knowledge sharing in an interorganisational network on regional sustainable development the purpose of this research was to examine how knowledge sharing occurs within a sustainable development group how the broad knowledge domain of the group can influence knowledge sharing and how the need to span boundaries between the group and external organisations impacts knowledge sharing this section outlines the results of this examination with a regional interorganisational sustainable development group case study title knowledge sharing in a multilevel group structure the group operates only according to a terms of reference and has no formal alliance to set the standards type or depth of knowledge sharing between members it operates across multiple levels similar to that described by manring et al and manring and pearsall and discussed in section 21 we have identified knowledge sharing and interactions between group members at three levels the top level in effect consists of the entire group and their involvement at group meetings members participate as and when they can at this level but there is no obligation to attend or join in discussions at each meeting while there is strong interest in participating at this group level members do find that their participation in the bimonthly meetings can be sporadic due to conflicts with other work commitments the bimonthly meetings have an average of 20 members in attendance the discussion at these meetings is focused on keeping members uptodate with recent or upcoming sustainable development events such as conferences and workshops outlining changes in government policies and regulations in sustainable development identification of new funding opportunities for sustainable development projects and news of what local government and industry projects have been undertaken by the members organisations however due to increased pressure to develop practical and educative projects that can be promoted within the region for state and federal government funding and the lack of time for indepth discussions at the bimonthly meetings members have recently developed a middle level of operations the middle level consists of working groups focused on particular projects there are currently five working groups that examine issues such as environmental leadership climate change and natural resources and assets development of these projects is based on the decisions made at the top group level the group has identified a need to carry out further work on a particular project such as climate change and have then developed the working group to pursue that work in a more intensive manner than is provided at the group level members volunteer to participate in one or more of these working groups and the participation is based on the individual members skills interest in the project and their availability the working groups consist of approximately 57 members from the group and they meet more regularly than the groups bimonthly meetings they provide the participating members with an opportunity to discuss the issues in more depth and to develop business cases project plans implementation plans andor grant applications at the lowest level are the informal knowledge networks that have been developed between members aided by the interactions of the members at the top group level these networks are developed by the individual members through their participation in the group and the opportunity afforded to develop ties with the other members the informal networks provide the members with opportunities to discuss issues related to the group and their own work outside of the groups regular meetings figure 1 knowledge flows across the multiple levels of group interaction knowledge sharing occurs at each of these levels within the group but also flows through the levels at the group level knowledge exchanged is often highlevel based on predetermined agenda items the group level meetings allow members to catchup on the developments from the midlevel working groups and also to develop a broad level understanding of the issues as they affect the region as described by one member …it will enable thinking to come back to the broader group the interaction at the group level has triggered the development of the midlevel projects for example the group understanding of the importance of sustainable development within the region has led to the development of the 2050 scenario project that was carried out by the midlevel working group on future directions members can …learn through the that a project is occurring where we can get together to discuss those projects in more detail additionally members involved in working groups may utilise their informal networks to gather specific knowledge or to test responses to decisions made in the working group for example with the 2050 scenario project the project needed to meet the regional sustainable development needs but also the political requirements of the local government municipal councils because if we came up with a scenario that any of the municipalities objected to it would never see the light of day at the informal network level the knowledge sharing is more specific to the members job roles and work places but it also occurs more spontaneously than is available at the group level members described the informal network knowledge sharing as …spontaneous…getting information that youre unaware of that can help you to do better work and as an opportunity to ask …nittygritty type questions however this informal network knowledge can filter into the midlevel working groups and also into the top level group interactions as members build their mutual understanding of the regional aspects of sustainable development this multilevel structure has provided advantages in allowing members to participate and contribute knowledge to the group through the differing levels even if a member may not always be available for group activities at all three levels due to work conflicts title through analysis of our observational field notes we identified members of the group that never attended meetings however from the knowledge network data collected through the questionnaire and confirmed through interviews members identified one of these nonactive members designated th highlighted in figure 2 as a key node in their personal knowledge networks indicating regular contact with them outside of the group meetings in areas such as sustainable development policies and practical knowledge figure 2 network map showing the high indegree centrality of member th at the informal network level network map is ordered from left to right in increasing indegree centrality as can be seen from figure 2 member th is in the third highest level of indegree centrality in the network map while member th is unable to attend the group meetings regularly due to other work commitments the multiple levels of interaction allow th to continue to share their knowledge with group members at the informal network level we can see that the knowledge sharing occurs over multiple levels as indicated in the ion template outlined in section 23 however what we also see is that the knowledge flows between the levels informing and directing activities at the three levels this is evident from the formation of the working groups at the middle level due to identification of the need for more specific knowledge sharing on particular projects the use of informal network knowledge to test ideas developed in the working groups and the provision of working group knowledge at the group level to keep members informed on progress this shows that the groups knowledge sharing is not restricted to particular levels of interaction but instead is dynamic influencing and building the knowledge shared and developed at other levels this multilevel interaction also allows for flexibility in the groups operations and knowledge sharing adapting to the changing needs of members the absence of formal arrangements for participation has allowed members to continue to participate and share knowledge at other levels within the groups operational structure when one level is not available to them by allowing opportunities to participate at other levels the groups multilevel structure has provided members with flexibility for their interactions and knowledge sharing this provides the group with the ability to retain valuable knowledge sources that otherwise might no longer be available to them author broad knowledge domain due to its regional focus and the inclusion of five municipal councils this group has a broad knowledge domain that includes economic social and environmental aspects but also has to consider urban agricultural industry and natural environment issues within the region such as water wildlife and national parks the mixed membership provides the group with knowledge and experience in these different issues members are able to build their knowledge and understanding of the effects and issues of sustainability beyond their working environment the group membership has altered over time with increasing membership and with new representatives joining the group as previous representatives move on to other positions for some organisations time constraints mean that attendance at group events is rotated through several personnel this evolving membership has provided new members with an interesting dichotomy in terms of knowledge sharing new members joining the group have a steep learning curve to develop the mutual understanding of the groups broad knowledge domain that the long term members share at the same time their involvement in the group accelerates the development of their own personal knowledge networks one member described the opportunity as without the …it wouldve taken five years for me to get around all those agencies probably and make those contacts and being able to attend the meetings within months youve got a good understanding of whos who and what agencies operate within the region this opportunity for rapid network development means that members are able to access this broad knowledge domain from the groups mixed membership for their personal work and in development of their mutual understanding of the groups perspectives members are able to develop contacts and knowledge resources through their personal network but can also begin contributing knowledge through their personal networks and this knowledge eventually distils through the entire group sharing knowledge between the group and external organisations any interorganisational group working together must at some time return knowledge that they have developed justifying their efforts to the parent organisations that provide support and to other reporting authorities as discussed in section 22 interorganisational groups particularly those that involve government agencies have complexities related to the political issues and multiple stakeholders involved secondly not all the knowledge shared within the group necessarily needs to be communicated to the external organisations and interorganisational groups need to develop some method of filtering and translating the knowledge that is shared beyond the groups boundary as can be seen from figure 1 the group shares knowledge they develop with a number of organisations that are external though not independent of the group as the group members come from these organisations such as the local government councils the alliance board of directors government departments and regional businesses one of the issues raised through our interviews was the difficulty with getting buyin from the organisations that make up the alliance and support the environmental groups operations this buyin is particularly important with the board of directors and local government councils that form the basis of the alliance and the environmental group …because its no use putting up something…thats at odds with what the councils title doing…and same with the government departments this has meant that when conveying knowledge about the environmental groups policy development or projects they need to translate it so that is conveyed in a format that ensure acceptance some members of the group thus act as gatekeepers or knowledge brokers of the knowledge dispersed by the group for example …the politics of the board are quite different to the politics of the and so the manner in what i tell the board and when i tell them needs to be sensitively handled these gatekeepers also fill a role in developing knowledge for the group on what the agendas and perspectives are because …you need to know what the governments agenda is so you can cast your submission the role of gatekeeper by some members of the group has been emergent based on their connections and knowledge of the external organisations the group reports to additionally not all knowledge shared within the group needs to be released to the external organisations the interorganisational group has developed filters for the knowledge sharing beyond the group using their knowledge of the external organisations agendas and perspectives the gatekeepers advise or aid in the development of the groups knowledge presentations to ensure that the knowledge can be accepted and not …scare the pants off some of the board members an intrinsic benefit of the groups development has been the spanning of sustainable development knowledge and issues across local government boundaries that have led to a reduction in boundary dependent isolated decision making within the region as one of the group members stated the formation of the group with membership that includes external organisations such as the local government councils has meant that the group often provides the one opportunity where many of these organisations are located in the same room for example a recent project of the group involved the release of catchment water into an ailing river system this project involved the local government councils that the river system transgressed and the local water authority catchment authority and a number of state government departments the group provided opportunity for the members representing these organisations to share knowledge on the state of the river system and to negotiate the adaption of agendas to develop a pragmatic solution as outlined to the group members at one of the observed bimonthly meetings the resulting decision has meant that a regular release of catchment water now maintains the river system allowing for the development of local biodiversity this filtering of knowledge and adaptation to suit reporting to external organisations and understanding that not all knowledge should be communicated is reflective of the semantic and pragmatic boundary crossing required in knowledge sharing as outlined by carlile we can see that knowledge developed within the group cannot just be dispersed to the external organisations as is but must be transformed and conveyed in a manner that allows for the groups knowledge to be heard and accepted additionally some members of the group take on the responsibility of ensuring that the group as a whole understands the political agendas of the board of directors local government councils and government departments that comprise some of the alliance membership the use of sustainable development groups can also facilitate knowledge sharing across organisational boundaries such as those between local government councils there is evidence through membership with this sustainable development group that participation brings opportunities to share sustainable development knowledge and issues across the boundaries between local government councils and government departments this facilitation has resulted in a reduction of isolated decision making and opportunities for pragmatic regional solutions to sustainable development issues that affect the author external organisations that are a part of the group these issues also highlight the complexities the group faces by working with multiple stakeholders that can have varying and possibly even conflicting agendas conclusions our research centred on a regional sustainable development group operating without the formal hierarchical requirements of business or government interorganisational relationships our first research question was to understand how knowledge sharing occurs within these interorganisational sustainable development groups through the literature we had identified that these types of groups do operate at multiple levels but there was no understanding of what and how the knowledge from within each level influenced or contributed to the knowledge sharing at the other levels we have found that the knowledge sharing within this sustainable development group is dynamic and flows between the levels the knowledge shared at the top group level can influence not only the development of middle level working groups but also the projects undertaken within those groups knowledge from the lower informal networks is utilised to test the development of ideas through knowledge sharing at the working groups the group maintains a cohesive understanding of all the knowledge shared by having the working groups report back to all the members at the top level to keep everyone apprised of progress and the knowledge that has been developed additionally as part of understanding how knowledge sharing occurs within this sustainable development group we identified that the flexibility of their operational structure utilising multiple levels has meant that the group has been able to retain access to participants knowledge even when that participant cannot effectively operate at the top level with the group instead members who cannot participate at the groups bimonthly meetings can still share their knowledge and expertise through the informal network this flexibility has allowed this sustainable development group to retain valuable knowledge sources that otherwise may have been lost to the group we also aimed to examine how the broad domain of knowledge within these mixed membership groups influenced the knowledge sharing particularly at the personal network level we have found that while the extensive membership means that members have a steep learning curve to develop a mutual understanding necessary for successful group knowledge sharing the benefit of this mixed membership is in the ability for members to rapidly develop their own personal networks and access to this broad knowledge domain the participation in this group of mixed membership has meant that members can develop contacts and knowledge resources with the other members more quickly than they would through normal work interaction this provides the members with a broad knowledge domain that they can access for their own work and to develop their mutual understanding of the regional sustainable development issues through the group activities that facilitate meeting others within the regional field thirdly we examined this regional sustainable development group to understand the impact of boundary spanning between the group and the external organisations has on knowledge sharing the differing agendas of the external organisations do add complexity when attempting to share knowledge outside of the group boundaries as the title knowledge shared needs to be communicated in ways that improves external acceptance this group has mitigated these issues by utilising gatekeepers these gatekeepers use their skills and experience with the external organisations so that knowledge shared is translated and or filtered to ensure acceptance of proposed projects thus they play a wider role than that of knowledge brokers defined in the literature that act to put the relevant parties in contact but do not contribute to the knowledge sharing additionally participation within the group by the external organisations facilitates opportunities to share knowledge and issues across the boundaries participation has allowed these members to examine sustainable development issues that extend beyond their own organisation such as issues that cross local government boundaries the group has provided the opportunity to bring the relevant stakeholders together in one place where they share knowledge of issues and negotiate pragmatic solutions and reduce boundary dependent isolated decision making this research is an early stage in a larger study on regional sustainable development groups and as such has only focused on one case study the use of a single case study design does present limitations with regards to generalisation of the results of the study however when exploring a research idea with limited previous study the use of a single case study has provided opportunity for more indepth understanding of the phenomenon further research is currently being undertaken to examine other regional sustainable development groups these further cases provide opportunity to compare findings from this case study and develop a more generalised perspective of knowledge sharing in these groups additionally research is being undertaken to examine the uses of external knowledge sources within the group while further research is required to develop generalisations with regards to knowledge sharing in a governmentindustry collaboration the initial research has been informative in providing greater insights into the multilevel structure of knowledge sharing in interorganisational groups and the role of gatekeepers and filters to aid in sharing knowledge beyond group boundaries these insights highlight once again an importance of such groups in facilitating dialogue between industry and government organisations in regard to the matters with complex and ambiguous knowledge such as regional sustainable development author author

there has been an increasing interest in the use of interorganisational groups to address regional implications in sustainable development these groups bring together local knowledge and expertise and span boundaries between government and industry organisations our focus is in understanding how knowledge is shared in such interorganisational groups utilising interviews observations and social network analysis we examine the knowledge sharing implications derived from the mixed membership multilevel interaction and the need to span boundaries with external organisations in these collaborations

introduction suicide is the third leading cause of death among youth ages 1024 years suicide rates for american indianalaska native youth are 25 times higher than the national average tailored programs are needed to address the suicide crisis among youth in general and for aians specifically however there are significant challenges to developing effective suicide prevention programming for these populations evidence suggests that most young people with suicidality do not seek professional help this barrier to helpseeking is amplified for aian youth who often experience high levels of stigma and mistrust and have limited access to culturally appropriate mental health care fortunately most young people do seek support from informal networks such as family or friends effective suicide prevention relies on a community safety net including informal helpers who recognize the signs of a person at risk of suicide and can take appropriate action thus training community members in suicide prevention skills can reduce the likelihood of a person slipping through the cracks while supporting the maintenance of a suicidesafer community gatekeeper trainings are a form of education that prepares adults and youth with knowledge and skills that can be used to respond to a youth atrisk of suicide these types of trainings are appropriate for a broad audience and are offered in many different settings frequently schools and workplaces research suggests that gatekeeper trainings can effectively improve suicide prevention knowledge and selfefficacy over time concerns remain about how trainings can maintain improvements over the long term and promote the translation of knowledge into appropriate action while gatekeeper trainings are accepted as appropriate for the general public they are often conducted with homogenous groups such as teachers college students or nurses research that considers individual characteristics suggests that professional role can impact the efficacy of trainings though the effect may depend on the depth of training beyond professional role scant research has been done to consider the role of other individual factors including educational attainment on the uptake and retention of suicide prevention knowledge this may be especially important as gatekeeper trainings vary in terms of indepth nature and teaching style individuals in youthfacing roles such as social workers healthcare providers and teachers have high exposure to youth and thus are in positions to identify and refer atrisk youth as needed however these professionals lack adequate and consistent training on suicide prevention in their formal training and continuing education training gatekeeper trainings are a good option to fill this gap but more knowledge is needed to guide recommendations on the best training type across professional roles and settings for suicide prevention among aian youth culturally specific education is needed to improve the efficacy of gatekeeper trainings for this population as 71 of aians live in metropolitan areas the youth population can be difficult to access for tailored prevention efforts outside of tribal settings additionally those who identify as aian are frequently misidentified as another race including on official documents thus in many settings individuals may be interacting with aian youth without knowing it and may miss opportunities to engage in appropriate suicide prevention efforts with this highrisk group in response to the identified need for youth suicide prevention in aian communities the manidookewigashkibjigan sacred bundle r methods between 20122019 56 suicide prevention gatekeeper trainings were conducted including asist and safetalk at the aihfs facility tribal locations public colleges and community organizations in michigan asist is an indepth twoday training including interactive practice of suicide intervention skills safetalk is a shorter fourhour training that focuses on identifying individuals at risk and connecting them to help livingworks worked with our team to create modified trainings with vignettes featuring aian characters and incorporating aian cultural norms safetalk and asist trainers had a range of backgrounds and lived experiences most were aihfs staff members trainers attended a training for trainers session and were required to coteach three trainings before becoming fully certified the majority of trainings included at least one trainer who identified as aian those who were not aian were allies with extensive experience working in aian communities in cases when an aian trainer was not present an aian person served as a helper to provide cultural guidance and foster trust training participants were recruited using flyers online announcements and inperson at the aihfs clinic and through partnering tribes universities and behavioral health organizations training enrollment was open to all those interested ages 16 years and older for asist and 15 years and older for safetalk recruitment focused on those most likely to interact with youth or the aian community thus almost a third of the trainings were held in tribal settings this study was approved by the institutional review board at the university of michigan as not regulated procedures the research design implemented surveys as pretests immediately before the training began posttests immediately after and sixmonths post training sixmonth followup was conducted using a database of participants contact information compiled from signin sheets participants were contacted up to six times to complete the t3 survey and were able to complete the survey online or over the phone for a 20 incentive gift card response rates to surveys were similar across time points for both trainings posttest surveys were completed by 97 of participants and 6month followup surveys were completed by 55 of participants instrumentation surveys included demographic information and evaluated participants selfrated thoughts knowledge and experiences in several suicide prevention related areas the five key indicators evaluated were knowledge behavioral intention ability comfort and preparedness in responding to an individual at risk for suicide data on knowledge came from a mean composite score in response to three suicide prevention knowledge questions on a 5point scales it is appropriate to ask someone who may be at risk of suicide about suicide i know how to get help for someone who is at risk of suicide and i can identify warning signs and risk factors for suicide data on the other factors came from participant responses to the following statements on a fivepoint scale if someone appears to be at risk of suicide i will ask them directly if they are thinking of suicide i can respond to suicidal behavior indicate your comfort level with discussing suicide with others indicate your preparation level with responding to a youth who is exhibiting depressed andor suicidal behavior data analysis data were analyzed using glm repeated measures to test withinsubject and betweensubject mean score changes on the suicide preventionrelated measures knowledge ask directly respond comfort and preparedness mean scores were tested between two time point dyads t1t2 and across all three time points t1t2t3 education level grouping of less than a bachelors degree bachelors degree graduate student or graduate degree was entered as a betweensubjects factor when modeling t1t2t3 to compare the longitudinal training effects for participants with different educational backgrounds ttests were used directly compare the mean scores for each measure and each education level from asist and safetalk differences in mean scores between the two trainings and 95 cis are reported results the main effect of time was significant for both trainings across all measures figure 1 depicts the trajectory of mean scores over the three time points for all measures by training type for both asist and safetalk the mean scores improved significantly from t1t2 on all measures demonstrating excellent uptake of information scores at t2 were significantly maintained at t3 on all measures for safetalk trainees but only on comfort for asist indicating greater longterm retention for safetalk than for asist when considering education group in the analysis the main effect of time was also significant on all measures for both trainings the between education group effect was also significant for all measures on both trainings except for asist on ask directly the interaction of education group and time was significant for both trainings on preparedness knowledge and respond for asist figure 2 depicts the trajectory of mean scores over the three time points by education group and training type for measures of knowledge and preparedness generally for safetalk higher education levels tended to score higher this trend is observed for all measures except preparedness for asist this pattern was not consistent though those with graduate degrees scored highest overall on most measures however those with less education showed the most improvement both trainings were the most effective at increasing and maintaining scores for those with a bachelors degree or with less than a bachelors degree there were significant t1t2 score improvements for the two lowest education groups for both trainings on all measures increases were maintained except for asist trainees with a bachelors degree on ask directly the two highest education groups generally had higher scores at t1 but did not consistently improve t1t2 or maintain improvements at t3 the graduate student safetalk trainees showed less improvement than other groups with no significant score improvement between t1t2 except on preparedness in contrast graduate student asist trainees showed a significant t1t2 score improvement on all measures but it was not maintained at t3 on measures of knowledge and ask directly among those with a graduate degree there was no significant increase in scores for asist trainees on knowledge or ask directly and significant score increases were only maintained from t2t3 for comfort for safetalk graduatedegreelevel trainees there was significant improvement on scores for all measures but the improvements were not maintained on ask directly for direct comparisons of mean scores between asist and safetalk using all participants there were significant differences at t1 on ask directly at t2 on preparedness and comfort and at t3 on knowledge among those with less than a bachelors degree there were significant differences between asist and safetalk participants mean scores on comfort at t1 and t2 for those with a bachelors degree there were significant differences in mean scores at t1 on ask directly and knowledge and for the same measures at t2 knowledge m difference 021 mean scores were also different at t2 on comfort for bachelors level participants among graduate students mean scores were significantly different between the two trainings at t2 on comfort and preparedness finally among those with a graduate degree the significant differences in mean scores between asist and safetalk occurred at t2 for ask directly and knowledge at t3 there were no significant differences on any measure for any education group discussion overall gatekeeper trainings seem to improve individuallevel reported capacity to address youth suicide at least in the shortterm for both trainings and longitudinally for safetalk and on comfort for asist the largest observed effect of the training was on preparedness especially from t1t2 this finding is logically expected as the construct preparedness incorporates multiple different aspects of suicide prevention training so it may include variation in individuals feelings related to the other variables for example maybe one feels less intention to ask directly about suicide but feels that the training overall significantly increased their preparedness to address suicide through other means such as increasing knowledge the significant interaction between time and education group on most measures for asist and preparedness for safetalk suggests that trainees with different educational training depth between the two asist is a more intensive training that included active role play and a focus on cultural competency for aian communities as part of examples and scenarios people who have less education or who are not working in interactive youthfacing environments may be less comfortable with this type of indepth activity which could explain the difference in response across education groups for asist trainees this is consistent with previous research demonstrating that skill practice during gatekeeper trainings does not significantly improve training outcomes over time though it does have a beneficial effect in the shorter term thus more basic and shorter training types such as safetalk may be sufficient at least as an introduction to youth suicide prevention and more accessible to a broader audience findings from the direct comparison of mean scores between asist and safetalk within education groups and across time periods are consistent with those from the glms while scores among asist participants tended to be higher as did those of participants with higher education there was no significant difference in mean scores for any education group after six months this suggests that despite being much less indepth safetalk performed just as well as asist in scores after six months for all participants among all participants the general trend indicates that those with a graduate degree have consistently higher scores about twothirds of the graduatedegree level trainees worked in behavioral health or child welfare services thus it is reasonably expected that their baseline suicide prevention skills would be higher anecdotally participants with a graduate degree commented that they did not find the safetalk training to be informative or provide new information this is consistent with previous research that reports those in healthrelated roles or those requiring higher education have higher baseline suicide prevention knowledge this study finds that those in the lower education grouping may benefit the most and better retain training content over time previous research has almost exclusively focused on training outcome variation by professional role and results are mixed for example in a study of veterans administration clinical and nonclinical staff both improved preand posttraining but the nonclinical staff had larger gains however another study found that higherlevel professional roles in school settings including social workers and health professionals responded best to indepth trainings another study from the netherlands found trainees in professional roles had similar training outcomes but healthcare professionals scored highest overall lamis et al found that school guidance counselors scored highest on suicide prevention at baseline but had the lowest gains compared to other roles together with the present findings this may suggest that education group is not a direct proxy for professional role and individual education background may exert a different effect on suicide prevention training efficacy however the efficacy of training in terms of improvements from baseline may depend on participants starting knowledge or experience in the area limitations though response rates were reasonably robust there was significant loss to followup at six months the individuals who responded to followup may not be representative of the entire sample of trainees or reflect bias based on individual tendency to respond additionally all measures were selfreported these measures do not necessarily translate into individuals actions related to youth suicide prevention other factors such as age gender or type of employment may influence individual responses to the gatekeeper trainings for example there may be a high level of agerelated factors influencing the outcomes among those with less than a bachelors degree because the group is made up of both young students and older people though each training included an aian leader in some cases these individuals were not established members of the community in which the training took place thus the uptake and retention of training material could have been impacted by the level of trust fostered by trainers and groups of participants conclusion continued communitybased engagement in suicide prevention is critical as suicide rates are increasing nationally and contribute to decreasing and stagnating life expectancies across the nation this study supports the use of gatekeeper trainings as one part of communitybased suicide prevention programs but suggests that trainings should be tailored to specific audiences in order to gain maximum benefit findings suggest that despite differences in shortterm gains after six months the skills from these two trainings are not different for participants of all educational backgrounds for individuals with less education or suicide prevention experience more training may not be best at least at first it may be beneficial to start with introductory trainings before proceeding to more indepth training the integration of culturally responsive approaches may be used to meaningfully engage participants working in ai an communities but this may not be feasible for the shorter 1 3 safetalk training a potential approach could include providing an aianspecific training booster training after six months such as gathering of native americans or native hope future research should evaluate whether mixandmatch approaches to suicide prevention education are more effective for retention of skills and confidence and whether asist is more effective when participants have had some earlier exposure to suicide prevention we suggest that future gatekeeper trainings should focus on engaging young people and those with less education in order to promote the largest benefit for the community for targeting the ai an community research and practice should incorporate culturally relevant approaches and evaluate the efficacy of those approaches on aianspecific engagement publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

according to the centers for disease control suicide rates in 2022 for american indianalaska native youth are 25 times higher than the national average an urban indian health organizations response to this crisis was to provide community and statewide gatekeeper trainings between 2012 and 2019 to teach trainees n 810 to respond appropriately to youth atrisk of suicide we report data on pre post and sixmonth followup surveys with trainees data were analyzed using generalized linear models repeated measures to test withinsubject and betweensubject mean score changes on suicide preventionrelated measures knowledge ask directly respond comfort and preparedness results indicated improved capacity to be prepared to address suicide in the short term and that having a graduate degree enhanced baseline suicide prevention knowledge over time those with less education benefited the most and better retained content future trainings should engage young people and those with less education to realize the largest benefit

given the contemporary boom in individualhousehold survey data collection it is arguably more possible now than ever to perform crosscontext comparative empirical research although data collection efforts have indeed fueled explicit crosslocal and crossnational comparative studies this research has mostly contrasted flows emanating from within the same world region namely latin america and the caribbean though also more recently in subsaharan africa while a relatively small body of crossregional comparative studies have examined the causes of migration in different settings more comparative research based on strategically chosen cases and strong research designs is necessary if we are to build a clear understanding of why the drivers of migration vary across places at a particular point in time or why they diverge over time within particular places to build accurate theoretical models for evidencebased policy formulation it is necessary not only to document differences in the drivers across periods and places but more importantly to explain the reasons why the structural factors of migration are different across contexts and at different stages in the migration process as shown throughout this volume over the last two decades relatively comparable household survey data have been collected using the ethnosurvey approach in particular communities located in china poland senegal ghana the congo bangladesh and in mexico guatemala el salvador nicaragua costa rica puerto rico the dominican republic haiti paraguay peru ecuador and colombia this approach blends survey methods with more indepth qualitative interview styles to gather data in specific sending communities and foreign destinations a centerpiece of its methodology being the compilation of retrospective life histories for both migrants and nonmigrants thanks to such data scholars are increasingly able to advance systematic understandings of migration by directly contrasting and comparing how relevant individuals families households and communities operate across carefully selected cases that generate different migratory outcomes although ethnosurvey methods hold much promise for migration research comparative work using them highlights many methodological challenges in some cases adding complications to those already prevalent in noncomparative research awareness of these problems and taking the appropriate countermeasures when designing research projects are necessary to avoid reaching incorrect conclusions such as when crosscontext differences in migration are taken to represent real differences in migrator dynamics prior scholarship has discussed both the potential and limitations of applying survey and to a lesser extentother methods in comparative crossnational studies of migration including issues of case selection data collection methods and overall research design this article contributes to this body of work by discussing the analytical challenges involved in comparing individualand householdlevel survey data across settings my aim is to provide a set of general guiding principles for a posteriori decisions about case selection sample construction and other adjustments that become necessary when datasets from different settings are combined i also offer guidance for a priori case selection and data gathering choices that crosscontext comparative researchers should bear in mind in future studies these lessons do not apply solely to crossnational or interregional research but also to the study of migration to or from different sending or destination communities within the same country as should be relatively clear these reflections do not pertain exclusively to studies using ethnosurvey approaches but apply to any data collection effort aiming at describing and explaining the drivers of migration in different settings and to retrospective data collection efforts in particular i nonetheless pay specific attention to the ethnosurvey studies discussed throughout this volume given that they represent perhaps the most promising avenue for direct crosscontext comparative analysis the ethnosurvey is part of a long tradition of specialized migration surveys that seek to characterize and analyze drivers of migration at the individual household and community levels all of which are important in understanding human mobility and which together constitute the central units of analysis for migration theorists nonetheless the ethnosurvey stands out from other migration surveys because its common principles have been applied more or less uniformly around the world within the universe of ethnosurveys crosscontext comparative work is particularly feasible because of common standards of sample design questionnaire construction variable definition and data collection however the use of ethnosurvey data for comparative analysis is by no means unambiguously warranted before discussing its possibilities and limitations i situate the migration ethnosurvey in a constellation of other large quantitative data collection techniques for the study of migration summarizing the main advantages and limitations of each capturing the spatiotemporal rhythms with migration surveys the rigor scarcity and inflexibility of prospective data on international migration migration cannot be captured adequately by using crosssectional survey or enumeration approaches that deal only with the here and now to measure migration fully data collection methods instead need to be able to capture the spatiotemporal rhythms of migration which is achieved using true or quasilongitudinal designs true longitudinal approaches require the collection of data prospectively prior to and after an event of interest whereas quasilongitudinal designs generally collect data at a single point by gathering retrospective histories i both rely on direct or proxy retrospective accounts of past events though the short interwave recall window in most longitudinal surveysparticularly shortterm panel studies generally yields less recall bias than purely retrospective approaches i as such panel surveys may include both truly longitudinal as well as quasilongitudinal information with crosssectional surveys comprising only the latter more important than better recall however is the fact that truly longitudinal approaches lessen interval censoring substantially in ways that retrospective approaches cannot provided subjects are not lost to attrition between waves retrospective data collection is especially vulnerable to the loss of survey respondents from emigration household dissolution and family reconfiguration likewise prospective longitudinal approaches allow for better and more direct measurement of premigration factors ii finally true longitudinal data increase the possibility of using a larger set of techniques to deal with endogeneity including the control of individual and household fixed effects while other data collection techniques may allow for a modicum of these features prospective approaches are likely to allow for a larger set of them and produce better quality information that is less affected by the aforementioned biases nationally representative longitudinal surveys have become in many ways the gold standard of household data collection for a variety of topics they are particularly powerful and indeed most useful for migration studieswhen they follow and collect information from individuals who move out of the original study area at the very least they need to offer the opportunity to identify the specific forms of movement that lead to a loss to followup to allow for the modeling of the drivers of migration like some labor surveys do despite these clear potential advantages however longitudinal surveys around the world are oftentimes not designed to deal with many forms of spatial mobility especially that spanning across national borders iii on a global or even regional basis even in recent decades short prospective panel data appropriate for migration studies are relatively scarce while longterm panel surveys are virtually nonexistent even when existing prospective data would thus be useful mainly for studying the drivers of specific coterminous contemporary migration flows leaving important periods in the recent past unexplored this further complicates the study drivers during specific stages of the migration lifecycle slight differences in the timing of the transition between these stages across settings are especially likely to be missed by prospective data collection methods coterminous vs stagespecific drivers of migration the examination of the drivers of migration fromto particular places and why these drivers differ over time and across places are arguably some of the most fundamental questions in migration studies this assessment can be approached in at least two main ii in addition to these some projects deal with internal migration across the world in similar fashion most notably including demographic surveillance systems in several developing countries however none of these to date follow international migrants though some may be able to identify them within the reasons of loss to followup iii with few exceptions movement out of the study area is treated as attrition rather than outcome meaning that registration of a move when it happens may not lead to very detailed measurement even sophisticated long panel studies designed for or with clear applications to migration studies do not quite study the causes of mobility in itself but rather its consequences limitations on definitions of what is a migration tripmove and on the windows covered in the data might also limit crosscontext analysis ways each yielding different substantive significance and policy relevance comparing the coterminous drivers of migration across places allows us to understand why migration rates may differ among sending nations and why immigration policies may be more effective on particular social groups iv the drivers of coterminous mobility could differ across sending areas because each is at a different stage of migration so it seems logical to trace these histories and more precisely understand the differences in their evolution given these dynamics a somewhat different question is how the causes of initiation takeoff maturation or decline differ across places each of which might have experienced these transitions during different times v while the crosscontext comparative study of stagespecific drivers is scarcer than that of coterminous drivers i would argue such design can further advance migration theory building and refinement in ways that the coterminous study of the drivers of mobility misses or otherwise provides insufficient proof the limitations and flexibility of retrospective measurement because the evolution of migration flows may differ considerably across communities nations and migratory systems prospective data collection methods would need to rely on fortuitous timing to allow for the study a particularly relevant period or stage in the migration process across settings the comparative study of coterminous flows at similar stages but at different points in space and time requires even nimbler research designs to obtain a reasonable representation of the migration risk set prevailing in a specific spatiotemporal context flexibility is thus needed to allow for the comparison of migration dynamics at different places in the same period or at a particular stage in the migration process crosssectional retrospective designs offer more flexibility to adjust sampling and instrumentation to cover significant differences in migration dynamics across time and places vi despite this potential flexibility one cannot simply collect retrospective data using conventional sampling designs and expect them to fit any and all analytic needs ipso facto or to offer good representation of both current and past events the main tradeoff in iv for instance comparative research of contemporary undocumented flows to the united states under a coterminous contemporary lens would look at why irregular mexican migration slowed down during the last eight years while that from el salvador honduras and guatemala did not this examination would provide nuance for several migration theories by testing the limits or nonlinearities in costbenefit calculations characteristic of neoclassical economics or by providing empirical guidance to build a more robust institutional theory that takes into account the capacity and effectiveness of states in influencing migration flows and their selectivity v using the prior example of unauthorized migration from mexico and central america the research question under this approach would be to understand the differences in the takeoff of flows from honduras in the 1990s from those from el salvador and guatemala in the 1980s from those of mexico in the 1940s when they were reactivated by the bracero program or even from the early 1900s when they first took off during the enganche era vi in addition crosssectional retrospective collection is much cheaper than longitudinal approaches while this may appear to be an important advantage in highuncertainty funding environments where seeking to renew a project and thus fund more than 23 waves of collection may be a bit risky finding funding to collect additional crosssections of retrospective data over a longer span is perhaps just as difficult prospective versus retrospective data collection methods lies in the information that is not collected by the latter vii from individuals and households not even sampled viii this is a problem that becomes more severe the further back in time the retrospective account aims to go this left censoring of individuals who died or left the study area before the survey year during periods that the analyst may be interested in studyingis the most pressing problem in retrospective data collection while some experiences lost to left censoring might be recovered through de jure sampling or proxy interviews these techniques are unlikely to overcome most of the attrition produced by the emigration dissolution or dramatic reconfiguration of complete households prior to the survey date the supplementary sampling of migrant households in destinations is probably the best way to overcome the problem but destination sampling is less commonly used in migration surveys for many important practical reasons such as a lack of a sampling frame and the cost and difficulty of reaching migrants given these issues representative surveys or even complete enumerations of a specific community will not necessarily yield a complete account of the population in times past especially the distant past ix quite surprisingly statistical offices and researchers around the world still lack substantial knowledge about the past emigration of people and especially past reconfigurations of households and communities rendering healthy skepticism about the usefulness unsolved although the potential biases might be relatively slight for some small number of years prior to the interview we truly do not know the extent of the problem with much precision or how biases might vary across communities contexts or countries depending on the net cumulative intensity of internal and international migration and return and whose specific migration histories are in fact being collected the problem likely varies in magnitude across places and thus hinders the study of particular communities in their own right let alone in a comparative framework these potential biases challenge crosscontext comparative studies more than other forms of research however analyses that do not use communities or countries as units of analysis are hardly exempt from these problems at a national scale statistical offices in a few countries have begun to use retrospective questions to capture the migration of members of sampled or enumerated households during some set period prior to the interview however this approach is limited because censuses and national statistical surveys tend to collect a relatively limited amount of data which with few exceptions are not retrospective thus the wide coverage granted by census surveys comes at a nontrivial cost for those interested in householdlevel vii recalling the timing and sequencing of events long before interview is challenging and can be influenced by how interviewers probe on the issues peoples memories tend to fail when they have made several short moves yet overall individuals do tend to remember the timing and sequencing of migrations especially in relation to other important life transitions viii although nonresponse rates are a growing concern in largescale social science surveys this is not overall a major problem in most census enumerations and surveys that gather migration data including the migration ethnosurvey ix just as crosssectional data may not provide a representative snapshot of the population of a given area in the past when used retrospectively longitudinal data may not provide a representative snapshot of this population at future waves however the difference between these two types of data collection lies in that prospective approaches do allow for the possibility of adding individuals to the original sample to reach this representation analysis though they can be used to better understand the role of aggregatelevel forces more importantly for crosscontext comparative work the typical question about migration in the past five years is not always asked in censuses around the world and even when it is asked the resulting information suffers from several limitations most notably the lack of comparable data on the experience of those who remained at points of destination given the limitations of standard census and survey questions on migration specialized retrospective surveys have been a recurrent methodological solution offering quasilongitudinal data to get at the reasons behind the international migration in particular the mexican migration projects ethnosurvey approach has generated a continuous stream of community surveys over nearly three decades additional efforts using similar versions of the ethnosurvey conducted under the auspices of the latin american migration project have allowed for a deeper understanding of flows to and from the caribbean central america and south america the resulting accumulation of data has allowed for a better understanding of the mobility of mexican migrants to and from the united states fujianese migration to the united states polishgerman migration and international migration from senegal the congo and ghana to europe as well as to other african nations more recently this approach has also been used to understand migration in bangladesh as such the migration ethnosurvey stands out for crosscontext comparative purposes because it has amassed data for a considerable number of communities in several countries across the world which has opened up new possibilities for crosslocal crossnational and increasingly crossregional comparative research commonalities and differences of migration ethnosurveys around the world the migration ethnosurveys done to date share many items in common with the general methodology discussed in more detail elsewhere here i consider several features common to nearly all ethnosurveys that are germane to comparative research on the drivers of migration first each survey aims to be representative at the local level usually within specific sending communities that are selected to represent a range of migration and urbanization conditions while this form of sampling particularly if it only draws communities with no prior history of migration whatsoever makes it difficult to estimate nationallevel rates for which a census or nationallyrepresentative survey are much bettersuited nevertheless local representation and a mix of communities jointly allow for robust comparisons across contexts helping for instance solve whether differences in the drivers of migration across nations are related to differences in drivers across particular settings in ways that are conducive to testing and refining tenets in several migration theories this form of sampling also facilitates the selection of communities as case studies focused on a particular substantive interest such as what explains the initiation of migration from particular places second all ethnosurveys include a basic sociodemographic profile and retrospective information on first and last internal and international moves for all people listed in the household roster this may allow for more a complete representation of migratory behavior across different ages and cohorts because household rosters generally also include all children of the head regardless of their place of residence at the time of interview which helps to reconstruct the prior history of migration in a community at a prior time point the broad representation of age groups and cohorts and by gender also facilitates stagespecific or coterminous analyses in both present and past by covering individuals who migrate in different epochs the data also allow for analyses of the drivers of migration at both the household level and the family level rosters have permitted the construction of communitywide migration measures that have been instrumental in assessing the role of broader migrant networks in the migration process these measures have also helped investigators to better understand and model the takeoff point of migration finally ethnosurveys also include more detailed retrospective migration and labor histories for at least one member of the household which can be used to analyze the drivers of migration beyond first or last trips more importantly life histories allow for a deeper examination of the drivers of international mobility than is possible using household rosters alone histories of union formation and dissolution fertility property ownership and migration by other family members generally collected in ethnosurveys can be usefully employed either as variables of interest or controls in event history analyses despite these basic commonalities crosscontext comparative research is complicated by important differences in how some data are collected perhaps reflecting differences in the spatiotemporal evolution of migration across settings with respect to community sampling for example different ethnosurveys define local representation differently in the migration between africa and europe project x the areas represented are the cities of dakar senegal kinshasa the congo and accra and kumasi ghana in contrast to the mafe the large city samples surveyed in the mexican and latin american migration projects xi are only representative of specific neighborhoods within these cities a final difference is that the mmp and lamp unlike the mafe also collected data in smaller cities large towns and smaller rural places where samples are often representative of the whole community selected via simple random sampling after own canvassing in slight contrast the fujianese ethnosurvey used stratified sampling in rural sending areas while the polish ethnosurvey used a multistage sampling procedure to oversample migrants in the sending communities selected likewise the size and more importantly structure of household rosters differ across projects because of the way each defines who is part of the household roster for example mmp and lamp ethnosurveys perform a type of de jure enumeration in which the person who customarily serves as the head of household is generally counted in the roster as head even if he or she is outside the sending community at the time of the interview xii in contrast the enumeration and structure in the mafe project follows more of a de facto approach as headship is assigned to an individual residing in the household at time of the survey xiii this difference is particularly important to bear in mind when making crosscontext comparisons as it may define who the children of the head listed in the household roster are thereby yielding differences in who is counted in the household roster in different settings while these differences might be surmountable technically they should not be glossed over or assumed away finally ethnosurveys differ in terms of which individuals detailed retrospective histories are collected for instance in senegal ghana and the congo as well as in poland they were gathered from a randomly chosen individual whereas in latin american and fujianese ethosurveys they were compiled for household heads and their spouses xiii mafe surveys also differ from most other ethnosurveys in that they include supplementary destinationbased samples collected with the goal of directly capturing the experience of individuals not interviewed in the sending country precisely because of their migration in contrast the mmplamp samples rely more on proxy reporting and on the notion that individuals are linked to sending areas in some fashion massey fischer and capoferro 2006 a random selection of individuals ensures a clearer representation of people across age groups and stages of the life course as of the survey date not to mention across gender and other social groups that are large proportionally in contrast given that heads are usually older on average than the general adult population the selection of household heads provides a better representation of migrationage individuals in years prior to the interview making it more likely to capture early stages of the migration process depending on the timing of transitions to adulthood and on the social rules governing family headship in different settings sampling individuals who have become household heads by the time of the interview may actually not yield a representative crosssection of people exposed to the risk of migration in the few years preceding the survey year also depending on the prevalence of marital dissolution the life histories of spouses will be more or less representative of any particular social group eg women in patriarchal systems where males are generally assigned the role or assumed to be the household heads a litany of checks and adjustments analysts should be aware of these nontrivial differences in research designs across ethnosurveys and how prior histories of both internal and international migration may amplify or reduce the relevance of these differences indeed any studybut crosscontext comparative studies in particularshould strive for accurate representation of each community and time period of interest which may need to be achieved with different instruments or by focusing attention on specific cohorts or social groups across communities the differences featured here require careful case and subsample selection based both on the substantive goals of the project and an understanding of the methodological limitations inherent in retrospective data collection once cases and subsamples are selected checks and adjustments for retrospective biases are needed as curran and riverofuentes pointed out logistic regression in particular may allow for the estimation of robust coefficients for communities or social groups though this likely assumes a wellspecified model with trivial unobserved heterogeneity something that is impossible to guarantee in any study whenever possible checks for the robustness of findings should be implemented for instance by varying the retrospective window of analysis and examining effects across different communities and social groups to assess if patterns go in the expected direction alternatively post hoc adjustments such as casecontrolmatching or propensity scorebased methods such as matching stratification or inverse proportional treatment weighting should be implemented to assess whether the drivers of migration differ when assuming a different representation of cohorts or social groups presumed to be more likely to be underrepresented in the data due to left censoring this allows for testing the robustness of regressionbased approaches that assume representation of these groups is adequate conclusion an agenda for comparative data collection and analysis this article has provided a broad overview of the strengths and weaknesses of prospective and retrospective approaches to the measurement and understanding of migration i placed particular emphasis on the comparative study of the drivers of international mobility as the proper measurement and understanding of these drivers through comparative research of carefully selected cases are necessary for effective theory building and policymaking and are essential to the analysis of related phenomena such as economic development i also considered several important weaknesses of retrospective as opposed to prospective data collection methods especially with respect to the added complications of left censoring produced by the emigration of individuals and the dissolution and reconfiguration of households prior to the time of the survey despite these weaknesses and their potential biasesthe true extent of which are surprisingly unknownretrospectively collected data from ethnosurveys have been and will continue to be quite valuable in advancing knowledge on the drivers of past migration that have not been effectively captured by prospective approaches retrospective data collection is particularly valuable for comparative research given the relative lack of comparable prospective data on migrants around the world which hinders in particular the study of specific stages of migration in different periods and nations thus i argue for the need and usefulness of retrospectively collected data for the comparative study of migration although transitions between specific stages in the migration process and what drives them are a matter of some debate most models include an initiation or takeoff stage a stage of maturity with some ebbandflow and given sufficient time a declining or winding down stage the most influential review and synthesis of migration theories clearly identified the theoretical mechanisms in sending and receiving societies posited to account for the initiation vs the continuation of migratory flows because these mechanisms are probabilistic rather than deterministic they should also inform when flows fail to take off and when they are likely to decline thus arguably accounting for what has come to be known as the migration hump stagespecific analyses of the drivers of migration in different contexts would further advance theoretical understanding and place the more commonly studied differences in coterminous migration into better perspective among the many retrospective data collection efforts those using the migration ethnosurvey stand out for gathering and continuing to collect data in hundreds of communities in several countries across the globe because of their extensive application the ethnosurveys covered in this volume will remain a key data source for the study of migration in the future especially for crossregional studies and other crosscontext comparative work despite their large recent and past contributions and further promise the potential biases of retrospective data are accentuated in comparative studies because of their clear need to have adequate representation across the different settings under study differences in sampling and retrospective life history collection between ethnosurveys may limit the extent or hinder the quality of comparative work to deal with these challenges sensible strategies should generally undertake community selection based on the substantive motivation behind the analysis while remaining aware of extant differences between cases they should also identify the cohorts and social groups that best represent the period or migration stage of interest and construct survey modules that best serve this representation finally robustness checks and posthoc adjustments including reweighting and matching can further bolster these examinations looking forward the challenge will be to keep migration data collection evolving to keep pace with the increasing elusiveness of human mobility and the changing nature of migration flows while ideally keeping the current impetus toward comparative research retrospective data collection as part of crosssectional or longitudinal surveys offers advantages relative to prospective approaches because of its flexibility this plasticity is evinced in instruments such as the ethnosurvey where the experience of many migration cohorts is captured through basic migration histories compiled for all individuals included in the household roster in no small part because the rosters often include information for all children of the head regardless of their current location representation is also aided because ethnosurveys either provide proxy reporting on absent migrant members or secure émigré representation using destinationbased sampling additional flexibility can be provided by stratified sampling approaches that overrepresent individuals most likely to be part of the risk set of core immigrant generations or during migration stages of particular interest such designs would allow a more accurate portrayal of generations periods or stages while also reflecting contemporary flows by drawing oversamples of older groups and providing weights for the representation of both population and oversampled groups greatly facilitating crosscontext research and enabling theory testing and development in addition reconstructing the household structure during years before the survey might also provide invaluable data to evaluate the extent of left censoring biases something that would be useful not only to migration studies but to any social sciencebased retrospective survey or census data although the challenges for comparative research are many its contributions to the understanding of migration flows and theory refinement has been and will continue to be of very high value thus we must continue developing data and methods that facilitate comparative work

this article is an overview of household survey approaches for the comparative study of international migration dynamics focusing on differences in the drivers of international mobility at different times and places i highlight the problems of obtaining data with adequate representation across time periods and geographies and discuss a broad constellation of prospective and retrospective approaches paying particular attention to the migration ethnosurvey i place this methodology within a broader constellation of prospective and retrospective data collection techniques briefly describing the advantages and disadvantages of each and summarizing the commonalities and differences of ethnosurvey approaches adopted around the world in particular i discuss the potential and limitations of crosscontext research and suggest post hoc case selection and other adjustments to ameliorate problems i conclude with ideas about how case and sample selection can help to bolster migration studies in the future

growing 60 and older population and the 10 th fastest growing 85 and older population in the united states between 2010 and 2030 during the 20th century the number of georgians aged 60 and over increased ninefold compared to a fourfold growth in the population overall akin to the national trends the older population in georgia is growing more rapidly in the rural counties compared to the nonrural counties adults aged 65 years and above make up about 18 of the rural population in georgia compared with about 13 of the nonrural population in georgia rural older residents face structural barriers which may prevent them from reaching their full health potential including oral health historically us medical and dental health services have been separated which created lasting public health consequences still seen today especially for marginalized rural aging populations oneil and colleagues point out that poor modernday communication and different healthcare insurance plans between dental and medical services generate missed opportunities to further the knowledge base for prevention and treatment efforts that address oral health issues in the context of overall health they also suggest that keeping these two systems separate relegates dental services to be considered nonessential further distancing oral healthcare from comprehensive healthcare understanding older adults accounts of living in rural communities is necessary as a robust sense of community has been found to preserve aging adults oral health a pivotal component of overall health however research is needed to examine the connection between community and oral health among rural older adults in the united states this study investigated how older adults living in rural communities of southeast georgia perceive whether and how their community impacts their oral health the connection between oral health and general health most chronic systemic conditions and oral disease share common lifestyle modifiable risk factors mediated by genetic environmental behavioral and socioeconomic factors oral health is one domain of health that can affect general and cognitive health including emotional cultural psychosocial and functional wellbeing the us department of health and human services report of the surgeon general highlighted the link between oral and general health the oral cavity is a wellbalanced ecosystem that harbors diverse bacterial species in highdensity biofilm lifestyle habits environmental disparities as well as hostindividual response to bacterial accumulation on the hard and soft oral tissues will shift the balance to initiate an inflammatory response with entry points to the respiratory system digestive tract the bloodstream and with the possibility to penetrate the blood brain barrier in addition numerous systemic conditions first present as changes in the oral cavity for example autoimmune diseases such as lupus erythematosus systemic sclerosis sjogren syndrome and amyloidosis are manifested as oral ulcerations changes in the salivary and parotid glands as well as changes in the tongue while hematologic disease is often observed as gingival bleeding as well as tongue changes endocrine disorders also are manifested in various oral markers oral health disparities in rural aging populations aging is a cumulative process that occurs at different rates in different tissues impacted by factors such as socioeconomic stressors lifestyle habits genetics physiologic reserves and biological resilience that influence health severity of cellular and molecular damage resulting in disease over the life course according to the centers for medicare medicaid services most medicare recipients are diagnosed with one or more noncommunicable lifestylerelated chronic systemic conditions that affect their quality of life loss of autonomyfunction and result in increased health care costs modern technological advancements and polypharmaceutical interventions have transformed once fatal diseases into chronic conditions expressed later in life that exacerbate oral manifestations oral health status during the early years of life lays the foundation for good oral health in the later years of life employerbased dental insurance has enabled older adults to retain their natural dentition yet they are still in need of complex dental services postretirement postretirementvulnerable populations also encounter environmental barriers that limit access to oral health care services with the emergency room as the only viable option to access dental services older adults are at higher risk of poor oral health due to lack of dental insurance underlying chronic systemic conditions and compromised immune systems lack of access to oral health care providers is especially prevalent in underserved urban rural communities and those with limited financial resources as dental care becomes an outofpocket expense postretirement since oral health is an important component of overall health and wellbeing structural obstacles also influence the oral health of older rural residents rural areas are typically geographically and socially isolated and lack transportation healthcare retail and other needed services many rural areas are designated dental health professional shortage areas according to the health resources services administration 68 of the nations dhpsas were in rural or partially rural areas the majority of counties 122 out of a total of 159 counties in georgia are considered dental health professional shortage areas including those areas where only specified populations face a shortage of dental care providers most of these counties are considered nonmetro or rural counties approximately 14 million georgians live in nonmetro counties designated as dhpsas many rural residents do not have dental insurance because of higher rates of poverty and unemployment in rural areas compared to urban areas and hence rely on public health insurance programs such as medicaid few rural dentists accept medicaid patients because of low reimbursement rates medicare the main health coverage for adults 65 years and over does not cover dental services some medicare advantage plans cover dental care however a recent study reported that more rural ma enrollees switched to traditional medicare compared to urban ma enrollees because of challenges to gaining access to care more recently federally qualified health centers have helped close gaps in access to timely and appropriate dental services thus reducing disparities in oral health however an analysis of trends between 2011 and 2014 showed an overall decline in the capacity to serve dental patients resulting in lower levels of utilization of oral health services among fqhcs in the south compared to the northeast the midwest and the west regions of the us based on data from 2018 older adults living in rural communities were less likely to have visited a dentist in the past year compared to their suburban or urban counterparts they were also more likely to have all their teeth removed compared to suburban and urban older adults these trends were consistent over the fouryear period examined previous research also shows high levels of dental anxiety among rural older adults high dental anxiety has been linked to poor oral health outcomes including periodontitis or gum disease additionally the american dental association reported that there is a bidirectional relationship between oral health and nutrition as poor nutritional intake affects oral health and loss of teeth and dental infections can prevent individuals from consuming a healthy diet poor oral health in rural older adults can further exacerbate their nutrition problems as they already experience challenges related to food insecurity access to healthy foods and the ability to shop for groceries and cook for oneself easily poor oral health among older americans is also more likely when they report low income lower educational attainment lack of insurance andor they belong to racialethnic minoritized groups for those living in rural areas the impact of these social factors is compounded by barriers inherent to rural areas such as lack of transportation and limited access to healthcare services health individualism despite growing evidence of systemic challenges contributing to poor oral health the public dialogue surrounding oral health in america is highly individualistic americans focus narrowly on brushing flossing and eating habits as the primary causes of oral health or the lack thereof problems are assumed to be the result of poor personal hygiene aubrun et al define health individualism as an individuals personal responsibility to make healthy or unhealthy choices and the impacts affect the individual…both the external causes of health and the broader implications of peoples health disappear from the picture drawing from health individualism oneil and colleagues explain that poor oral health is typically attributed to individual choices and lack of control ultimately shifting the focus from the inconspicuous community or political causes making it more difficult for older rural people to obtain oral healthcare views of health individualism may be more prevalent for people living in rural communities with few resources and may involve a level of perceived selfreliance for example oneil et al theorize that people dont connect the absence of water fluoridation or a shortage of oral health care providers in rural areas with their perception that a region has bad teeth they simply assume that such areas have a preponderance of people with poor personal hygiene and that these failures of personal responsibility arent a matter of public concern research on how older adults in rural areas manage their understanding of health provides insights into rural aging older adults struggles in maintaining oral health ultimately individuals normalize selfreliance and assume personal responsibility for poor health outcomes without realizing that resources create choices and community healthcare systems are not apolitical research with us rural older adults is needed to examine whether health individualism is also prevalent regarding oral health community the concept of community refers to a group of people situated in the same geographicallybound area or to a group that shares common interests characteristics or skills previous research shows strong feelings of community belonging among rural andor older residents in countries such as the united states and canada the psychological sense of community a widely used construct in community psychology was defined by mcmillan and chavis as a feeling that members have of belonging a feeling that members matter to one another and to the group and a shared faith that members needs will be met through their commitment to be together a strong sense of community has been associated with increased community engagement and participation and with positive oral health and general health behaviors social support is one of the important functions of social relationships and positively influences the sense of community house conceptualized social support as aid and assistance exchanged through social relationships and interpersonal transactions thats meant to be beneficial social support can be divided into categories of supportive behaviors and includes emotional instrumental and informational support although types of social support are distinct they can be challenging to research as relationships that provide one type often also provide other types another related concept is that of social capital while sense of community is a psychological construct social capital is embedded within communities and entails informal or organized social networks and social structures which have the potential to tie people and communities together socially mapping and mobilizing social capital in communities has been one way of collective action to promote health growing evidence supports the association of oral health with social capital social support and a sense of community in older adults and other age groups examining older adults experience in rural communities is essential as a strong sense of community is protective to older adults oral health yet no studies have explored the concept of community concerning oral health in us rural older populations this study aimed to fill a gap in the literature by examining how older adults living in rural communities of southeast georgia understand their communitys role in shaping their oral health types of social support were also assessed as it is vital to understand the nuances of social support that can influence a sense of community needed to promote oral health in rural communities methods study design and participant recruitment this study is part of a larger mixedmethods study participants were recruited through senior centers and other communitybased services including meal delivery services the surveys in the first phase of quantitative data collection in the study were conducted at senior centers and at participants homes from september until december 2018 at that time the participants filled out a form expressing their willingness to participate in a followup interview during the studys second phase of qualitative data collection the followup interviews were conducted between march and april 2019 only findings from these interviews are presented in this paper the study sites were located in five rural counties in southeast georgia using convenience and snowball sampling several definitions of rural are available we followed the office of management and budgets guidance for selecting the counties that would participate in the study ombs guidance is used by many federal programs and policies when determining funding financial incentives and targeting omb designates the counties with 50000 or more people as metropolitan areas and those between 10000 49999 people as micropolitan or nonmetropolitan areas often micropolitan or nonmetro is used as a proxy for rural based on this guidance all the study sites were in micropolitan nonmetropolitan or rural counties data collection interviews were conducted over the telephone allowing for privacy and to engage participants dispersed across different communities especially those who were homebound the recruitment and interviews were done simultaneously and participant recruitment continued until no new information emerged from the interviews the principal investigator conducted all the interviews the average length of the interviews was between 30 and 45 minutes participants were asked to describe what it means to live in a rural community how living in a rural community affects the health of their teeth gums and mouth and how important oral health is for their community and how their community can help with their oral health all interviews were audiorecorded and supplemental notes were taken interviews were transcribed verbatim by a professional transcription service pseudonyms were used to protect participants identities any personal information identifying the participant was removed from the transcripts the proposed study was approved by the georgia southern university institutional review board verbal consent was obtained from all the interviewees prior to beginning the interviews data analysis data analysis was guided by the following question how do older adults living in rural communities of southeast georgia understand their communitys role in shaping their oral health two analysts including the principal investigator reviewed the data independently using braun and clarkes framework for thematic analysis the first five transcripts were used to inform the development of the codebook inductive codes were developed and modified throughout the coding process and the first five transcripts were revisited after all the codes had been finalized nvivo11 a qualitative data analysis software was used steps were taken to ensure that the data were trustworthy the two analysts met intermittently to discuss their analysis including any disagreements the analysts also maintained memos or notes while understanding and interpreting the data to ensure that the meaning of codes did not drift or shift during the process of coding finally because social support positively impacts a sense of community deductive coding using a social support framework was applied to the data using instrumental emotional and informational support findings first participants defined their understanding of community and subsequently two themes were identified community barriers and selfreliance findings centered on the tensions between rural older adults concept of community and independence related to oral health types of social support including instrumental emotional and informational were also applied defining community overall participants tended to define community as geographic as a group of people getting together or living together in proximity to one another community included the town or neighborhood they lived in and the people in their immediate surroundings such as their friends family and congregants at their faith community community also meant the people who shared common interests and values such as social clubs most participants enjoyed living in what they described as a quiet and serene rural community rather than living in a more urban area participants tended to speak positively about their community for example ross explained how meaningful the relationships in their community are and how helpful people can be community means a lot you know they can do a welfare check come and see how if im okay and sometimes you have cold real cold night and stuff and they come and make sure im okay you know make sure youre taking your medication and everything alright with you and you know in my case sometimes i may need help opening a can can of food to get something to eat you know and they can help me out you know so community means a lot to have good neighbors and family you know eleanor also found community members to be supportive she lived by herself and had only one neighbor she did not interact with much regardless she posited that her neighbor would likely lend a helping hand if theres something going on with you and you have to go to them and i feel like they would help you with whatever you needed on the other hand some participants like deena were less optimistic well my neighbors and friends dont help me i have to do that myself they dont help me yeah community barriers despite noted strengths from many participants they were well aware of the downside of living in a rural community including the impact on their oral health first isolation was discussed by the participants and reflected difficulties with all three types of social support the geographic seclusion made it difficult for them to access instrumental and informational social supports such as oral health care and education resources when asked about the experience of living in a rural community sheila described a sense of geographic and social isolation its got nothing but a post office and a gas station but i really dont know nobody in this town…its real quiet i dont ever see nobody i just see the cars and trucks that go by the road and thats it vera shared a similar sense of seclusion and said donald was concerned about the lack of informational support in his community and articulated the consequences for peoples oral health it your teeth get rotten faster what to do when your gums are bleeding you have lack of information of how often you should brush your teeth and the information you need about how often you should go to the dentist how often you should get your teeth cleaned because you brush them and thats it you learn to brush them but you dont know how to take care of them you learn brushing them is all you need to do steve shared ideas for improving oral education he suggested a type of informational support and proposed that dental providers could hold an exhibition with specific resources for lowincome people have a doctor dentist or something you know to come out and talk to everybody and everybody would learn certain things you know show us any stuff we need to know we might not know about our mouth teeth and gums and stuff and the ones that cant afford to go to a dentist and get advice they could have one come out and talk with us or someone of that nature you know participants explained that isolated rural areas lacked other instrumental social supports like public transportation making it difficult to get to their doctors appointments they relied on either special transportation services provided by their health insurance program or on family or friends to drive them to health appointments dwayne stated i find it to be peaceful to live in a rural community but when you do need medical services you got be able to go where you going get where you going because there is no public transportation or anything earl compared resources in the city to his rural community and is fortunate to have access to transportation through his health insurance he reported chicago has the street buses if you dont have a car down here you need transportation i have united healthcare and they have a system where i can get special transportation to my doctors appointments and things like that when asked directly about oral health in their community participants believed that it was essential and it often centered on emotional support and concern about disconnection from others according to vera all oral health is important to the community most people thought it was socially undesirable to have poor teeth earl stated its very important because when you meet people you dont want an odor from your mouth or anything like that likewise marvin explained its kind of embarrassing to be around people that doesnt have good teeth good healthy mouth and teeth and gums especially when youre speaking with them youre near them probably they have an odor even though they might brush their teeth if their teeth is bad its still gonna be kind of embarrassing and have a bad look another reason participants may believe community is important to their oral health is that their oral health tends to worsen with age steve suggested the older i get i know the worst state my mouth gets in vera has the same challenge as i got older my teeth have gotten weaker in my mouth and they also have gotten tooth decay as i get older deteriorating oral health may lead to further isolation social disintegration and potentially less emotional support instrumental support is needed to cover the high cost of dental services blocking some participants from the oral health care they would like to have linda is unable to afford dentures well i wish i could get some dentures i havent got much money with my medicaid and medicare i thought i might could get dentures without costing me anything in some cases the absence of teeth or dentures can be distressing and may reduce social interaction and emotional support thus the lack of instrumental support may lead to less emotional support kim described the connection between the shame of tooth loss and low selfesteemanother instance where instrumental support and emotional support are paired in the apartment complex that i live in the majority of the people that live in this apartment complex are in the same boat that im in a lot of them have had all their teeth removed but they cant afford dentures a lot of them have teeth that are broken missing and it just looks bad and like i said it destroys your selfesteem and your selfconfidence it just does participants however indicated that few people have direct conversations about oral health because it is a private matter likely shameful for some people bob stated we dont sit around and discuss oral health we really dont michelle explained its very important to people around me oral health but thats something we dont ask other people about is their oral health thats a personal thing with them she continued thats something private that i dont talk about it my mouth to other people dwayne explained that oral health is only brought up in passing conversation we discuss little things if we have a colonoscopy done if we have a tooth pulled you know well talk about that…but kind of briefly selfreliance interestingly participants expressed a disconnect between the concepts of community and oral health despite rural community barriers and lack of emotional informational and instrumental support that participants could easily list they believed they were solely responsible for maintaining their health from their perspective their community neither supported nor hindered them in maintaining their oral health they did not think that geography or social support impacted their oral health in a major way the only instance of social support suggested by the participants was that of getting a ride from a family member or a friend to dental appointments the participants believed their oral health was solely dependent on how regularly they performed oral hygiene habits such as brushing flossing and visiting the dentist although they knew that regularly visiting dentists was important for preventing oral diseases they felt that dental work was expensive and they could avoid it if they maintained regular oral hygiene habits kim stated i dont think it community has any effect on it oral health thats something an individual has to do vera explains the contradiction between community and selfreliance but you know the community is supposed to be a unity but its not really like that but thats why i tell you have to take care of yourself although dwayne identified a lack of transportation in rural areas as problematic he did not see place mattering to his oral health i dont think living in rural community would make me pay less attention or more attention to my dental care my dental savvy because i would still go to the dentists and get cleanings checkups i would do that no matter where i lived trevor stated i dont see anything about being in this community that limits someones ability to get proper oral care regardless of community belonging participants tended to use an individualistic rather than collectivist interpretation of oral health michelle explained you have to do it all the time because if you stop caring for your mouthyour teeth will start deteriorating but if you dont keep it up thats how you get a bad mouth thats how you get gingivitis and bad teeth if you dental floss and brush every day you still have to see a dentist but it wont be as bad as it is if you dont do these things of course theyre gonna deteriorate and rot and youre gonna have to go to the dentist and thats a lot of money going to the dentist some people cant even afford to pay for them because ive been around people that have their teeth but they are soft and theyre dingy and thats because of the buildup that over the years has caused theres nothing much you can do except try to do the best you can to keep them clean and keep the upkeep of them discussion this qualitative study explored a gap in the literature regarding how older adults living in rural georgia perceive the role that community plays in shaping their oral health it is essential to explore the lived experiences of older rural georgians to best meet their unique regional health needs participants defined their understanding of community and similar to previous research most described a sense of at least some community belonging community barriers and selfreliance were identified as the key tensions between the concept of community and independence of oral health among rural older adults participants recognized the inherent barriers and absence of social support in a rural community such as isolation lack of transportation educational resources and cost that prevented them from getting the care they needed however they expressed notions of health individualism and felt they were fully responsible for their oral health in their estimation poor oral health resulted from them not keeping up with dental care habits such as brushing and flossing thus in their view where they lived did not matter to their oral health despite the barriers they identified most participants desired going to a dentist and getting dentures but they recognized that dental services were expensive and hence they had to do the best they could to avoid these outofpocket expenses or live with the consequences they also may have relied on hygiene habits more because issues like lack of affordable dental coverage were beyond their control like in other qualitative studies the participants in this study described community in terms of where they lived and the groups of people who they shared a connection with family friends neighbors and those who they shared common interests and values with and obtained support from when needed were considered as part of their community however these aspects of a community were not viewed as enablers to optimal oral health in general living in a rural community was described as an isolating experience for many participants which is similar to the experience of rural residents participating in previous studies conducted in the united states as well as in other countries social isolation and loneliness have been linked to poor health outcomes among rural older people a strong sense of community belonging and social capital have been associated with positive oral health outcomes and general wellbeing among older adults in both rural and nonrural areas altogether the participants in this study recognized factors that influenced their oral health yet ultimately oral health and community were disparate concepts for them they viewed oral health as a product of sustained and regular dental care habits such as brushing and flossing this is not surprising as previous research has shown that the public perception of oral health and health in general is highly individualized they are viewed as isolated concepts without awareness of the social and structural factors shaping them limitations study findings must be considered in light of its limitations for example the research consisted of a small convenience sample conducted in five rural counties in the southeast region of georgia approximately four to five years ago which limits the generalization of the results to older adults in other rural regions especially those in other countries the study consisted of people served by specific communitybased programs that consented to become study sites the demographic composition of this study sample emulated the demographic characteristics of the program clients hence some biases may have been introduced during the participants selection which may have influenced the findings nevertheless this study gave voice to older rural georgians understanding of how community impacts oral health a neglected topic in the literature in the current sample african american participants took part in this study at higher rates than their white counterparts most african americans live in the southern united states and georgia currently ranks as the second largest state for the black population racial equity and oral health are critical so this area deserves intentional inquiry as one of the social work grand challenges is closing the health gap and eliminating racism future research should explicitly highlight oral health disparities among aging african americans living in rural areas please note that the data used in this study is limited to the timeframe of four to five years ago serving as a contextual snapshot for our analysis implications for social work practice to move us discourse beyond health individualism frames social workers can follow the oral health framing reform recommendations by oneil et al oneil and colleagues advocate using images and discussion of oral health that intentionally link oral health with overall health and avoid using conceptions only of teeth they recommend using health equity frames rather than a onesizefitsall health approach they found health equity boosts the publics agreement that society has a collective responsibility to address oral health inequities oneil and colleagues promote using effective economic frames that include a discussion of avoidable costs highlighting how current approaches create incentives for people to defer treatment leading to more serious problems that are ultimately more expensive to treat they also call for the public to reimagine oral healthcare delivery systems beyond the dentist office to interdisciplinary teams social workers must be included in these teams as they work across numerous community locations and have specialized training in biopsychosocial models as recommended by lyons et al licensed social workers can be integrated into dental teams to improve access to care which would help promote better oral health outcomes social workers are uniquely positioned to reduce barriers to care in rural communities as they are already working closely with underserved populations social workers can also help interdisciplinary teams apply strengthsbased personinenvironment approaches and policies that help move the public discourse away from a health individualism perspective and reduce health disparities in line with oneil et al social workers can direct public attention away from deficit thinking about populations that experience poor oral health and toward systems thinking about how disparities arise and how they can be redressed and to explain how structural factorsincome race and ethnicity language geographic locationinfluence oral health outcomes and show how shifts in the system can address disparities within a strengthsbased perspective it is essential to identify and build on existing assets or supports and services that already exist within rural communities to help prevent oral diseases among older people in rural areas individuals associations and institutions can be mobilized to come together to build on their assets rather than focus on just their needs for instance oral health education programs and risk assessment and examination can be integrated with communitybased supports and services such as mobile dental vehicles homedelivered meals chronic disease management classes at senior centers and mental health services social workers need to include oral health as a part of biopsychosocial assessments and provide community resources azhari points out since many social workers dentists and health care professionals have mutual clients it is crucial to understand the connection between oral health mental health and general health social workers can partner with dentists to provide clients with the tools to take responsibility for their oral health to further enhance holistic healthcare and bridge the gap between oral and general health it is recommended to incorporate basic dental screenings into routine general health checkups this integrated approach aligns with the comprehensive perspective advocated by oneil et al emphasizing the interconnectedness of oral and overall health by including basic dental screenings in general health appointments social workers can play a pivotal role in early identification of oral health issues promoting preventive measures and fostering a more inclusive healthcare delivery system this step aligns with the strengthsbased personinenvironment approaches and policies recommended by oneil et al lyons et al andazhari empowering social workers to address disparities and contribute to the overall wellbeing of rural older adults upstream interventions can help target and improve structural factors identified by the participants in this study such as lack of transportation lack of dental coverage and changing the built environment of rural communities equitable policies focused on decreasing economic inequality can help create opportunities within rural communities to support and maintain oral health along with overall health and wellbeing social workers can be a bridgelink to other types of healthoral health needs and community support social workers already integrate physical and behavioral health in their healthcare delivery systems thus including them in oral physical and behavioral health care settings including fqhcs is a practical solution to improving oral healthcare for rural and underserved groups adding oral health to social work education will benefit the participants in this study as well as other excluded groups incorporating social workers may be the key to empowering rural older adults to pursue and advocate for their oral health author note address correspondence to swaha pattanaik georgia southern university email

oral health is essential to overall health however structural obstacles influence older rural residents oral health outcomes especially those from disadvantaged backgrounds in the south poor oral health is typically attributed to individual choices shifting the focus from the inconspicuous community influences making it more difficult for older rural people to obtain oral healthcare this qualitative study explores how older adults in rural georgia understand the communitys role in shaping their oral health twentytwo older adults were interviewed from five rural communities in southeast georgia participants defined their community in geographic terms community barriers and selfreliance emerged as themes of how living in a rural community affects oral health the concepts of community and ones oral health were perceived as distinct participants did not see how where they lived could matter to their oral health even when they identified critical community barriers to oral health in collaboration with rural healthcare systems social workers can support healthy selfreliance moving beyond a health individualism lens by helping bolster older adults social supports an essential function of social relationships that positively influences a sense of community additionally social workers can advocate for equitable policies to create opportunities for rural communities to support and maintain oral health

background the collapse of the soviet union resulted in large fluctuations in household resources and increased uncertainty for the russian people much academic research has explored the socioeconomic and political ramifications of this transition to a mainstream market economy the importance of health in times of rapid change in the economy has been highlighted in economic development literature 12 preston 3 concludes that factors other than individual income play a powerful role in the determinants of health conditions that are often associated with poverty this reinforces the idea that individual incomes in isolation from the community in which people are located do not immediately reflect health status neighbourhood affluence is a more powerful predictor of health status than poverty above and beyond individual demographic background socioeconomic status and health behaviours 4 an empirical study using spanish living conditions survey datasets revealed that the relationship between health and income operates through comparison information with respect to societal peers conversely material deprivation in terms of financial difficulties basic necessities and housing conditions exerts a direct effect on ones selfperceived health status 5 vella 6 has reported the prevalence of a considerably high share of dissatisfaction with selfperceived health status among the respondents of the russian longitudinal monitoring survey 1993 and cockerham 7 has found no relationship between income and selfperceived health status among the respondents of the russian longitudinal monitoring survey 1995 another crosssectional study by cockerham et al 8 reported a similar relationship between income and selfperceived health status among the respondents of the russian longitudinal monitoring survey 1998 further the russian longitudinal monitoring survey 1998 reflected a strong negative correlation between the health status of the individual and the desire to return to the former soviet regimea reflection of dissatisfaction with the economic and social conditions of the time 8 a panel data frame study using russian longitudinal monitoring survey datasets showed little effect of income on selfperceived health status when the possibilities of reverse causation and incidental association between income and health were accounted for however a longitudinal study using russian longitudinal monitoring survey datasets suggested a correlation between negative health consequences with concern about the likelihood of job loss kraus et al 9 have shown that chronically experienced negative affects explains rather than confounds the link between socioeconomic strata and selfperceived health the systematic review study of ostrove and adler 10 suggests that the pathway from socioeconomic strata to health is through exposure to different environments and adaptations to these environments environmental demands and supports shape individual responses to selfperceived health unemployment and inflation have often been considered two of the most robust determinants of individual happiness with unemployment typically having a stronger negative impact than inflation eggers et al 11 found that in the russian federation higher unemployment rates lead to more happiness as people tend to revise their expectations upwards when their neighbours are suffering rodríguezpose and maslauskaite 12 argued that citizens are quite tolerant of interpersonal inequality and as the economy is still dynamic open and volatile the influence of macroeconomic factors on happiness varies substantially over time therefore crosssectional analysis cannot provide any robust conclusions an empirical study reflects a larger effect of activity status on selfperceived health than the effect of income inactivity is associated with the largest absolute effect in part among individuals claiming disability allowances due to ill health 13 a crosssectional study 14 on the evolution of health inequalities in switzerland found no systematic trend in the changes with the measure of health inequalities between 1982 and 2002 the ecosocial theory of health distribution introduced by krieger in 1994 15 postulates that population health and health inequities must be analysed in a societal historical and ecological context and neither the forms of social inequality nor their associations with health status are fixed but are instead historically contingent the relationship between socioeconomic strata and health changes with age since the mediators of ses act differently in different stages of the life course health in later life is the result of multiple social and biological processes whose effects interact and accumulate over time 16 17 18 the microeconomic perspective assesses health costs at the individual or household level macroeconomic consequences are viewed from the level of the national economy generally considering the level of population health that retards a countrys economic growth the realization of the economic objectives with a concurrent reduction of poverty necessitates evidenceinformed policy development for investment in health the micro perspective is also specifically important for individuals and households as freedom from ill health adds different dimensions of economic wellbeing to individuals and households further the concern for poverty and inequality recognizes that in health status societal averages typically disguise as much as they reveal therefore the interest is not in health status that prevail in society as a whole but in health status of different socioeconomic groups 19 this paper investigates how the difference in the selfperceived health status of russians has evolved in the context of the transition to a mainstream market economy and following the approach of wagstaff makinen et al and castroleal et al 20 21 22 this study examines the trend in the distribution of such difference across the socioeconomic strata of the population from 1994 to 2013 our data is unique in the sense that we follow the same individuals over an 18year period methods the data for this study are from the 19942013 waves of the russian longitudinal monitoring survey rlms is an ongoing longitudinal household survey of the russian federation the survey was designed to be representative of the russian population in the early 1990s the survey contains an array of information on the economic social demographic and health characteristics of respondents their households and the environments in which they live an initial representative sample of dwellings was drawn in 1992 and surveyed every six months until 1994 a second more broadly drawn representative sample replaced the initial sample in 1994 and is being followed annually since then for cost reasons rlms does not attempt to follow individuals or households who move from their original sample dwelling units instead any new household member or household living at that dwelling is included in the sample in each wave thus the rlms sample remains representative of the underlying population if new residents can be considered exchangeable with those that moved 1 the rlms data sets contain poststratification weights that is weights that adjust not only for design factors but also for deviations from census characteristics variation in individual weights reflects the geographic effects for households as well as differentials due to poststratification of the sample by major geographic region age and gender the multivariate distribution of the sample by gender age and urbanrural location compared quite well with the corresponding multivariate distribution of the 1989 census from this unbalanced sample we chose rlms participants who had been included in all 18 waves thus after balancing the panel we followed 1496 individuals henceforth to be read as study sample we explored the study sample selection with the binary using logit model hence with the long followup of the individuals we have controlled the variations attributed to the sampling population per se the use of more than one observation facilitates causal inference in situations where inferring causality becomes very hard if only a single cross section are used and the panel nature of the data allows for the unobserved effect to be correlated with the explanatory variablesthus ensures a better control for the unobserved effects of the variables 23 our dependent variable for the analysis is selfperceived health individuals were asked how would you evaluate your health and the response was recorded on a fivepoint likert scale with the answers very good good averagenot good but not bad bad and very bad sah variables have been widely used in literatures 24 25 26 27 that analyse the socioeconomic health gradient we constructed an ses index by applying principal component analysis using a set of variables with a kaisermeyerolkin score of 080 and above with the rlms 1994 pca resulted in two principal components first pc accounting for 29 of the total variance captured in seven items while the second pc accounted for 15 captured in four items with the data subset the first pc accounted for 33 of the total variance captured in seven items while the second pc accounted for 15 captured in four items the income variable represented the sum of incomes from all sources for the household deflated to the value of june 1992 we calibrated the household income as per adult equivalent using the modified oecd scale 2 for our analyses we measured inequality in income by the gini index 3 we standardized 2829 the selfperceived health status by age gender and diagnosed chronic diseases applying the indirect method of standardization 4 we estimated the correlation of the confounding variables with selfperceived health status conditional on nonconfounding variables this regressionbased approach corrects the actual distribution of the selfperceived health status by comparing it with the distribution that would be observed if all individuals in the group had their own age and gender characteristics but the same mean age and gender effect as the entire population y i ¼ α þ x j β j x ji þ x k γ k z ki þ ið1þ where y i is selfperceived health status i denotes the individual and α β and γ are parameter vectors the x j are confounding variables which we want to standardize and the z k are nonconfounding variables which we do not want to standardize but to control for in order to estimate partial correlations with the confounding variables the neweywest 5 estimator estimates the individual values of the confounding variables and sample means of the nonconfounding variables are then used to obtain the predicted or xexpected values of the selfperceived health status ŷ i x ŷx i ¼ α þ x j βj x ji þ x k γ k z k ð2þ estimates of indirectly standardized selfperceived health ŷ is i ¼y i ŷ x i þ yð3þ where ŷ i is indirectly standardized selfperceived health status y i actual health ŷ i x xexpected health y overall sample mean in the next step following the principles of previous analyses 3031 we dichotomized the fivescaled measure into a binary variable 32 selfperceived health the conventional regressionbased statistical methods report the magnitude and the direction of association between socioeconomic position and the health status of the individual but ignores the possibility of variance in the effect of explanatory variables across distribution further such traditional methods cannot reflect the extent of health disparity across socioeconomic strata of the population and thus do not allow for comparison over time 30 therefore we used the health concentration index as our measure of sesrelated inequality the concentration index becomes positive if health is concentrated amongst the betteroff negative if health is concentrated amongst the worseoff and zero if no inequality is observed thus ci can also be interpreted as the slope of a line passing through the heads of an army of people ranked by their ses with the height for each individual proportionate to the value of hisher selfperceived health status expressed as a fraction of the mean for the group finally with the achievement index 6 we measured the average level of health and the inequality in health between the worseoff and the betteroff achievement is the weighted average of the health level of the individuals in the study where higher weights are attached to worseoff than to betteroff thus achievement index is distributionally sensitive measure of population health ci captures the extent to which ill health is concentrated amongst the worseoff achievement index indicates the degree of aversion to inequalities in health between the worseoff and the betteroff 33 ethics this study uses secondary data collected from perpetual surveys the datasets are anonymously coded with no individual identification identifiable by the user the user has explicit authorization to use the datasets made available for analysis results table 1 exhibits that the study sample of this study was represented by a greater number of females in addition the proportion of the 3160 age group was relatively higher and the proportion of the over 60 age group was substantially lower in the balanced panel the distribution of respondents with selfperceived health status as good and not good was similar between study sample and rlms1994 datasets the inflation adjusted adult equivalent household income was smaller for the respondents in the study sample and also the proportion of respondents with access to public service utilities was smaller in the study sample when compared with rlms 1994 datasets however the rural respondents and the respondents with having own tractor was higher in the study sample though the distribution of respondents by ses quintile was almost similar between study sample and rlms 1994 datasets the test of independence between the study sample and rlms 1994 datasets were significant for all the variables used in the study except for such test of respondents with having motor vehicle the descriptive statistics reflected a decline in selfperceived health status by more than 20 of the respondents over the 19 year period this period registered a rise in diagnosed chronic disease by the respondents during the same period affluence level and living condition exhibited a positive movement amongst the respondents the inflation adjusted adult equivalent household income increased by more than 85 amongst the respondents from 1994 to 2013 the gini index for the study sample changed from 0272 in 1994 to 0382 in 2013 but overall satisfaction in life increased by 23 times amongst the respondents of this study during the 19 years table 2 presents the selection of study sample from rlms 1994 datasets we found that study sample was a representation of more female respondents with relatively smaller household income and less house owners there was no statistically significant difference in the selfperceived health status between the study sample and rlms 1994 datasets when other potential selection variables are included in the model there was no genderage interaction in the sample selection process table 3 indicated that the nonstandardized perceived health gets worse over time as one can expect however in our sample the standardized perceived health improves over time a predictable trend was observedthe nonstandardized selfperceived health status declined while the standardized selfperceived health status improved over time the test of significance indicated that for the sample population the standardized selfperceived health status from 2002 onwards and nonstandardized selfperceived health status from 2006 onwards remained same as was in 2013 ci was positive for non standardized and standardized selfperceived health status for all the years the difference in absolute size between ci for non standardized and that of standardized selfperceived health status was 0149 in 1994 and 006 in 2013 ie a reduction of almost 60 over the 19 year period the annualized average of this difference was 0052 a smaller standardized variant of cis implied that some of the inequalities in selfperceived health status were unavoidable though the ci for both the non standardized and standardized selfperceived health status changed in every year such change in absolute size for both the cis did not follow any definite trend a relatively smaller standard error for cis with standardized selfperceived health status suggested that the serial correlation was corrected with the method of indirection standardizationstandardization reduced the variations in selfperceived health status the tvalues indicated the existence of significant inequalities in selfperceived health status in almost all the years without any definite trend in changes of such inequalities the weighted average of selfperceived health status i was equal to ci when v was equal to 2 with increased v disachievement became significantly large enough for all the years the highest disachievement was in year 2000 discussion we followed 1496 adults over a period of 19 years to investigate the evolution of health differences among russians in the context of neoliberal restructuring with welfarestate retrenchment 34 and to examine the distribution of evolved health differences across the socioeconomic strata of the population from 1994 to 2013 our approach removed the effect of the changing composition of the sample and relied on the interindividual differences to reduce the collinearity between current and lag variables to estimate unrestricted timeadjustment patterns 35 denisova 36 acknowledged potential importance of attrition bias in the study using rlms datasets of 14 years while concluding that the effect of such attrition bias did not have any significant health differences between those left in the sample and those remained in the sample datasets of rlms further applying inverse probability weighting estimation method 37 on rlms datasets gerry and papadopoulos 38 have established that selfperceived health related attrition in the longitudinal elements of rlms surveys do not have the effect on the model results in spite of this fact the individuals in the sample are getting older and our results indicated a systematic trend of improvement though not consistent in the age gender and diagnosed chronic diseasesstandardized mean of the selfperceived health status after controlling for the effect of region settlement of residence and ses for the study population the standardized mean selfperceived health status registered an overall positive shift of 460 from 1994 to 2013 during this period the gini indexa measure of distributional equality of material affluencebecame positive by 4044 our results also supported the evidence from gerry and papadopoulos 38 who had showed that there was a significant unobserved individual heterogeneity associated with age and with initial selfperceived health status in the rlms datasets we could not find any obvious effect of the macroeconomic crisis on the selfperceived health status within our study cohort though inequality indices in the distribution of good selfperceived health status the highest value of the disachievement index of year 2000 might be attributed to the macroeconomic effect of the 1998 economic crisis on standardized selfperceived health status of the study population this absence of consistent time trend is largely consistent with a similar phenomenon found in previous research 14 using swiss survey datasets a same absolute size of ci for standardized selfperceived health status in 1994 2003 2004 and 2013 indicated a uniform effect of age gender and diagnosed chronic diseases on the selfperceived health status of the study population when effect of the confounding variables ie region settlement of residence and ses were controlled average effect of these standardising variables on the selfperceived health status of the study population was found to be more than 40 but without any consistent trend on yearonyear perhaps a phenomenon like this can be explained by the pathways 10 from socioeconomic strata to health that have shaped individual responses to selfperceived health status in addition changes in concentration indices can be decoded as the expressions of macroeconomic factors on happiness when the economy is still dynamic open and volatile 12 further such a phenomenon also reflects life course variation in the ses gradient in health 3940 concerning the extent to which the inequality in good selfperceived health status varies with position of the individual in ses quintile we found evidence that the variations of good selfperceived health status was not uniform within study population across we found evidence that the betteroff enjoys good selfperceived health status in all the years though the absolute size of ci for nonstandardized selfperceived health status was reduced by 4427 from 1994 to 2013 there was not much change in the distribution of study population across ses quintiles in these two years but overall satisfaction with life for the study population became more than doubled from 1994 to 2013 further inequalities in selfperceived health status for the sample population was reduced by almost 60 over the 19 year period this reflection of positive shift of good health for the worseoff was consistent with plausible theoretical and empirical findings that the selfperceived health status of the individual is related to subjective rank perceptions of the individual with the ses 41 42 43 44 in other words subjective socioeconomic status 7 rather than ses relates better to the selfperceived health status of the individual marchand et al 45 argues that any health gains among the betteroff in the course of implementing efforts to improve the health of the worseoff is a positive externality because of the dilution in inequality reduction such argument translates to a policy that resulted in the same proportional improvement in everyones health would raise the value of the distributionallysensitive measure of population health while a policy that led to the same increase in the mean but a larger proportional improvement in the health of the poor would produce a larger increase in it the mean selfperceived health status weighs everyones health equally so we estimated degree of aversion 33 to selfperceived health differences between the worseoff and the betteroff within the study population with the weights attached to the standardized selfperceived health status of the worse off we found disachievement was becoming larger and larger indicating that the values of the achievement index are sensitive to the weight set on the health of the worseoff population conclusion an orientation towards inequity demands reduction of health status difference between worseoff and the betteroff the significance of measuring health inequality becomes a policy relevant tool if we can identify the aversion to inequality the gini coefficient a general measure of the distribution of wealth often does not correlate with the measure of health inequality in a transitional economy that lacks predictability furthermore subjective socioeconomic status proxied by overall satisfaction with life has emerged as an important determinant that correlates better with selfperceived health status sss the rankbased facets of ses shapes the revealed health status for the russian federation we consider our results fairly robust since we find the presence of diagnosed chronic disease risks in the respondents with bad and very bad selfperceived health this study contributes by exploring the evolution of differences in selfperceived health in the transition from a welfare regime to a marketdriven open economy we analysed the recent survey datasets to capture the changes and the distribution in selfperceived adult health status in different socioeconomic stages of life course this panel study which has followed the adult respondents for a long period provides empirical evidence in subscribing to the fact that the incountry average of selfperceived health status is not sufficient enough to guide policy action in reducing health inequalities and the socioeconomic strataspecific mean and the distribution of selfperceived health status within socioeconomic strata are important guides to improve the average health of the population despite unfolding selfperceived health status gradient of selected individuals over 19 year period the study sample selection and size of the study sample limits the generalisability of the study findings for the entire russian population rlms is a nationally representative instrument with a multistage stratified sample but the size of our cohort restricts the full representation of the entire country the selection can have an impact on the association between neighbourhood factors and selfperceived health status though our measure of collective efficacy 8 is purged of its association with individuallevel social support and sociability the datasets do not allow individuallevel control to be derived directly from rlms our finding that differences in the distribution of selfperceived health cannot be explained by the socioeconomic strata position of the individual suggests that future research should take into account the context of stated selfperceived health status in the realm of subjective socioeconomic status ie the individuals subjective perceptions of their position relative to others in the socioeconomic hierarchy of the neighbourhood endnotes 1 because of the decline in response rate in big cities the proportion of the big cities in the sample became less than needed and continued to decrease each round so in round 15 sample repair was done new households were added to reconstruct the share of each region in the sample 2 oecdmodified scale after having used the old oecd scale in the 1980s and the earlier 1990s the statistical office of the european union adopted in the late 1990s the socalled oecdmodified equivalence scale this scale first proposed by haagenars et al assigns a value of 1 to the household head of 05 to each additional adult member and of 03 to each child where covar is the covariance between income and ranks of all households according to the income ranging from the poorest household to the richest n is the total number of households and y is the mean of the adult equivalent household income 4 indirectly standardised health is the difference between observed and expected health where expected health for an individual is the average health of individuals with the same levels of the standardising variables as the individual with groups expected health for an ses group is the weighted average of health levels conditional on the standardising variables where the weights are the proportion of the ses group population in the sub groups defined by the standardising variables 5 a regression method that corrects for heteroscedasticity and autocorrelation 6 defined as a weighted average of the selfperceived health status of the respondents where higher weights are attached to poorer people it reflects the average level of selfperceived health status and the inequality in health between the worseoff and the betteroff 7 subjective socioeconomic status is defined as a persons subjective perceptions of their rank relative to others in the socioeconomic hierarchy 8 emphasizes mutual trust and solidarity and shared expectations for prosocial action in theorizing the impact of neighborhood social organization on local residents wellbeing evidence suggests that collective efficacy is a generalizable resource capable of influencing a wide range of outcomes including selfperceived health status appendix a the concentration curve plots the cumulative proportion of selfperceived health against the cumulative share of the population ranked by ses variables the curve lies below the 45°line of equality if selfperceived health is concentrated among the betteroff and above the 45°line of equality if selfperceived health is concentrated among the worseoff the ci is defined as twice the area between the concentration curve and the diagonal n is the sample size and r denotes the individuals fractional rank in the ses distribution μ the mean of the binary variable y whose distribution across ses is the subject of interest for μ 0 the minimum value of ci is equal to and the maximum value is equal to for a given μ 0 the maximum of the ci is when the poorest j individuals have a value of y equal to zero and the richest nj individuals have a value of y equal to one therefore μ ¼ nj n and ci ¼ 1μ þ 1 n for the large samples the 1 n term vanishes and the minimum and maximum tend to μ 1 and 1 μ respectively 46 w i where w 0 0 r i denotes the weighted cumulative proportion of the population up to the midpoint of each individual weight and is bounded in the interval r i represents the cumulative distribution function of ses and indicates the individuals position within the ses distribution we estimated ci from regression of a transformation of the selfperceived health status on the fractional rank in ses distribution 47 neweywest regression 48 which corrects for autocorrelation as well as heteroscedasticity where h is a measure of standardized selfperceived health is to be considered as good v inequality aversion parameter if v 1 everyones health is weighted equally as v is raised above 1 the weight attached to the health of a very poor person rises r i fractional rank of the individual so the weight attached to the i th persons health share is hence the achievement index captures inequality in the distribution of health and is deduced to if standardized selfperceived health declines monotonically with ses the greater the degree of inequality aversion the greater the wedge between the mean μ and the value of the index i competing interests the authors declare they have no competing interests authors contributions pp has carried out the analysis of the datasets and drafted the manuscript hv and pp interpreted the analysis hv finally edited the manuscript both authors have read and approved the final manuscript

background to assess and quantify the magnitude of health inequalities ascribed to socioeconomic strata from 1994 to 2013 in the russian federation methods a balanced sample of 1496 adult individuals extracted from the 1994 wave of the russian longitudinal monitoring survey rlms is followed for stated selfperceived health status until 2013 the socioeconomic strata ses index is constructed with a set of variables adult equivalent household income ownership of assets and living conditions by applying principal component analysis pca we use a regressionbased concentration index to measure differences in selfperceived health status finally we examine the degree of aversion to inequalities in selfperceived health status between the worseoff and the betteroff with the achievement index results by 2013 the mean standardized selfperceived health status has improved by 46 compared to 1994 the absolute size of concentration index ci for non standardized selfperceived health status is reduced by 4427 from 1994 to 2013 no systematic trend emerges in the evolution of ci for selfperceived health status of the russians over the 19 year period however avoidable inequalities in selfperceived health status of the russian population is reduced by almost 60 over the two decades 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 conclusion ses as defined with objective indicators shows little consistency in association with selfperceived health status in the russian federation this study highlights the need for future research that considers the context of stated selfperceived health status in the realm of subjective socioeconomic status sss

in 2016 the world health organization has embarked on a global campaign to combat ageism with the goal of changing the way we think feel and act towards people because of their age four years later due to the covid19 outbreak ageism became ever more prominent in the global discourse specifically two main narratives have become prominent the first is the vulnerability narrative as older adults are at a higher risk for covid19 severe illness and mortality current discourse has portrayed them as a highly homogenous and vulnerable group the burden narrative has flourished as a result of an overwhelmed health care system that cannot provide adequate care to all as a result in some countries an age limit for intensive care treatment or a ventilator machine was established this practice highlights the notion of older adults as a burden to society this study aims to examine how the narratives of vulnerability and the burden of older adults are perceived in the context of the covid19 outbreak by adults in mid to later life we evaluate dying anxiety experiences of ageism and intergenerational and social contact as potential predictors specifically according to the terror management theory one explanation for ageism stems from peoples fear of death and dying as older adults remind us of our own mortality we attempt to distance ourselves from them and might hold more ageist attitudes towards older people to protect ourselves from the discomfort involving frailty and sickness associated with older age hence we expect that individuals with higher dying anxiety might also believe others are distancing themselves from older adults the perceived experience of age discrimination might also contribute to peoples perceptions of societal ageism past research has shown that those individuals who reported exposure to age discrimination also reported worse selfperceptions of aging possibly the experience of discrimination serves as a priming effect to ageist attitudes and might make adults more sensitive to ageist attitudes in other contexts hence we expect age discrimination to be associated with higher perceived ageism in contrast social contact is expected to be associated with lower perceived ageism a recent review found intergenerational contact to be highly effective in reducing peoples ageist attitudes specifically individuals with more intergenerational contact are more likely to report nonageist views that portray older and younger people as belonging to the same community on the other hand the division between young and old people in society is thought to promote ageist attitudes and animosity between the generations social contact with friends and family might also have an ageismreducing effect and lead older adults to perceive society in general as less ageist this study is important as it highlights societal perceptions of older adults during the covid19 outbreak moreover it attempts to identify potential predictors of these perceptions in order to potentially intervene and change the experiences of older adults method participants and procedure data are based on a nationally representative survey of adults aged 50 and above in israel surveys were conducted in hebrew via the telephone data were collected between march 29 and may 3 2020 a period in which israel employed partial lockdown due to the covid19 outbreak the sample was composed of 1092 people the sample for the current study consisted of adults who had full information on all the study variables thus it consisted of 888 participants selectivity analysis showed that participants who did not have full information were older had less years of education were less likely to live with children and less likely to experience discrimination they did not differ in terms of perceptions of bias against older people gender health dying anxiety and social contacts measures perceptions of societal ageism perceptions of ageism during the corona times were measured using two questions participants were asked to rate to what extent they thought that people aged 60 were perceived as a burden or as vulnerable by society following the coronavirus pandemic responses were rated on a scale from 0 to 10 the 60 age was chosen because it represents a highrisk group for serious illness and death of covid19 socialdemographics background information was gathered using age gender and years of education years of education were a continuous variable we recoded scores higher than 30 to missing participants were also asked to define the state of their health with responses ranging from 1 to 5 chronic illnesses were a count of six illnesses diabetes high blood pressure heart problems high cholesterol levels arthritis and cancer dying anxiety the dying anxiety subscale of the death anxiety scale includes six items responses ranged from 1 to 5 cronbachs alpha 89 agebased discrimination in health care we measured experiences of discrimination in the health care system respondents were asked how often they had four discriminatory experiences in the health care system because of their age in a year these options were based on the leavebehind questionnaire of the health and retirement survey we calculated a dummy variable that was 1 if participants reported having any such experience social resources we asked participants with whom they lived responses were divided into living alone living with a partner with children with a partner and children and with someone else we also inquired about the frequency of nonfacetoface contact with noncohabiting family members and with friends since the outbreak of covid19 responses ranged from 1 to 8 data analysis we began out analyses with descriptive data of the study sample we then conducted bivariate analyses of the study variables with the two dependent variables the main stage of analysis was regression models that predicted the dependent variables using the independent study variables results table 1 shows the sample characteristics of the study participants reported relatively high dying anxiety and almost a quarter experienced discrimination due to their age in the health care system more than half lived with a partner and they maintained frequent contact with family and friends during the outbreak participants were less likely to agree that people aged 60 are perceived as a burden by society during the outbreak while they were significantly more likely to agree that those aged 60 are perceived as vulnerable table 1 also shows bivariate associations with the outcome variables individuals who thought that older adults are perceived as a burden were also older had worse health reported higher dying anxiety experienced agebased discrimination in health care were less likely to live with children and had less contact with their family and friends those who thought older adults were perceived as vulnerable were more likely to be women tended to rate their health as worse reported higher dying anxiety and experienced agebased discrimination in health care the main stage of analysis was regressing perceived societal ageism on the independent study variables the first regression model predicted perceptions of adults as a burden older participants were more likely to think that adults are perceived as a burden additional associations were seen with dying anxiety and with experiences of agebased discrimination in health care while lower perceptions of adults as a burden were associated with living with children and contact with noncohabiting family members the next model in table 2 predicted societal perceptions of adults as vulnerable associations emerged with being a woman and with dying anxiety while those who lived with children were less likely to think older adults are perceived as vulnerable while the ageism measures ask about perspective on adults age 60 the sample included adults age 50 this study design allows for comparison of study results among those both under and over the age of 60 to examine these differences we performed additional analyses in which age was dichotomized into two groups the main effect of age remained similar when using age as dichotomous we also examined an interaction of the main study variables with the dichotomous age variable the only significant interaction was of discrimination in relation to perceptions of adults as vulnerableonly respondents aged 60 who experienced discrimination thought adults were perceived as vulnerable while no such association was seen among those aged 5059 discussion the current study set out to examine older adults perceptions of societal ageism during the covid19 outbreak it examined two aspects of societal perceptionsolder adults as a burden and as vulnerable ageist stereotypes can become internalized and become a selffulfilling prophecy thus it is necessary to understand how adults think society views older people the findings indicate that adults are less likely to believe society sees older adults as a burden and more likely to believe they are seen as vulnerable these perceptions are influenced by their daily lives and personal characteristics risk factors for perceived societal ageism were higher dying anxiety and agebased discrimination in health care in accordance with the terror management theory fear of dying can further make adults feel alienated from society additionally encountering ageism in health care settings might provide adults with evidence that such ageist perceptions are prevalent in society in the times of the covid19 pandemic particularly if these adults are aged 60 social resources emerged as protective in particular living with children and maintaining contact with family members during the covid19 outbreak intergenerational contact with children and social contact with family members could serve as evidence that adults are not negatively perceived by others contact with children could be especially important in this regard due to the relevance of intergenerational contact to reducing ageist attitudes in society this study has several strengths especially its large representative sample collected at the height of the covid19 pandemic in israel we note a possible limitation concerning the items about societal ageist biases while we interpret them as representing the perceptions that older adults have of society they might also assess these adults own ageist attitudes that is the way people perceive societal views might partially reflect their own views additionally we note that in israel triage was not based on chronological age thus findings might be different in countries such as italy that had chronological age as a criterion for triage to sum the current investigation showed that during the covid19 pandemic older adults perceived society as more ageist if they encountered ageism and feared dying while maintaining intergenerational and familial contacts protected them from such perceptions these findings indicate that the way older adults perceive societal ageism is related to their own interpersonal experiences they provide impetus to improve the daily experiences of older adults and reduce their fear of dying especially in the current times of the covid19 pandemic policy stakeholders should be aware of the prominent role that perceptions of vulnerability and burden have in the lives of middle aged and older adults during the current pandemic as such the entire discourse concerning covid19 should be modified to ensure that it does not spread ageist perceptions further efforts should aim to enhance intergenerational contact due to the beneficial psychological effects of such contacts to intergenerational solidarity and cohesion conflict of interest none reported

objectives to examine the factors associated with older adults perceptions of ageism in society during the covid19 outbreak in particular the portrayal of older people as a burden and as vulnerable method data are based on a nationally representative survey of adults aged 50 in israel conducted during the covid19 outbreak n 888 regression models predicted perceptions of societal ageism the independent variables were dying anxiety experiences of agebased discriminations and social resources results participants who believed older adults were perceived as a burden during the covid19 outbreak had higher dying anxiety and reported more agebased discrimination living with children and contact with family were protective against perceptions of adults as a burden participants who believed older adults were perceived as vulnerable had higher dying anxiety and were less likely to live with children discussion the daily lives of older adults can impact their perceptions of societal ageism during the covid19 outbreak

introduction bisexual individuals face significant and unique health disparities in both physical and mental health compared to heterosexual lesbian and gay individuals compared to heterosexuals bisexuals have the most adverse physical health outcomes among sexual minority groups bisexuals are at greater risk than heterosexuals for depression obesity and impairments in functioning due to pain similarly compared to heterosexual women bisexual women are more likely to report back problems chronic fatigue syndrome and digestive complaints disparities in health have been explained by increased stress and discrimination that bisexual individuals experience however more research is needed to understand how bisexual individuals experience and cope with discrimination and how it affects their health this study aimed to examine how bisexual individuals experience discrimination how they perceive discrimination to affect their health and coping mechanisms utilized when discrimination is experienced definitions of bisexuality have varied greatly in research while some definitions require selfidentification as bisexual in their criteria bisexuality can also be defined based on other dimensions including attractions to more than one gender or having sexual partners of more than one sexgender individuals stated sexual orientation identities are sometimes different from their attractions and partners bisexual individuals can differ in their own definitions of bisexuality as well as vary in how they define themselves to others sometimes using multiple sexual orientation labels a survey of participants at one bisexual conference indicated that over half of attendees identified as both queer and bisexual the participants in the current study included both selfidentified bisexual individuals and other nonmonosexual individuals who reported attraction to more than one gender participants indicated a range of nonmonosexual identities including pansexual and queer however the majority of participants identified as bisexual previous research has examined bisexual issues utilizing broader samples that included both bisexuals and nonmonosexuals consistent with prior work we utilize the term bisexual throughout the paper as an umbrella term inclusive of other nonmonosexual identities to refer to the entire sample the findings we report are relevant to both bisexual and other nonmonosexual individuals previous research has evidenced that bisexual individuals may be at greater risk for victimization and discrimination experiences for example adolescent girls with sex partners of multiple genders were nearly twice as likely to be physically attacked as those with partners of only one gender beyond sexual minority subgroup differences in rates of victimization evidence suggests that bisexuals experience unique discrimination due to bisexuality that is different from gaylesbian individuals bisexuals experience binegativity or antibisexual prejudice from both heterosexuals and lesbian and gay individuals as well as the lgbtq community more broadly research on attitudes toward bisexual individuals shows that heterosexual and lesbian and gay individuals hold negative attitudes toward bisexuals binegativity includes the belief that bisexuals are confused about their sexuality or that bisexuality does not actually exist concern that bisexual individuals are promiscuous and the belief that bisexual individuals do not make trustworthy partners for instance heterosexual lesbian and gay individuals are less likely than bisexual individuals to have romantic or sexual relationships with bisexual partners than were bisexual individuals this body of research indicates strong evidence of stigmatization of bisexuality by monosexuals sexual minorities increased burden for poor health can often be linked to the stress of experiencing discrimination otherwise known as sexual minority stress minority stress theory proposes that oppressed minorities experience prejudice and discrimination related to their stigmatized identity which in turn negatively affects their health in part via a psychological stress response pathway sexual minority stress is associated with physical and mental health problems among bisexual individuals experiences of bisexual discrimination such as physical and sexual victimization related to stigma associated with bisexuality may cause bisexualspecific minority stress culminating in adverse health outcomes previous research has indicated that greater bisexualspecific minority stress is significantly associated with poorer overall physical health greater pain and poorer general health among bisexual adults beyond the effects of sexual minority stress alone and that bisexualspecific minority stress is associated with more psychological distress and suicidality among bisexuals research also indicates that microaggressions brief daily verbal behavioral or environmental indignities that communicate hostile or derogatory slights toward members of oppressed groups may act as a source of discrimination that impacts bisexuals health however there is limited research examining the lived experience and impact of discrimination on health for bisexual individuals several studies have examined coping strategies used by members of stigmatized populations in response to discrimination some coping mechanisms like utilization of mental health counseling may be positive and strengthen individuals resilience to discrimination whereas other coping mechanisms such as substance misuse may be detrimental to health and render individuals more vulnerable to the development of psychiatric disorders or poorer physical health although some behavioral coping strategies utilized by sexual minorities to combat discriminatory experiences have been identified research has not yet examined how bisexual individuals cope with discrimination by analyzing the openended responses of bisexual adults the current study the aim of the current study was to examine and elucidate discrimination experienced by bisexual individuals examine how bisexual individuals cope with discrimination and examine how discrimination affects their health to address these aims data were analyzed from openended responses on a survey of bisexual cisgender and transgendernonbinary adults method participants participants were 442 bisexual and other nonmonosexual adults age 18 to 68 years the sample was primarily white and 660 of participants had a college degree or higher 38 of the sample were students and 570 were low income the participants primarily identified as bisexual participants who did not identify as bisexual reported attraction to multiple genders other participant demographic information is presented in table 1 researchers the authors of this study represented a diversity of perspectives related to holding differing social positions and identities the life experiences stemming from these positions informed this work the researchers identities are described to better position themselves in relation to this study doan van is a biracial heterosexual cisgender female graduate student in public health and social and behavioral research science mereish is an ethnic minority queer cisgender male assistant professor trained in psychology and lgbtq health woulfe is a white queer cisgender female counseling psychologist with expertise in ptsd the intersection between interpersonal violence and marginalized identity and lgbtq health katzwise is a white queer bisexual cisgender female assistant professor trained in developmental psychology gender and womens studies and social epidemiology with expertise in lgbtq health procedure participants were recruited online by contacting sexual minority and bisexualspecific online groups and mailing lists inclusion criteria were age 18 years or older and identifying as bisexual or having attractions to more than one gender all potential participants received a link to the data collection website where they provided informed consent completed the online survey and were given the option to enter into a raffle to win one of five 25 prizes upon completion of the survey participants were provided with a list of online resources providing sexual minorityspecific mental health support and services the survey hosting platform was qualtrics the study was approved by the boston college institutional review board measures among other measures reported elsewhere participants were asked three openended questions at the end of the survey what are your experiences with discrimination what helps you cope with these experiences with discrimination how does discriminationoppression affect your health sociodemographic characteristics multiple dimensions of sexual orientation were assessed including sexual orientation identity and sexual attractions assigned sex at birth was not assessed gender identity was assessed with the following response options maleman femalewoman transgender and other some participants selected other and indicated that they are nonbinary participants age raceethnicity education employment annual individual income and geographical region were also assessed analytic method openended responses to survey questions were analyzed by doan van and katzwise prior to beginning coding procedures the coders discussed and documented their biases and assumptions then an immersioncrystallization approach was used to begin the analytic process this approach involves immersing oneself in the data by reading and rereading the text while remaining open to new knowledge emerging from the data then a subset of 25 participant responses was randomly selected and an initial codebook was developed by doan van using a template organizing style approach the codebook then underwent a review process with katzwise in which codes and code definitions were revised and clarified following this the coders separately completed initial coding of the 25 participant responses then met and came to consensus during which any discrepancies in the coding were discussed and resolved and the codebook was further revised as needed coding and analysis of all subsequent responses was completed by doan van using the mixedmethods program dedoose for data management and overseen by katzwise with weekly meetings to discuss issues that might have arisen during the coding process and further refine the codebook new codes that emerged throughout the coding process were added to the codebook and applied to previously coded participant responses codes were grouped into three main categories based on the survey questions perceived discrimination coping with discrimination and perceived effects of discrimination on health themes were developed within each category and representative quotations were chosen to illustrate each theme finally we examined social identity differences particularly for multiple marginalized identities in individuals experiences of discrimination coping and health outcomes in order to do this code occurrence was examined by gender raceethnicity educational attainment and income codes that demonstrated the most salient differences within and between these categories were selected and are presented in table 3 and in the differences by gender raceethnicity educational attainment and income section in the results results analysis of study participants openended responses to the survey questions resulted in 73 total codes and subcodes which are listed in table 2 with the number of times each code was utilized although the code counts presented in table 2 represent the number of participants whose responses were coded using a given code the findings are not meant to be interpreted as true statistics of bisexuals experiences with discrimination coping mechanisms or health effects rather the code counts indicate which experiences may be more salient in this sample frequently expressed codes were grouped together to form themes which are presented below table 3 presents occurrence of selected codes by gender these and code occurrence by raceethnicity and socioeconomic status for selected codes are described in the differences by gender raceethnicity educational attainment and income section codes were chosen based on which codes demonstrated the most salient differences proportionally between identity groups therefore table 3 does not represent all codes utilized in the study perceived discrimination the survey questions did not specify that participants describe discrimination associated specifically with being bisexual therefore discrimination described by participants does not exclusively reflect bisexualspecific discrimination but rather any discrimination experienced among this sample of bisexual adults within the perceived discrimination category codes were further divided into the following subcategories source of discrimination type of discrimination discrimination of an identity other than bisexual and protective factors from discrimination the most common codes identified for sources of discrimination were gay andor lesbian individuals or communities heterosexual individuals and family the most common codes identified for types of discrimination were identity invalidation identity invisibility verbal abuse and stereotyping participants also mentioned experiencing discrimination related to other identity constructs including gender raceethnicity body type gender identity gender expression and disability the most frequently mentioned protective factors from discrimination were concealment of bisexual identity the location within which the participant lived and the participants ability to pass as straight within the perceived discrimination category three themes emerged double discrimination of bisexuals by heterosexuals and lg individuals bisexual identity invalidation and erasure and sexual victimization double discrimination of bisexuals by heterosexual and lg individuals participants in our study reported experiencing discrimination from both heterosexual and lg individuals and communities and the type of discrimination was often distinct depending on whether the source was heterosexual or lg participants reported lg individuals and community as a source of discrimination more often than they reported heterosexuals as a source of discrimination participants who described double discrimination expressed the emotional toll of being discriminated against by both groups and not being accepted or considered to have a valid sexual orientation by either group the following quote illustrates an experience of double discrimination as a bisexual individual it is difficult to find a community that will accept you you are viewed as gay by the majority of the heterosexual community and yet not accepted within much of the gaylesbian community due to the fact that you arent actuall y gay people dont view bisexuality as something legitimate and its a distressing reality to face furthermore results demonstrated that the discrimination experienced from each group can be distinct the code for discrimination from lg individuals often cooccurred with the codes for both exclusion and discrimination by a potential romantic or sexual partner indeed a recurring experience described by participants was being excluded from lgbtq community events support groups and spaces because of their bisexual identity participants also often described being rejected by gay or lesbian potential romantic partners when their bisexual identity was known often being told they were tainted likely to cheat in a relationship or just experimenting as one person described to lg people i have always been treated as an experimenting straight person that bi is not a real identity just a phase young women go through i was treated as dirty or tainted by some lesbians for having had sex with men conversely the code for discrimination from heterosexual individuals often cooccurred with the code for sexual harassment participants expressed being sexually harassed by heterosexual individuals when they disclosed their sexual orientation including being asked to engage in sexual acts they were not comfortable with and to describe their relationships with samegender partners for the heterosexual individuals sexual pleasure bisexual identity invalidation and erasuremany participants mentioned experiencing their sexual orientation as being denied and treated as illegitimate or ignored and forgotten altogether both codes describing discrimination from lg individuals and discrimination from heterosexual individuals often cooccurred with the codes for identity invalidation and identity invisibility sometimes for participants this meant less outright or direct discrimination and more isolation and lack of acknowledgement from queer communities and society as a whole one participant wondered maybe the reason i rarely experience discrimination is because people dont realize i exist participants also described difficulty coming to terms with their own sexuality because they had been told bisexuality was not real or because it was mentioned so little that they questioned whether bisexuality existed many participants also described being treated with hostility or excluded based on their sexual orientation by both heterosexual and lg groups participants described being treated this way by lg groups because they were not considered a legitimate part of the same community and by heterosexual groups because they were sexually deviant and faking being gay participants described being told by both heterosexuals and lg individuals that bisexuality was not a true sexual orientation but rather that bisexuals were truly gay but afraid of coming out or really heterosexual but wanting to experiment as a bisexual woman i am discounted as a straight male fantasy instead of a legitimate orientation the men i have dated have either felt threatened or have thought that my orientation was not serious the women i have dated feared i would choose to fall into the easy straight path when choosing a longterm life partner i feel like the straight people i know either think i am an oversexed greedy promiscuous person or that i am faking attraction to women one participant described how exclusion and invalidation by lgbtq communities was particularly upsetting ive often been alternately ignored erased and marginalized as a lesser member of the online lgbt community online … this is much more depressing than the tootypical biphobic ideas within the community … im used to those ideas but to be discriminated against by what is allegedly my own community is truly painful sexual victimizationparticipants reported experiencing sexual victimization including sexual harassment sexual violence and hypersexualization or being stereotyped as hypersexual participants described being sexually objectified and stereotyped as being more promiscuous and sexually deviant because of their sexual orientation participants also described experiencing sexual harassment and sexual violence including assault and rape and felt the behavior was directed at them because they were bisexual one participant stated ive had straight women sexually harass me because being bisexual to them means that i no longer need give consent the following quote illustrates another example of one participants experience of sexual victimization straight men would either refuse to date me … or would try to take advantage of me sexually or get me to do really out there things sexually because they thought thats what a bi woman deserves … people act like just because im bi ill automatically cheat or that i couldnt possibly want a monogamous relationship … i truly believe the worst discrimination i have experienced though were some very bad sexual encounters with men that i think only happened because they thought they could get away with it because im bi i think a lot of men treat bi women as less than human as sex toys to toss around and use however they want participants recognized an association between the stereotype that bisexual individuals are sexually promiscuous deviant and untrustworthy and the sexual victimization they experienced this stereotyping not only contributed to rejection by sexual partners but to targeting and abuse as well one participant described how hypersexualization of bisexuals contributed to her experience with sexual assault and harassment i feel i am targeted for sexual assault and sexually inappropriate behavior because i am openly bisexualqueer people think im slutty or up for anything including inappropriate and nonconsensual sexual approaches others treat me as if i probably hav e stds another participant described how stereotypes of sexual promiscuity were related to sexual abuse by her partner and furthermore described how hypersexualization of bisexuals was even present in healthcare affecting how her doctor perceived her experiences with rape i was raped by a former significant other who was angry at my imagined cheating with other women in his own words he was going to fix me because all i needed was the right man to turn me straight it took me awhile to realize that this was not only rape but rape as a hate crime i didnt discover until years later that socalled corrective rape was a real thing that happens far too often there was nobody to tell me a local doctor helpfully informed me that it wasnt really rape since i previously consented to sex with the man he also bluntly stated that as a bisexual a high libido and then he implied that it wasnt rape because i must have enjoyed it coping with discrimination the coping with discrimination category was not further divided into subcategories three themes emerged from this category social support resilience and identityspecific media consumption the most common codes utilized for mechanisms of coping with discrimination were those describing social support other coping mechanisms commonly expressed by participants included relying on their sense of self and identityspecific media consumption social supportsocial support was often mentioned by participants as a means of coping and often came from friends family and partners significantly participants also mentioned the need to find support through other individuals who had similar experiences such as social support from lgbtq and bisexual individuals or communities as one participant explained having people who share and understand my experiences is very important participants also expressed that it was important to receive social support from individuals with whom they shared multiple identities which fostered greater mutual understanding such as specifically seeking out queer people of color social support was helpful to participants in coping with the negative emotional impact of discrimination as well as in providing them with knowledge regarding discrimination ways to manage experiences of discrimination and ways to cope in potentially discriminatory settings the following participants response exemplifies how bisexual adults utilized social support to cope with discrimination i have coped really well by getting involved with an active bi community in city of residence the bi community in city of residence has peerfacilitated support groups which i attend and its really helped with coping in both queer and heterosexual spaces resiliencemany participants expressed relying on a strong sense of self or high selfesteem to overcome or ignore their experiences with discrimination indicating resilience in the face of experiences of discrimination while individuals who indicated a strong sense of self were not immune to experiencing discrimination many were able to find strength or pride in the aspect of their identity that was oppressed participants also expressed certainty of their selfworth that made it easier to brush off discrimination aimed at them one participant stated that they were able to cope through the knowledge that i am worth something and that i am right in knowing my orientation the following quote exemplifies sense of self as a coping mechanism i love being bisexual and i love the bisexual community im proud to be bi so when people exclude me because of my sexual orientation it doesnt particularly bother me identityspecific media consumptionparticipants frequently mentioned coping through utilizing media that featured bisexual and queer characters such as reading accounts of the experiences of other individuals that were similar to them one participant explained how consuming identityspecific media helped her cope with discrimination if im feeling particularly upset i usually seek out happy media portrayals of bisexual or homosexual people to make myself feel better and remind me that it gets better other participants coped with discrimination by reading and learning about bisexuality discrimination and other facets of their identities in academic literature as expressed by the following quote i think studying gender and sexuality scholarship helps me articulate why and how these instances are harmful not just to my own wellbeing but also more importantly within the context of larger social justice issues reading makes me feel as if the perpetrators of such discrimination i face are misinformed or idiotic to the point of amorality so that helps while some participants mentioned seeking out bisexual representation in media specifically as a means to cope others mentioned queer representation or lgbtq representation in media more broadly as a source that enabled them to cope with discrimination perceived effects of discrimination on health within perceived effects of discrimination on health codes were further divided into the following subcategories perceived negative health effects and barriers to health and healthcare the most prominent codes in perceived negative health effects were anxiety emotional distress and depression the most common moderating factors were related to experiences with healthcare including relationships with healthcare providers healthcare access and avoiding healthcare not all participants attributed a direct causal relationship between experiencing discrimination and adverse health outcomes rather perceived adverse health outcomes or effects on their health were described by participants to be either due to experienced discrimination or exacerbated by discrimination within the findings on perceived negative health effects three themes emerged impact on mental health impact on physical health and effects of discrimination in healthcare as the first two themes tended to intersect they are described first separately and then together impact on mental healthmental health of participants was negatively impacted by discrimination in the following ways exacerbation and triggering of anxiety including panic attacks and ptsd emotional distress depression and stress participants described that their mental health was negatively affected as a direct result of experiencing discrimination as well as due to anticipating experiencing discrimination one participant described how anticipating discrimination exacerbated her anxiety i struggle with anxiety and the fact that i know im not really a part of the community at large makes that a lot harder it can be exceptionally difficult to convince yourself that no one is actually judging you while you shop for groceries when youve had proof that people do think quite awful things about me because of who i am participants did not always state that negative mental health outcomes were directly caused by discrimination but that experiencing discrimination was indirectly related to their mental health for example one participant stated that the majority of their mental health struggles were triggered after coming out as queer rather than related specifically to experiences of discrimination ive been diagnosed with a variety of mental illnesses and some of them may or may not have occurred regardless of me being queer and facing discrimination for it but i feel that most of them are related in some way to being oppressed i didnt contemplate suicide until i realized i was queer i didnt selfharm until i realized i was queer i didnt misuse drugs or alcohol until i realized i as queer i didnt feel angry and depressed almost every single day until i realized i was queer when i hear voices they often tell me that i am worthless because i am queer and call me homophobic slurs which is fairly obviously related to my internalized feelings in response to discrimination impact on physical healthnegative impacts on physical health were also mentioned by participants including chronic pain exacerbation of chronic disease nausea and causation of disability some individuals attributed their physical health outcomes directly to the discrimination they experienced one participant expressed in a world without oppression against the groups i belong to i dont think id have been disabled i became chronically ill as a more or less direct result of these things another described how experiencing structural discrimination due to sexual orientation led to adverse health outcomes i cant afford decent food or healthcare because no one in my area hires someone suspected to be a dyke or fag so that tends to put a tremendous strain on my physical health i cant see a doctor so i am going without thyroid medication which affects my entire health and im experiencing permanent nerve damage due to lack of b12 injections for my pernicious anemia the intersection of impacts on mental and physical healthother participants stated that their experiences with discrimination affected their mental health which then impacted their physical health one participant described how experiencing discrimination impacted their mental health by increasing stress which then exacerbated their fibromyalgia i have fibromyalgia and bipolar depression both of which are strongly impacted by stress i have to modulate my experiences with discrimination or oppression to keep my stress levels as low as possible on a practical level this means avoiding news item facebook postings etc that are upsetting several participants posited a potential pathway whereby experienced discrimination led to an increase in stress which led to poorer sleep which worsened physical health and exacerbated existing physical health problems the following quote illustrates this pathway i believe it primarily affects my mental health which can in turn affect my physical health effect of discrimination in healthcaremany participants described how experiences with discrimination in healthcare affected their health and acted as a barrier to their ability to be healthy discrimination in healthcare impacted access and quality of healthcare individuals relationships with their healthcare provider and their willingness to avoid seeking healthcare a participant expressed health care workers have been the worst i have been stereotyped judged given inadequate or inappropriate care and subjected to invasive and unnecessary sexual health exams another participant stated that past discrimination had impacted her willingness to seek care often doctors or nurses or therapists treat my sexual orientation in a negative way which makes me reluctant to seek professional help for health issues participants also described withholding information regarding their sexuality from their healthcare providers in order to avoid discrimination even if the information seemed relevant to their health or treatment participants described how discrimination and implicit bias from healthcare providers negatively affected their health and healthcare a participant explained how disclosing her sexual orientation negatively impacted her ability to receive the treatment she was seeking i have had a straight doctor give me a hard time about my identity when i was in the hospital experiencing severe acute illness i have had therapists at an lgbt clinic attempt to redirect the focus from the depression i was seeking help for to an imposed narrative where they thought i was there to come out as a lesbian one participant described their fear of discrimination from health care professionals due to their intersecting identities as bisexual and nonbinary transgender and explained how this prevented them from disclosing their identity to their doctor discrimination within the health field is a huge issue for my life im so terrified to tell my doctors i am trans … because i cant risk my life and basic safety by being refused care … i dont have transportation that can take me far enough to see a psychologist who i can get recommendations from others for vouching that they wont treat me like shit because im queer and nonbinary trans … my life has been endangered before by doctors failing to give me proper treatment telling them im queer and trans has to be at the bottom of my to do list for my own basic safety differences by gender raceethnicity educational attainment and income when examining the occurrence of discrimination codes by gender group discrimination was not uniformly found across gender groups for instance the microaggression code which was frequently mentioned by participants in this study was expressed more often by cisgender women and transgendernonbinary participants than by cisgender men some participants described how having several stigmatized identities could amplify or result in more frequently experienced microaggressions one participant explained how microaggressions experienced at the intersections of their identities negatively impacted their health i have bipolar disorder ocd and ptsd and oppression related to bisexuality gender issues my being intersex poly on disability fatits a long list that easily triggers my ptsd and depression and intrusive thoughts its very hard to maintain positivity fighting my illnesses while faced with constant microaggressions for multiple identities cisgender women and transgendernonbinary participants also expressed the following types of discrimination more often than cisgender men discrimination in healthcare physical threats sexual harassment and sexual violence however cisgender men expressed experiencing potential partner rejection and physical assault more often than did other gender groups cisgender men were also more likely than other gender groups to report experiencing no discrimination as well as not experiencing an effect of discrimination on health in comparison transgendernonbinary participants expressed experiencing microaggressions discrimination in healthcare physical threats physical assault sexual harassment and sexual violence more frequently than any other gender group when examining raceethnicity groups in the study participants of color experienced discrimination in healthcare more frequently than white participants of those that mentioned discrimination in health care 28 were biracial 45 were black and 16 were latinx whereas only 11 were white participants often expressed that they experienced discrimination not only based on their sexuality but also based on other stigmatized aspects of their social identities the following participants described how their ethnicity skin tone gender and sexual orientation all impacted their experiences with discrimination i have had many experiences equally because of my queerbisexual identity and my identity as a brown person or chicano i have been beat up called names and harassed i feel like ive experienced a great amount of discrimination in my life due to the different identities that i hold i am a brown biracial queer female so i am considered different in many situations other participants expressed that privilege held due to raceethnicity social class gender expression and ability buffered their experiences with discrimination and served as a protective factor from discrimination as a white upper middle class ablebodied femme working for an lgbtq organization i have a great deal of privilege that insulates me from discrimination… differences in coping mechanisms were also seen across different identity groups cisgender men expressed relying on a strong sense of self to cope with discrimination more so than other gender groups of those that expressed the sense of self code 40 were cisgender men 43 had a graduate degree or higher educational achievement and 41 earned 70000 or more per year discussion the aim of this research was to examine how bisexual adults experience discrimination which coping mechanisms bisexual individuals employ to cope with perceived discrimination and how they perceive discrimination to affect their health a secondary aim was to assess how discrimination adverse health effects and coping might occur at the intersections of different identities findings provide an understanding of bisexual individuals experiences with discrimination in their own voices and lived experiences double discrimination findings from this study strengthen existing literature on antibisexual prejudice previous literature has documented that bisexuals experience discrimination from both heterosexual and lg individuals resulting in double discrimination our study expands upon these findings interestingly lg individuals and community was mentioned as a source of discrimination more often than heterosexual individuals in the current study it is possible that this difference was found because participants felt it necessary to specify discrimination coming from lg individuals whereas discrimination from heterosexuals was considered default and thus not worth mentioning however the sheer number of responses mentioning both lg and heterosexuals as a source of discrimination demonstrates that bisexuals do in fact experience discrimination from both groups based on the differing cooccurrences of codes with lg and heterosexual groups as sources of discrimination this finding also lends credence to literature that states that the types of bisexualspecific discrimination can differ based on the source of discrimination bisexual identity invalidation and erasure some of the most prominent codes indicating types of discrimination were identity invalidation invisibility and exclusion which are consistent with prior literature on biphobic prejudice current study findings show that bisexuality was often not considered a valid sexual orientation by either heterosexuals or lg individuals and that lg communities often did not consider bisexuality to have a legitimate place in the queer community moreover participants in this study expressed experiencing bisexual invisibility by being assumed to be monosexual or omission of bisexuality in queer communities and discussions surrounding sexual minorities exclusion was experienced by bisexuals from both heterosexual and lg individuals furthermore bisexual adults in this study described not feeling able to come out as bisexual because they felt intense pressure to choose a sexual orientation that was monosexual and sometimes did not even know that bisexuality was real this calls into question in which spaces bisexuals can feel safe and accepted these findings are consistent with quantitative work showing that experiences of antibisexual prejudice and identity concealment are associated with increased loneliness and in turn poor mental health additional research is needed to understand the health impacts of bisexual invalidation and erasure particularly as they affect mental health sexual victimization the emergence of sexual victimization as a theme in the current study is also particularly telling considering previous research documenting high rates of sexual violence among bisexual individuals in particular bisexual women experience significantly higher rates of sexual victimization compared to heterosexual and lesbian women while some studies have found that bisexuals experience greater victimization than lesbians and gay men other studies have found the opposite pattern a largescale study examining hate crimes against lesbian gay and bisexual adults in sacramento california found that bisexual men and women reported experiencing sexual assault based on their sexual orientation at greater rates than gay and lesbian participants participants in the current study described feeling targeted for sexual violence due to their sexual orientation and some described suffering sexual assault by perpetrators who felt that because they were bisexual they deserved violence or their sexual orientation was a deviance that could be fixed by acts of sexual violence many participants in the current study described being sexually harassed because they were hypersexualized perceived as sex objects and stereotyped as highly sexually promiscuous previous qualitative literature has also found that bisexuals report being hypersexualized based on their sexual orientation participant responses indicate a possible pathway between hypersexualization of bisexuals and sexual victimization whereby hypersexualization of bisexuals promotes sexual harassment and sexual violence against bisexuals and perhaps justifies the behavior to perpetrators furthermore findings from the current study indicate that hypersexualization of bisexuals may even impact health care professionals perceptions of bisexuals affecting the quality of care bisexual adults receive when pursuing medical care after experiencing sexual violence this indicates the danger of promoting stereotypes regarding bisexual individuals and of sexualizing them as this may be one of the ways that higher rates of sexual violence among bisexual adults is fostered the findings also speak to the impact of bias in healthcare regarding bisexuals and how this may affect bisexuals ability to receive proper health care and support after experiencing sexual violence microaggressions the number of participants who mentioned experiences of microaggressions also necessitates discussion although microaggressions can be unintentional and not perceived as discriminatory or impactful by perpetrators research demonstrates that microaggressions nonetheless can have negative impacts on the targets mental health it is also meaningful that microaggressions were expressed more often by cisgender women and transgendernonbinary participants than by cisgender men in the current study considering that minority stress theory emphasizes the cumulative effects of minority stress it is likely that individuals experiencing microaggressions due to several oppressed identities may be experiencing microaggressions at a greater magnitude and this in turn may make them more vulnerable to the negative health impacts of minority stress and discrimination coping with discrimination social support was one of the most commonly mentioned coping mechanisms among participants indicating its importance in bisexual adults ability to cope with discrimination participants emphasis on social support from the lgbtq community as well as from the bisexual community specifically suggests that social support resources geared toward lgbtq individuals generally may not address the unique social support needs of bisexual adults social support services geared specifically toward bisexuals may be a vital resource for bisexuals to cope with discrimination however social support services should also account for other aspects of bisexual individuals identities participants who mentioned seeking out social support from others who understood them often spoke of this in relation to experiencing not only bisexual discrimination but also discrimination based on race ethnicity gender identity and other social identities assuming a onesizefitsall approach to social support for bisexual individuals may not be effective the finding that many individuals utilized a strong sense of self as a coping mechanism suggests resilience in these individuals that allowed them to cope more easily with discrimination the findings also indicate that fostering higher selfesteem in bisexual individuals may help them cope with discrimination based on the findings regarding identityspecific media consumption it is possible that these types of media can serve as a resource that encourages higher selfesteem and mitigates feelings of isolation and invisibility the expressed desire and helpfulness of these identityspecific resources implies the importance of representation of bisexual and queer characters in media and production of bisexualspecific research effects of discrimination on health findings from the current study show that bisexual adults perceive discrimination to negatively affect their mental and physical health these results are consistent with prior quantitative research documenting the negative effects of bisexualspecific discrimination on health not only did some participants in the current study perceive their physical health to be directly impacted by discrimination they also perceived a connection between mental health and physical health as supported by prior research bisexual health disparities may be associated with bisexual discrimination from medical providers and reduced access to bisexual health resources but most research has examined discrimination and healthcare against lgbtq individuals more broadly findings from the current study indicated that participants experienced discrimination in healthcare via diminished access as well as biased and discriminatory treatment from healthcare providers these accounts and the fact that some participants even feared experiencing discrimination so much that they actively avoided seeking healthcare is indicative of how discrimination can directly impact health and drive health disparities among bisexual adults findings from the current study indicating that discrimination in healthcare was mentioned most frequently by black participants and transgendernonbinary participants demonstrates that even within bisexual adults as a group additional health disparities may exist depending on an individuals other intersecting identities intersectional implications the intersections of sexual orientation with raceethnicity gender socioeconomic status and other facets of identity were apparent throughout this study intersectionality theory emphasizes the way multiple social identities intersect in order to construct individuals experiences while accounting for systems of oppression and privilege by extension an intersectional lens would observe how bisexual individuals experiences with discrimination are affected and shaped by the intersections of their social identities while intersectionality theory emphasizes that the interaction of multiple identities is not a simple additive process previous research has demonstrated how an additive approach to data analysis can be utilized in order to examine sexual minority discrimination intersectionally our findings demonstrate that bisexual individuals do not experience discrimination isolated purely to their bisexual identities but rather their multiple identities compound the ways in which discrimination impacts their lives the amount severity type and source of discrimination varied among participants largely because bisexual individuals did not experience discrimination based on sexual orientation alone as such their experiences with discrimination differed and even affected whether they experienced discrimination at all and whether discrimination affected their health in the current study cisgender men made up a large proportion of those who expressed a strong sense of self reported never experiencing discrimination and reported that discrimination had no effect on their health in comparison transgendernonbinary participants were least likely to express no discrimination and no effect of discrimination their health furthermore a greater proportion of individuals who expressed utilizing a strong sense of self to cope had a higher income and greater educational attainment thus other identity constructs may influence bisexual adults experiences with discrimination their ability to cope with them and the ways in which discrimination impacts their health this has been observed in previous quantitative research in which transgender individuals were found to be at greatest risk for experiencing bisexualspecific minority stress and sexual minority stress compared to cisgender women and men indicating that bisexual transgender individuals may experience additional prejudice for their gender identity alongside prejudice targeted at their sexual orientation the current studys findings provide more detail on the lived experiences of bisexual individuals experiences with discrimination and how their intersecting identities affect their risk of discrimination and minority stress the findings demonstrate that prejudices like sexism racism and transphobia can intersect with antibisexual prejudice to make certain individuals more vulnerable to the impacts of discrimination on health and others more resilient further they demonstrate the possibility of an additive effect of multiple social identities on the experience and effects of discrimination on bisexual individuals altogether the results provide a basis for the importance of future research that utilizes an intersectional framework to understand how discrimination impacts bisexual health more research utilizing an intersectional framework is needed on bisexual health and discrimination that accounts for other facets of identity outside of sexual orientation study strengths and limitations study strengths should be considered alongside limitations the sampling strategy utilized reaching out to lgbtqspecific electronic mailing lists this strategy may have resulted in more participants in the sample who identified as bisexual than participants who did not identify as such but still had attractions to more than one gender however we did have participants in the current sample who fell into the latter category the choice to recruit participants online may also have contributed to a less racially and ethnically diverse sample although it may have allowed for a wider geographic reach additionally the sample although large was predominantly made up of cisgender women this limited our ability to meaningfully examine transgender women transgender men and nonbinary individuals separately in our gender analyses due to their small proportion in the sample we recognize that the individuals in these groups likely have distinct and unique experiences of bisexual discrimination and encourage future research to disaggregate these groups in their analyses future research could oversample cisgender men and transgendernonbinary participants to enable further comparisons across gender groups we also did not examine whether findings differed between participants who identified as bisexual vs participants who used other nonmonosexual identities another potential limitation of this study is that the survey question assessing experiences with discrimination did not explicitly assess bisexualspecific discrimination or ask for specification as to the perceived motive behind the discrimination experienced although the inclusion of discrimination of all kinds allowed us to more comprehensively examine the way discrimination is experienced by bisexual adults the lack of specificity did not allow us to always be explicit about to which aspect of the individuals identity the discrimination could be attributed conclusions many of the findings in the current study align with prior research related to bisexualspecific discrimination and health as well as add to the extant quantitative research with respect to how discrimination is experienced and embodied among bisexual adults this includes our findings on double discrimination bisexual invalidation and erasure microaggressions and adverse effects on mental and physical health many of our findings were also novel including sexual victimization as a significant form of bisexual discrimination and bisexual discrimination in healthcare our findings on social support and identityspecific media as important coping mechanisms also provide important insight into coping resources for bisexual adults that have been infrequently addressed in previous research these findings could serve to increase awareness regarding the unique and significant discrimination bisexuals experience elucidate the health risks facing bisexual individuals that are impacted by discrimination as well as identify specific areas of intervention that can help bisexuals cope with discrimination and its effects finally our conceptualization of the impact of multiple social identities on how bisexual and other nonmonosexual individuals experience discrimination provides evidence to support future research using an intersectional approach to understanding bisexual discrimination

bisexual individuals experience unique discrimination related to their sexual orientation which may increase their risk for adverse health outcomes the study goal was to investigate how bisexual and other nonmonosexual individuals experience discrimination understand how they perceive discrimination to affect their health and examine the ways in which they cope with discrimination by analyzing responses to openended survey questions the sample included 442 bisexual and other nonmonosexual adults ages 1868 years m 2897 sd 1030 who either reported a bisexual identity or reported attractions to more than one gender gender identities included women n 347 men n 42 and transgendernonbinary individuals n 53 29 of participants were currently located outside of the united states participants completed an online survey including three openended questions regarding their experiences with discrimination how discrimination affects their health and methods used to cope with discrimination themes related to perceived discrimination included double discrimination of bisexuals and other nonmonosexual by heterosexuals lesbian and gay individuals bisexual invalidation and erasure and sexual victimization themes related to the perceived effects of discrimination on health included impact on mental health impact on physical health and effect of discrimination in healthcare themes related to coping with discrimination included social support resilience and identityspecific media consumption findings demonstrate that bisexual and other nonmonosexual individuals experiences of discrimination can be additive based on other marginalized facets of identity including raceethnicity gender and socioeconomic status our findings have implications for advancing bisexual health research from an intersectionality framework

introduction kpop is becoming increasingly popular in the global music entertainment industry kpop artists now have more fans and attention from western media than ever before however competition among kpop groups and artists has become fiercer in recent years korean entertainment companies must develop effective marketing strategies for their groups and artists to differentiate themselves from competitors as a result some korean groups and artists have had greater success and popularity than others through an online survey the researcher will discuss how important marketing is in the kpop industry how entertainment companies use different marketing tools to create a competitive advantage and suggest some methods and ideas entertainment companies can use to improve even more since 1992 when seo taiji boys first took the stage and integrated english lyrics dance and hiphop elements into their repertoire korean pop culture has steadily gained global prominence with vibrant colors eclectic styles and undeniable talent that resonates with audiences worldwide korean artists have pioneered an entirely new genre of their own kpop will redefine your perception of music and once you delve into it theres no turning back the paper entitled korean pop takes off social media strategy of korean entertainment industry discusses the role of social media in the recent boom of kpop the paper focuses on the major entertainment agencies in korea namely sm entertainment yg entertainment and jyp entertainment and presents lessons on how to manage social media strategically the lessons include aligning strategic business models with social media maximizing various social media channels engaging customers with onand offline promotions and stimulating the audience with exclusive content the paper highlights the worldwide success of kpop and its contribution to improving the korea image and making a positive impact on the korean economy the paper also mentions that around 1000 entertainment agencies are active in korea while there exist the big three record labels and entertainment agencies the paper titled comparing western and south korean celebrity twitter strategies aims to investigate the differences in twitter strategies between western and south korean artists the study focuses on the effective use of social media for global music distribution and how identifying the twitter strategies of korean idol groups can have applications beyond the music industry the study collect data from a constructed week sample and the content and response for each tweet will be analyzed the paper highlights the success of south korean idol group bangtan sonyeondan in winning a billboard music award for top social artist in 2017 which indicates strong audience engagement and a skillful use of social media the paper suggests that comparing how western and south korean artists use twitter will bring to light new strategies for both organizations and businesses on the platform the paper titled culture and content industry an analysis on new korean wave based on social capital perspective discusses the impact of the new korean wave on global fans and their adoption of korean cultural goods from a social capital perspective the study highlights the shift in media from the first generation of korean wave which mainly refers to the exports of korean tv dramas via broadcasting systems to the new korean wave era brought by kpop via the rapid growth of social media the paper emphasizes that most global fans of kpop are young and use social media to access digital content and share their opinions spontaneously social media providers such as youtube and facebook not only act as information providers to usher the fans to online music retailers but also function as links between these fans and cultural producers by turning bonding social capital into bridging social capital telecommunication and advertising companies participate in this market as a third party by providing funds for supporting digital circulation and distribution the paper suggests that in this multisided market with interdependent agents it is extremely important to secure a platform that leads the evolution of its business ecology without owning the platform there is also a very little chance to produce linking social capital as a means to maximize the impact of new korean wave kpop has proven over the years to cross borders and break down language barriers by enthralling fans from all over the world kpop with its asian roots and subtle western undertones has evolved into a true hybrid novelty undoubtedly the south korean music industry has made an indelible mark on the global stage with its exceptional production standards and diverse musical genres it has swiftly ascended to a position of worldwide prominence however the impact extends far beyond asia were witnessing its resonance throughout the entire globe despite the widespread acknowledgment of the global popularity of kpop and its profound impact on the korean music industry there is a gap in understanding the specific social media strategies employed by major entertainment agencies such as sm entertainment yg entertainment and jyp entertainment to effectively manage their online presence and engage a diverse global audience this research aims to address this gap by investigating the role of social media in the success of kpop and identifying the strategies used by leading agencies to harness its potential ultimately contributing to a deeper comprehension of the intersection between social media and the music entertainment industry research methods in this research paper our primary research objectives revolved around examining the impact of social media strategies on the korean music industry specifically within the kpop genre to effectively achieve these objectives we adopted a research method centered on comprehensive secondary data analysis heres a detailed breakdown of how this research method aligns with our research objectives 1 data selection and sources to understand the relationship between social media strategies and the kpop industry we carefully selected various data sources these sources included academic studies industry reports government databases surveys and data from social media platforms 2 data collection and extraction the chosen research method allowed us to collect relevant data points from these sources we extracted information pertaining to kpop industry trends social media engagement metrics fan interactions and the strategies employed by kpop entertainment agencies 3 data synthesis and analysis with our dataset in hand we conducted a thorough synthesis and analysis of the data we looked for patterns trends and correlations between social media engagement and the success of kpop artists and agencies by analyzing data from multiple sources we could offer a holistic view of how social media impacted the industry 4 comparative analysis one of our research objectives was to compare different kpop entertainment agencies specifically the big three record labels sm entertainment yg entertainment and jyp entertainment through data analysis we were able to compare their social media strategies audience engagement and the outcomes of their efforts practical insights and recommendations to address our research objectives effectively we used the synthesized data to draw practical insights and recommendations we could illustrate how kpop agencies aligned their strategic business models with social media maximized the use of various social media channels engaged customers through online and offline promotions and stimulated audience engagement through the creation of exclusive content results and discussion kpop industry kpop short for korean pop music has experienced tremendous success and gained global attention in recent years it captivates music fans worldwide with its infectious melodies captivating choreography and stylish fashion several kpop groups and artists have achieved widespread recognition including bts exo twice blackpink psy and many others these artists are typically represented and trained by entertainment companies who actively scout talent not only in south korea but also in other countries after being scouted aspiring artists undergo rigorous training as trainees within the entertainment industry for a period of 5 to 10 years those who successfully complete their training are then offered official contracts and make their debut under the companys name the above figure depicts the reasons for kpop at an early stage all kpop songs and singers are placed in a systematic entertainment company for preparation following that the new kpop songs and image of the kpop band are promoted on social media services along with singing and dancing styles that are emphasis elements in kpop kpop eventually reaches consumers with a knowledgeable fan base spreading the product throughout the population the first kwave emerged in the late 1990s when korean dramas gained popularity in china and japan before spreading to other asian countries one significant success was the 2003 television series jewel in the palace which depicted the story of the first female physician serving the king and achieved tremendous success across asia the middle east and eastern europe another notable drama winter sonata became a sensation in japan when it aired on nhk in 2004 garnering the highest audience rating of 20 with the rise of globalization and the internet in the past two decades the kwave has captured worldwide attention extending from asia to the west following the dramaoriented craze of the first korean wave korean pop music became an integral part of the second korean wave international fans purchased original soundtracks and naturally became interested in kpop artists after watching korean dramas and listening to the songs in the dramas furthermore with the rapid spread of social media platforms such as youtube and twitter kpop has expanded its fandom outside of asia to meet the growing demand of global consumers youtube added the kpop genre to its music page in december 2011 alongside r b rock pop and rap among others marking the first time that a specific countrys music was introduced as a separate genre in addition billboard an international music news magazine launched a kpop hot 100 chart in august 2011 according to data obtained from youtube kpop music videos on youtube received 29 billion hits from asia in 2012 followed by america and europe the global success of kpop has significantly improved south koreas image and positively impacted its economy traditionally koreas exports depended on industries such as semiconductors cell phones and automobiles however the kwave represented by kpop has emerged as a new engine of economic growth by projecting a positive image of korea the popularity of idol groups and kpop artists contributes to increasing koreas exports and attracting foreign tourists social media social media has gradually evolved into one of the most effective platforms for brand and artist promotion this trend started in 2003 with the rise of myspace which allowed users to feature their favorite songs on their profiles recognizing the potential of social media the kpop industry developed their own successful strategies for cultivating online fandoms and keeping them engaged with fresh content what sets kpop apart from other musicians today is their strong social media presence while many korean singers maintain personal accounts on platforms like facebook twitter and instagram they often lead private lives outside of their work as a result instead of individual public accounts most kpop groups use a shared social media page for fan communication fans only need to follow one page to stay up to date on all their collective endeavors driving all fan traffic to a single location streamlines all band updates and content allowing them to reach a wider audience and achieve higher engagement rates furthermore this strikes the ideal balance between fan interaction and artist privacy korean pop music in indonesia korean pop music commonly known as kpop has made a significant impact on the indonesian music and entertainment scene indonesia is one of the many countries where kpop has gained a massive following and has become a cultural phenomenon having established kpops global appeal and its role in indonesian culture there exist nultifaceted influence and significant presence of kpop within indonesia 1 popularity and fanbase korean pop music or kpop has garnered an enormous following in indonesia indonesian kpop fans often referred to as kpopers constitute a passionate and dedicated fanbase the popularity of kpop in indonesia transcends age gender and background making it a unifying force among diverse segments of the population kpop idols and groups have become household names and their music is widely listened to and appreciated across the country 2 music charts and concerts kpop songs frequently dominate music charts in indonesia its not uncommon to see kpop tracks ranking high on indonesian music charts reflecting their widespread appeal moreover kpop concerts fan meetings and showcases are regularly held in major indonesian cities such as jakarta surabaya and bandung these events attract thousands of fans demonstrating the immense popularity of kpop in indonesia international kpop acts often include indonesia as a stop on their world tours 3 the korean wave indonesia is an active participant in the global korean wave or hallyu which encompasses the spread of korean culture worldwide beyond music hallyu encompasses korean dramas fashion food and cosmetics kpop as a significant component of hallyu has played a pivotal role in introducing korean culture to indonesian audiences the korean wave has influenced indonesian entertainment preferences fashion trends and beauty standards 4 kpop cover groups and competitions indonesia has a thriving kpop cover group scene these cover groups consisting of passionate fans meticulously replicate kpop music videos and live performances they participate in competitions showcases and talent events showcasing their dedication and talent the popularity of kpop cover groups has led to the emergence of cover dance competitions where groups compete to mirror the choreography of their favorite kpop songs 5 online presence kpop enjoys a robust online presence in indonesia indonesian fans actively engage with kpop content on various social media platforms including youtube twitter instagram and tiktok youtube in particular is a hub for indonesian kpop fans to share dance covers reaction videos song covers and fan theories social media has become a space for fans to connect share their love for kpop and interact with idols and fellow enthusiasts 6 language learning one notable effect of kpops popularity in indonesia is the increasing interest in the korean language many fans take up korean language courses to better understand the lyrics of their favorite songs follow kpop news and engage with south korean culture language learning centers and online platforms offering korean language courses have witnessed growing enrollment driven in part by the kpop phenomenon 7 local talent in kpop indonesia has produced some talent that has gained recognition in the south korean kpop industry for instance alexander lee eusebio formerly a member of ukiss and kevin woo who was also part of ukiss and is now a solo artist have made significant contributions to the kpop scene in south korea their achievements are a source of pride for indonesian kpop fans 8 cultural exchange kpop serves as a medium for cultural exchange between south korea and indonesia south korean artists often express their appreciation for their indonesian fans during concerts and fan meetings fostering a sense of connection likewise indonesian fans showcase their affection for south korean culture through fan projects fan art and fan letters this cultural exchange strengthens the bond between the two nations 9 economic impact the popularity of kpop in indonesia has had a notable economic impact this impact extends to various sectors including merchandise sales digital music downloads streaming services concert ticket sales and the growth of the entertainment industry kpoprelated events and merchandise generate significant revenue and provide opportunities for local businesses powerful and consistent online presence social media has evolved into one of the most profitable platforms for promoting products and artists the kpop industry capitalized on this window of opportunity by developing its own innovative digital strategies for attracting and retaining fans the prominence of kpop artists on social media platforms distinguishes them from other contemporary musicians youtube instagram twitter and facebook are used to notify fans of upcoming performances new albums tour dates and merchandise weverse and v live are just two apps that kpop labels use to increase their artists exposure to their fans building the hype the kpop industry creates bands through auditions most companies hold open auditions all year and select applicants to train with them these applicants are signed as talents who will train for a set period before making their debut in a group or as solo artists aini et al highlights the success of the kpop industry through talent development offline and online promotions and the implementation of marketing systems putri explores the phenomenon of kpop fans creating a hyperreality around their idols influenced by simulation from friends and mass media oh lee discusses how kpop has transformed the perception of the popular music industry in korea with government support and television stations actively recruiting new kpop stars joongho ahn et al focuses on the role of social media in the global success of kpop emphasizing the strategic use of various social media channels and engaging customers through promotions and exclusive content in summary these papers demonstrate that the kpop industry utilizes talent development promotions government support and social media strategies to build hype and create a dedicated fan base for their artists in the months leading up to a groups debut the managing company promotes them through various digital marketing channels they share virtually every moment of their lives as performers at this point with content such as teaser photos rehearsal clips and behindthescenes videos posted to build excitement they would have already built a fan base and promoted their brand concept by the time they appeared on a variety show or music channel kpop entertainment agencies and their social media outlets as previously stated kpop is the driving force behind the current kwave according to the ministry of culture sports and tourism there are approximately 1000 entertainment agencies in korea there are big three record labels and entertainment agencies in korea in terms of the number of kpop artists total sales and global reputation such as sm entertainment yg entertainment and jyp entertainment these three entertainment agencies are allegedly distinguished by their recruitment philosophy and practices according to s yim sm entertainment is more likely to value its artists physical appearances whereas yg entertainment values their artists unique characteristics some compare sm entertainment to an elite school where its artists receive a thorough education ranging from acting to singing and dancing whereas yg entertainment tries to maximize trainees strong points rather than complementing weaknesses jyp entertainment prioritizes foreign language speaking abilities and places a greater emphasis on education for its artists to communicate with international fans the term social media is defined in a variety of ways kietzmann et al argued that social media employ mobile and webbased technologies to create highly interactive platforms through which individuals and communities share cocreate discuss and modify usergenerated content social networking sites video sharing sites business networking sites collaborative websites virtual worlds social bookmarking sites microblogging services and so on are examples of representative social media social media channels kpop entertainment agencies focused on a few social media channels such as youtube facebook and twitter given their business models and the current internet environment they opened official youtube channels to promote new music videos and used other social media platforms like facebook and twitter to communicate with their youth audience at the same time major kpop labels manage individual dedicated youtube channels for their artists to facilitate communication with the audience in some cases an individual kpop artists youtube channel is more popular and vitalized than their entertainment agencies a study by s kim et al highglight that high popularity and fan engagement rates are influenced by kpop artists video uploads and the support from v live and entertainment companies while joongho ahn et al said that social media has expanded its fandom outside of asia to the west sung compares korean and japanese youtube channels and highlights the involvement of individuals in creating content while oh 2013 emphasizes the significance of mass media technologies particularly youtube in the global distribution of kpop music these findings suggest that individual kpop artists youtube channels can play a crucial role in their popularity and reach surpassing the influence of their entertainment agencies engage customers contests have been used as a major marketing activity to engage customers and recruit potential talent in the entertainment industry sm entertainment holds its global audition program every year to find talented singers actorsactresses and dancers any applicant regardless of age gender or nationality is welcome to audition and finalists will have the opportunity to sign a contract with sm entertainment stimulate audience teasers are released on social media by kpop entertainment agencies to promote new music videos or events and increase virality among their fans while yg entertainments 2ne1 released its seventh korean single i am the best on youtube a series of teasers were exclusively leaked to pique the interest of its fans on june 19 2011 the first teaser for the song was released featuring 2ne1s leader cl the teaser was shared on yglife along with the songs official artwork yg entertainment also revealed that a 10second snippet of the song would be released every day until the full track was released finally on june 27 2011 the songs music video debuted on 2ne1s official youtube channel further kusumawati widita found that kpop group blackpinks photo teasers on social media were consistent with their brand and conveyed messages of beauty and strength jung shim explored the grassroots and corporatecontrolled aspects of kpop consumption and circulation on social media while jung focused on the impact of social mediaenabled online fandom on the transcultural circulation dynamics of kpop particularly in indonesia these findings highlight the significance of social media in the promotional strategies of kpop entertainment agencies and their efforts to increase virality among fans conclusion with the rapid expansion of social media the influence of kpop fandom has extended beyond asia the global success of kpop has not only enhanced the perception of south korea but also positively impacted the countrys economy in this case we explore the broader phenomenon of kpops popularity and examine the role of social media in its success specifically we present strategies for managing social media platforms in major kpop entertainment agencies such as sm entertainment yg entertainment and jyp entertainment focusing on the business potential of social media the kpop entertainment industry attempts to promote music videos and communicate with a global audience through various social media channels along with releasing official music videos and teasers on youtube entertainment companies open and manage facebook and twitter accounts to better communicate with their audiences even though each social media platform serves a distinct purpose agencies strive to integrate the channels into their business strategy and maximize their potential korean entertainment agencies social media strategy is as follows align strategic business model with social media maximize various social media channels engage customers with onand offline promotions and stimulate audience with exclusive content this case study could serve as a model for any entertainment companies looking to maximize their business potential through social media

the korean wave kwave also known as hallyu is the term used to describe the phenomenon of korean pop culture including tv dramas movies pop music fashion and online games becoming widely popular and shared among the people of japan china hong kong taiwan and other asian nations korean pop music also known as kpop became a major component of the second kwave after the first kwaves dramafocused craze additionally kpops fanbase has grown outside of asia to the west thanks to the quick adoption of social media platforms like youtube and twitter the popularity of kpop throughout the world helps to improve the perception of korea and has a positive effect on the korean economy according to reports korea has 1000 active entertainment agencies in addition to the big three record labels and agencies sm entertainment yg entertainment and jyp entertainment in this instance we talk about the kpop phenomenons global appeal and how social media has contributed to the genres recent boom our lessons on how to manage social media strategically with a focus on the major agencies mentioned above include aligning your strategic business model with social media maximizing different social media channels enticing customers with onand offline promotions and stimulating audience with exclusive content

introduction population aging has been a crucial policy issue globally in the past two decades the fertility rate in china has continuously reduced and the aging population structure has become increasingly serious the fifth chinese population census in 2000 revealed that china had entered an aging society after 20 years according to the latest seventh chinese census in 2021 the proportion of population aged ≥60 years accounts for 187 of the total moreover researchers have forecasted that in the following decades the population aging rate in china will continue to accelerate and maintain a highspeed growth after reaching its peak around 2060 which could be termed as a plateau trend with a low fertility rate traditional family care in china has become challenging family care is insufficient to meet the care needs of older adults in 2015 the demand for senior care services in urban and rural areas reached 153 which considerably increased compared with 1237 in 2010 and 66 in 2000 therefore meeting the senior care needs has become an urgent problem for the chinese government community care service as a more winwin option has become the most widely used senior care model in china combining the advantages of traditional family care and institutional care the community can be seen as a platform for connecting professional institutions and nursing staff with older adults at home this means older adults can receive medical and nonmedical services and solve their daily living problems in the community or even at home pardasani and thompson studied six types of community care services namely community center wellness center lifelong learning continuum of care entrepreneurial center and the café program in china community care services mainly comprise the first three types with the continuous expansion of the older population the demand for senior care service is gradually showing a diversified and differentiated trend thereby pushing communities to upgrade their service contents and quality however numerous studies have revealed the persistence of problems of underutilization and low service satisfaction in senior care service hu et al 2019 first from the supply and demand perspective the choice of current senior care service is limited by contrast because of factors such as regional culture income level age and gender the service demand among older adults is quite different therefore a gap exists between the supply of senior care services and the diversified and differentiated care service needs of older adults the current senior care services often cannot accurately assess need unneeded and want from the older adults thus resulting in an imbalance in the supply and demand structure of senior care service second from the perspective of characteristics of older adults differences in factors such as age gender marital status income level and selfcare status have an impact on the satisfaction with senior care services similarly the attitude and acceptance toward social senior care services among older adults significantly affect the utilization of these services a study revealed that people less influenced by the filial piety culture were more likely to use the senior care services to a great extent third social psychological factors such as social trust social capital social integration social equality and social participation significantly affect the satisfaction with senior community care services specifically older adults experience psychosocial problems such as social isolation identity threat and lack of social support all of which affect the senior care intention the current research on the satisfaction with utilization of senior care service focuses more on personal characteristics service quality and affordability but relatively less on social psychological factors this paper constructs a model by adding another dimension about social psychosocial factors in the traditional anderson model using binary logistic regression analysis this study explored the main factors that affect the satisfaction with community senior care services the findings hopefully provide some effective suggestions for improving the community senior care service utilization rate and realize the chinese social vision of the older will be looked after properly methodology analysis framework the anderson behavior model was used to study the conditions facilitating or impeding the utilization of personal medical services over the years the model has undergone continuous improvement it has now been extended to analyze the actual or expected use of various services by different people groups the traditional framework focused on a series of predisposing enabling and need factors influencing service utilization over the years scholars have modified the model for answering different research questions by combining the anderson behavior model with the pe fit theory wu found that interpersonal spatial and information linkage would have a great impact on facilitating service utilization in the process of older adults adapting to a new environment according to the pe fit theory older adults using community care services is more of a process of their readaptation to the social environment which includes two aspects adaptation to the organization and interaction among people as the linkages with the community are becoming tighter older adults would more likely to become comfortable with their new identities and be able to better utilize community resources in meeting their needs yu et al reported that the anderson behavior model has been studied mostly from the demand perspective and not from the supply perspective according to the previous research the anderson behavior model has been studied mostly from the demand perspective and not from the supply perspective the quality price and accessibility of the service would significantly impact the demand from elders these findings are consistent with those of one study reporting that an increment in community senior care services would in turn increase the demand for these services bradley showed that although the traditional anderson behavior model referred to the concept of faith in predisposing factors it mainly discussed about factors such as older adults view on diseases and health services while focusing little on social psychological factors shi also demonstrated that the psychological perception of older adults would influence the supplydemand satisfaction on the one hand older adults psychological perception about basic living needs living environment personal traits and livability for the aged would directly influence their satisfaction as clients on the other hand in the process of using communitybased senior care service perceptions of inequality independence of consciousness social trust tradition and other cultural values would affect older adults attitude and action about accepting social help moreover based on the results of bradleys research zeng extended the model with social psychological factors and found that intergenerational ties unmet needs for longterm care and selfimage evaluation would influence ltc needs therefore fairness perception was examined as a psychological factor in our model studies have often adopted equity theory to analyze the reasons for social help from social psychology perspectives in most studies about fairness scholars have focused on the inequity status in the utilization process such as the unequal utilization status because of race gender income etc fewer studies have examined whether differences exist in older adults subjective perception of fairness which thus affects their community service utilization satisfaction wang et al found that with age people are more inclined to exhibit interpersonal tendencies in social interactions that is when interacting or comparing with other old people they become more tolerant of unfair treatment and become less competitive therefore this study incorporated the perception of fairness as a social psychological factor into the research framework model more or less inequity in service supply will be observed in the actual service utilization process this study divided old peoples resonance of unequal treatments into two dimensions the perception of vertical and horizontal injustice we propose that vertical injustice more significantly influences service utilization than horizontal injustice to summarize an extended anderson behavior model can be established for the satisfaction about community healthcare service utilization among older adults as shown in figure 1 frontiers in public health 03 frontiersinorg this study extends the traditional anderson behavior model from three dimensions to four dimensions by adding social psychological factors as a dimension based on this model we examined how fairness perception has an impact on older adults satisfaction of communitybased senior service moreover compared with a previous study this study discusses not only the utilization of medical community healthcare services but also the nonmedical community healthcare service with life care service satisfaction and spiritual comfort service satisfaction by comparing the differences between their contributing factors we can make more targeted recommendations data and sample economic development in shaanxi province located in the west of china had been limited by its location and fastgrowing aging population the policy support from the central government and new immigrants have recently ensured some promising development in this province selecting shaanxi as the study area expanded our survey scope to reach different senior groups as shaanxi is a province of diversity and possibility owing to its unique geographical environment and historical and cultural background the sample was drawn from 12 urban communities in three cities of this province in total 340 urban community residents aged ≥60 years responded to the survey later 18 responses were deemed invalid resulting in the inclusion of 322 survey responses in this study dependent variables our dependent variable is satisfaction with the communitybased senior care service this study analyzed the differences in factors influencing various community service types considering both physical and psychological service demands we categorized communitybased service for senior into three types life care service health care service and spiritual and mental care service the questions such as how satisfied are you with life care services healthcare servicesmental and spiritual service provided by the community were asked to assess the outcome we here recoded the variables so that very satisfied and satisfied were uniformly categorized as satisfied and neutral unsatisfied and strongly unsatisfied were categorized as not satisfied independent variables 241 predisposing variables predisposing factors were typically associated with demographic social structure and health beliefs age gender education and marital status were included to measure biological and social imperatives enabling variables enabling factors refer to the accessibility of service resources among older adults from the wus perspective when old people attempt to use community care services they are readapting to the environment after their retirement in this process when older adults reach their optimal state with the environment they become more willing to use senior care services therefore this study primarily focused on personnel spatial and information linkage factors to indicate the basic conditions of older adults and the environment whether it would enable or impede their senior care service utilization first closeness with others was the crucial predictor for measuring personal linkage personal linkage was measured through the question how frequently do you see your family and interact with neighborhoods and friends spatial linkage mainly pointed to the accessibility of communitybased aging service and was measured through the question the convenience you went to senior service organization such as the community senior service center community health care center and community recreation center lastly information linkage a crucial method for older adults to adapt the environment was measured on the basis of the index of seniors proficiency in using smartphones the answers for these three questions equity perception need factors chronic disease retiring pension figure 1 analytical framework of community service utilization satisfaction need variables need factors included those caused by the physical function or financial limitations and those perceived service demands chronic diseases retiring pension and labor income were selected as the indices for use as need variables we enquired old people whether they have any chronic disease retiring pension and labor income the answers were yes and no social psychological variables as illustrated in our analytical model fairness perceptions including vertical and horizontal fairness perceptions were introduced in the framework vertical fairness perception was measured by comparing whether the services they received matched with their previous contributions to the society and horizontal fairness perception was measured by comparing whether other old people received the same treatment of senior care services they were measured on the basis of questions such as do you agree that the services you received are equal to those other old people and do you agree that the services you received can match with your contributions to the society the answers included disagree agree and strongly agree the measurements of all variables are shown in table 1 results descriptive statistics the characteristics of predisposing enabling and need factors are presented in table 2 from the perspective of predisposing characteristics 194 respondents were women and 128 were men age of the majority of the respondents ranged from 60 to 80 years and their physical and cognitive skills functioned relatively well this group of older adults would be more likely to know and utilize senior care services in total 89 respondents received elementary school and below education and 413 of the respondents received high school and above education regarding enabling factors when questioned about their closeness with the community over half of the respondents expressed that they maintained a frequent contact with others for spatial linkage measurements although most old people were satisfied with the convenience to all types of community institutions 3882 2555 and 3075 of the respondents reflected that they had some trouble in visiting the nearby community life care center healthcare center and recreation center respectively for information linkage 6894 of the respondents could not operate their smartphones properly moreover regarding need factors in general approximately half of the survey respondents claimed that they had at least one chronic disease overall 96 of the respondents had retirement pension and 2578 of the respondents chose to work and had labor income after retirement table 3 presents the characteristics of social psychological factors overall 5186 of the respondents felt unfair in the process of receiving community care service and approximately 48 of the respondents felt that they received the same treatments as others in terms of service contents and quality regarding vertical fairness 6211 of the respondents indicated that their current service benefits did not match their social contribution value before retirement a sense of being underserved approximately 38 of the respondents agreed that they had been valued by the community table 4 lists the characteristics of dependent variables respondents who expressed dissatisfaction with the three different care services accounted for 3168 4161 and 2888 respectively the results showed that people had a relatively higher negative impression about the health care service than about the other two types of services by contrast majority of the respondents were satisfied with the community care services they had received binary logistic regression table 5 presents the results of the binary logistic regression model for satisfaction with the utilization of three service types we conducted three different regression analyses for the three dependent variables of life care healthcare and mental and spiritual service satisfaction as shown in table 5 models 11 21 and 31 all incorporated predisposing characteristics enabling factors and need factors and then psychological factors were incorporated in models 12 22 and 32 as shown in table 5 in models 11 21 and 31 factors affecting utilization satisfaction levels regarding three service types were different regarding predisposing factors age exhibited no significant relationship with service satisfaction gender marital status and educational level had different effects on service satisfaction in life care service men mostly provided a negative evaluation compared with women moreover people who were married were also more satisfied than those who were single thus marital status had a similar relationship with healthcare service gender exhibited no significant relationship with healthcare service satisfaction whereas the education level was negatively related the higher the education level the more likely the people to be unsatisfied the educational level was the only predisposing factor that was significantly related to mental and spiritual care service people with middle school literacy or high school and above literacy were mostly unsatisfied with the service than those with primary school and below education regarding enabling factors old people who were closely linked with family and friends in their communities exhibited lower satisfaction with healthcare services and mental and spiritual services than those who were not for spatial linkage convenience to nearby community service centers such as life care center healthcare center and mental and spiritual service center had a positive effect on satisfaction the satisfaction of respondents who find it convenient or very convenient to visit service centers was approximately three to seven times higher than that of people who do not find it convenient for information linkage proficiency in using smart phones negatively affected the evaluation of satisfaction about healthcare service but positively affected the evaluation of satisfaction about the mental and spiritual care service regarding need factors respondents who had chronic diseases apparently agreed that the healthcare service in the community did not meet their expectation regarding economic condition the satisfaction of respondents who received retirement pension was higher with the mental and spiritual service than that of those who did not receive respondents who had labor income were more satisfied with all three types of service than those without any income models 12 22 and 32 introduced psychological factors mainly including horizontal and vertical fairness perceptions in the process of using senior care service in the community as table 5 shows in both sets of models predisposing enabling and need factors showed consistent relationships between the dependent and independent variables for the horizontal fairness perception it apparently affected older adults satisfaction in the mental and spiritual service people who perceived themselves to be receiving fair treatment were more satisfied than those who claimed to receive unfair treatment no significant difference in satisfaction was observed between people who received equal and very equal services moreover the vertical fairness perception positively and significantly influenced older adults satisfaction in all three service types in general the satisfaction of older adults who agreed or strongly agreed that the service they received sufficiently matched their previous contribution was approximately three or four times higher than that of those who believed they were not treated fairly compared to their former contribution discussion in this study communitybased senior care services included life care service healthcare service and mental and spiritual service based on an extended anderson behavior model with social compared with other senior citizens the fairness about the equal access to all senior care services 1 disagree 2 agree；3 very agree variable type variable name variable label measurement the received services whether reflect the respondents social contribution before retirement 1 disagree 2 agree；3 very agree psychological factors the study revealed that horizontal and vertical fairness perceptions were positively related to the satisfaction of older adults the results indicated that the proportion of respondents who were dissatisfied with community healthcare service was higher than that of respondents who were dissatisfied with the et al 2017 our survey revealed that people with high educational levels expected higher service quality especially in medical care and recreation activities regarding predisposing factors people with better conditions such as higher education levels and having a spouse are more likely to be unsatisfied with community services than others regarding enabling factors guided by the pe fit perspective this study examined that the utilization satisfaction with different types of communitybased senior care services varies among personal spatial and information linkage in line with the results of previous studies the accessibility of care services would allow older adults to use the community care service this is understandable because of physical weakness older adults depend more on nearby services in this study the proficiency in using smart phones negatively affects the satisfaction of using the healthcare service and positively affects the satisfaction of using mental and spiritual service because an increasing number of older adults use smartphones using smartphones was proven beneficial for improving older adults health status and psychological condition however older adults were likely to have some psychological problems such as depression and emotional disturbances caused by excessive smartphone usage for example older adults generally tend to be more interested in news and knowledge related to health and illness the overwhelming information on the internet much of it being incorrect or inaccurate will make them more anxious and suspicious therefore with older adults using smartphones more frequently and proficiently they may become less patient in the process of using the community healthcare service on a positive note the use of smartphones provided convenience to older adults allowing them to participate in community recreational activities regarding needing factors older adults with chronic diseases rely more on social support and professional medical services the current community healthcare service supply was still limited in meeting some basic needs and was a type of welfare wherein services were provided for free or at a low price for older adults this study revealed that older adults with chronic diseases were more likely to be unsatisfied with the community healthcare service than others because the main research subjects were the urban older adults they mostly had a retirement pension whether or not having a retirement pension only influenced the satisfaction of using the mental and spiritual care service different from the retirement pension additional labor income after retirement significantly and positively affected utilization satisfaction of all three service types life care service and healthcare service are linked to old peoples daily life and recreational activities were only considered as nonnecessities furthermore retirement pension was considered a guaranteed item that can only support the old peoples basic daily life but labor income can help old people seek some other highquality services regarding psychological factors our study highlights that the fairness perception was positively associated with the satisfaction of using the communitybased care service among respondents as expected the data revealed that the vertical fairness perception had a more profound influence than the horizontal fairness perception according to relative deprivation theory with the increasing age old people usually tend to reject social help because their relative deprivation sense decreases with age and so they would not pay any additional attention to chase highquality life consistent with previous findings older adults were more tolerant with some unfair treatments and were careful in maintaining good relationships with others refined and differentiated senior care services are required the service quality must be improved to ensure that older adults feel being valued in this study being treated equally positively affected the utilization satisfaction of the mental and spiritual service such services or activities are often arranged in groups with no distinction and thus many older adults would easily feel being treated unequally people tend to have higher demands for entertainment services when their basic living needs are ensured this is consistent with the results of needing factors that respondents with more economic support tended to demand for more service content and quality beyond basic life care or medical care services it may suggest that old people tend to care for their subjective perception such as fairness more when they have more money in the future studies we can attempt to justify whether older adults with better conditions such as more economic and emotional support would feel more unsatisfied in receiving basic level senior care services this study has some limitations first owing to the challenges in recruiting respondents we could not measure aspects such as ethnicity and other potential confounding factors that could affect the service utilization satisfaction of older adults additionally all the data in this study were from the shaanxi province and the results may not be applicable to other regions conclusion this study extended the anderson behavior model from the original three dimensions to four dimensions by including social psychological factors first the study reflects different influential factors for three types of communitybased senior care service utilization satisfaction second guided by the pe fit theory we discussed how personal spatial and information linkage worked in the readaptation process lastly we testified that in terms of psychological factors fairness perception was associated with the service utilization satisfaction of older adults as chinas population is aging rapidly enhancing the community service quality and improving the service utilization satisfaction among older adults are of great significance data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by the ethics committee of xian jiaotong university the patientsparticipants provided their written informed consent to participate in this study 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

communitybased senior care as a convenient and promising care model has gradually been accepted by the public however community services developed to facilitate older adults often fail to achieve the expected effect with the fastgrowing aging population in china the problems of underutilization and low service satisfaction of senior care facilities need to be resolved urgently in this study we further developed an extended anderson behavior model by incorporating social psychological factors and the vertical and horizontal fairness perceptions in addition a binary logistic regression model was used to analyze factors affecting the satisfaction of older adults in life care services health care services and mental and spiritual comfort services the study used data from a survey of 322 urban area seniors in shaanxi province the results showed that factors influencing older adults satisfaction of different service categories are different moreover with the addition of the social psychological factors we observed that the vertical fairness perception of the survey respondents affected their satisfaction of senior care services significantly more than the horizontal fairness perception

background heatrelated illness is an important cause of preventable death globally 12 hri comprises a spectrum of disorders ranging from heat rash to heat stroke which can be fatal unlike classical hri which occurs more commonly in the elderly very young and those with chronic medical conditions exertional hri can occur in young otherwise healthy individuals with high metabolic output rates from increased workloads particularly when working in hot and humid environmental conditions the physiological response to dissipate heat and maintain a normal core body temperature which is overwhelmed in exertional hri can also occur in relatively cool environments depending on the amount of metabolic heat produced and the degree of acclimatization of the worker 34 although classical hri and exertional hri in athletes and military personnel and have been studied extensively less is known about exertional hri in certain vulnerable working populations including agricultural workers 5 6 7 8 9 between 2003 and 2008 the united states agriculture forestry and fishing sector had the highest mean heat fatality rate compared to all industries with the majority of fatalities occurring in the crop production and support subsectors 410 studies using us workers compensation claims data have identified a high burden of nonfatal hri in the aff sector despite probable substantial underreporting 11 the us aff sector employs over two million workers and about half of these workers are employed in the crop production subsector 12 hired farmworkers in the us are largely seasonal foreignborn spanishspeaking workers 13 climate change threatens to increase the risk of hri in farmworkers over time extreme heat is associated with heatrelated deaths and the frequency and intensity of heat waves is projected to increase locally and globally 1415 these findings indicate that the identification of risk factors for hri in farmworkers with the overall aim of hri prevention is timely and of public health significance hydration and hrirelated cultural beliefs and practices in latino farmworkers may affect the prevention and treatment of hri previous studies in latino communities have described distrust in the municipal water supply and of water provided in opaque containers where the contents and cleanliness of water is difficult to determine 16 17 18 in a qualitative study of farmworkers in washington state farmworkers expressed a belief that a cold shower should be avoided immediately after heat exposure as cold water on a hot body could cause pain in the bones and joints 17 in addition machismo attitudes in certain latino men may influence how hri symptoms are addressed and communicated to peers and employers 8 although reports indicate that latino farmworkers perceive hri as an important health issue 7 and hri knowledge and general beliefs have been studied 61920 little has been done to systematically characterize cultural beliefs that may serve as barriers to hri prevention in this population certain us states including california and washington have adopted workplace safety standards intended to address outdoor heat exposure and prevent hri 2122 the wa agriculture heat rule which applies to outdoor workers from may 1 through september 30 exposed to outdoor heat at or above specified temperature action levels includes requirements for employers to address heat safety in the written accident prevention program washington administrative code 2963070973011 encourage employees to frequently consume acceptable beverages ensure sufficient drinking water is accessible to employees and that employees have the opportunity to drink at least one quart of drinking water per hour respond to employees with signs and symptoms of hri and provide worker and supervisor hri training 2122 however these standards impose generic rules that may not be equally protective in all agricultural settings and populations for example the exact amount of drinking water required for a particular employee to stay optimally hydrated may depend on several factors including environmental conditions metabolic heat production and certain personal factors this formative study was performed as an initial stage in a larger us centers for disease control and prevention national institutes for occupational safety and health funded study of risk factors for hri in agricultural workers conducted by researchers at the pacific northwest agricultural safety and health center at the university of washington the objective of this study was to identify potential barriers to hri prevention and treatment including culturallygrounded beliefs in order to inform the development of a validated survey of hri risk factors which will be conducted among latino farmworkers along with environmental and physiological measurements in later stages of the study this paper describes how participatory rural appraisal focus group discussion methods were used to identify potential barriers to hri prevention and treatment among latino farmworkers in the central wa usa area reports the results of the study and discusses possible implications of these findings on the prevention of hri methods study sites and population the study was conducted in the central wa area which is characterized by warm dry summers and a productive agricultural sector climate and irrigation have contributed to the successful production of apples pears peaches hops cherries grapes blueberries and other crops in wa between 1980 and 2006 the mean daily high humidex between may and september was approximately 2528°c 14 the 99 th percentile of daily high humidex annually was approximately 3638°c and the mean annual number of heat events was 1 6 in an analysis of outdoor wa workers compensation agriculture and forestry hri claims between 1995 and 2010 the mean daily difference in maximum and minimum temperatures by date and location of injury was 41 spanish bilingual and bicultural research staff conducted three focus group discussions in spanish using semistructured interviewing techniques and pra methods pra methods include participantgenerated visual diagrams and maps direct observations and journaling of local conditions analytic games storytelling and seasonal calendars 23 these methods have been successfully used in farming field research to generate data to tailor health services and education programs to agricultural workers 24 pra methods were used to better engage our study population and enhance data collection in a manner similar to the addition of activityoriented questions to focus groups discussions that has been previously described 25 however since we used methods adapted from pra we describe our focus groups as pra focus group discussions during pra focus group discussions participants in this study were asked about knowledge and practices related to hri symptoms and associated risk factors treatments prevention and hydration we deduced information about beliefs from participant discussion of practices when beliefs were not specifically verbalized a pra facilitators guide developed prior to the focus group discussions was used to standardize discussion across the three sessions for consistency all sessions were led by the same research staff member the size of the focus groups ranged from 11 to 12 people each and the length of the focus groups discussions ranged from 182 minutes to 233 minutes with a mean length of 209 minutes pra focus groups discussions were held at participating worksites or the pnash field office in yakima wa as an incentive for worksites to participate in the study we offered hri education required by the wa agriculture heat rule 21 in addition all focus group participants were offered a 40 gift card to account for missed work time while participating in the study the uw institutional review board approved the study protocol and each participant provided written informed consent prior to participation data collection demographic information was collected at the beginning of each focus group discussion using questions that were administered in spanish either with an electronic audience response system which allows participants to enter individual responses or selfadministered on paper all demographic questions were read aloud by research staff and staff members were available to help participants answer these questions knowledge beliefs and practices regarding hri causes treatments and prevention were assessed by having participants write and draw organize notes drawings and ideas and explain to the group what they believed to be hri causes treatments and prevention strategies signs and symptoms of hri were assessed using pra body mapping techniques 26 participants were asked to draw an outline of a body and indicate on the body map what they believed to be hri symptoms and the corresponding body part affected preferred characteristics of drinking water were assessed using a pairwiseranking approach 27 in which different combinations of participantgenerated characteristics of water were compared and prioritized by the group all pra focus group discussions were audiotaped participant responses were also recorded using written notes that participants placed on pra diagrams and charts data analysis pra focus group discussions were transcribed in spanish utilizing investigator triangulation three researchers reviewed the transcripts and field materials in spanish to identify patterns that may be potential barriers to hri prevention and treatment codes to describe these themes and patterns were discussed agreed upon by consensus by the three researchers and recorded atlasti version 70 software was used to code and categorize observations demographic characteristics were summarized using descriptive statistics and presented as overall totals for the whole study group and stratified by focus group results thirtyfive workers participated in the study demographic characteristics of participants are shown in table 1 three focus groups discussions were completed in blueberry peach and apple and cherry workers the majority of participants were male all participants in the first focus group discussion were female all participants in the third focus group discussion were male and both male and female workers participated in the second focus group discussion the majority of participants were born in mexico were between 26 and 45 years of age and had been living in the us for more than 10 years at the time of the study a minority of participants had more than a 9 th grade education only two participants reported having previously received formal hri training all but one participant reported believing that extreme heat can cause illness and participants accurately reported most hri symptoms including symptoms consistent with heat rash heat exhaustion heat cramps and heat syncope four main observations reflecting potential barriers to hri prevention and treatment related to hydration cooling treatments clothing use and the desire to lose weight were identified during the pra focus group discussions further details of results regarding hri risk factors hydration and hri treatment and prevention are presented in the sections below hri risk factors hydration participants described not drinking enough water as a cause of hri both male and female participants reported that they do not always have water with them while working which could lead to dehydration…dizziness…and headaches one female participant remarked we can get sick if we dont bring water to work both male and female participants also identified drinks with a lot of caffeine and drinking alcohol as causes of hri participants reported knowing that they were dehydrated if they were not sweating lacked energy to work felt nauseated or dizzy or felt that their skin was looser clothing participants reported that wearing dark or tight clothing could cause hri one female participant reported that dark clothing…burns more however participants also reported wearing darker clothes in order to sweat more and lose weight if you want to sweat…if you want to…burn fat…dark colors give out more heat female participants reported wearing lycra® leggings and shortsleeved shirts underneath their clothes to stay warm during the cooler early hours of the work day however they noted that they often did not take all extra layers off as the day became progressively warmer several participants noted that they wore sweatshirts layered on top of other shortsleeved shirts to keep them cool with their own sweat male participants reported wearing back support belts and female participants reported wearing girdles under their clothing for back support during the harvest participants reported that men use support belts to provide back support and prevent hernias when lifting several participants noted that women thought they lost weight when wearing the girdles which was an incentive to wear them in hot weather sometimes …even though its hot…the more you sweat the more you like it because you lose weight • farmworkers subscribe to varying degrees to the belief that cooling treatments should be avoided after heat exposure with some believing that such treatments should be avoided after heat exposure and others encouraging the use of such treatments • the location of water at work and whether water appears clean but not necessarily chemicallytreated are important considerations in deciding whether to drink the water provided at worksites • highly caffeinated energy drinks such as monster® and red bull™ are strongly preferred to increase work efficiency and maintain alertness • the desire to lose weight may be reflected in behaviors that promote increased sweating participants of both genders described that not wearing enough clothing or not using a hat could lead to sunburns however others noted that wearing too much clothing to protect from sunburns could cause overheating some participants reported using sunscreen to prevent sunburns however some female participants described that sunscreen made them feel warmer and thus they would never wear it participants noted that longsleeved blouses lightcolored sweatshirts and hats were worn to cover the body and protect from sunburns a female participant described that wearing protective clothing to reduce exposures to dust and chemicals contributes to hri some colleagues are all covered up…covered up to the nose…some people get sick because there is too much dust chemicals and pollen and you have to be covered from the mouth and nose…it can produce allergies the eyes the sneezing it causes bronchitis similar to asthma and i feel like i cant breathe being covered up can cause heat illness…breathing in the hot air participants also reported wearing denim jeans because they are thicker…and wont get caught on tree branches environmental conditions work characteristics participants of both genders noted that working long hours in the hot sun and high temperatures contributed to hri participants reported that not taking breaks in the shade can cause heat illness and noted a lack of shade in the crop areas in which they work several women working in blueberry fields described how their work in areas without shade made them feel much warmer both male and female participants also identified other factors such as excess work and working quickly as causes of hri personal risk factors participants reported that chronic conditions including high blood pressure and being overweight can contribute to hri participants also noted that fatigue lack of sleep lack of physical fitness and a poor diet could play a role in the development of hri many participants reported that medications play a role in hri however when asked about medications that increase the risk of hri participants recalled being told that exposure to sunlight was not advised when taking certain medications such as medications for bladder infections medications that lead to dehydration increase metabolism inhibit sweating or blood vessel dilation or reduce heart rate andor contractility were not specifically mentioned hydration beverage types participants reported that gatorade® is a popular beverage to help replace the electrolytes lost while sweating participants also reported drinking crystal light™ to help flavor…water female participants reported drinking certain local drinks such as agua de jamaica or agua de arroz to help refresh the body and stomach several men also discussed bringing hidden beer to the worksite to help overcome thirst to help stay alert…work faster…and fatigue more slowly participants reported drinking soda energy drinks and coffee however participants of both genders acknowledged that water is the healthiest beverage to consume at work workers reported that water is the only beverage provided by employers all other beverages were brought from home by the workers or bought from a stand or store frequency of hydration most participants discussed drinking beverages at different times of dayeither during breaks or at the end of working reasons for not drinking water more frequently included not wanting to interrupt work in order to avoid upsetting their supervisor and to make more money one participant noted sometimes we dont drink water so we wont have to use the bathroom because its too far away male and female participants noted they drank water when they were thirsty but whether they were thirsty depended on how hot it was outside some participants talked about drinking beverages every hour water characteristics for many participants water cleanliness was the most important water characteristic compared to freshness potability location or source participants of both genders seemed to make a clear distinction between clean water and potable water participants described clean water as water that appeared clear and not cloudy but was not necessarily potable participants described potable water as water that was chemically treated participants of both genders stated that they preferred clear water to chemically treated water indicating that they did not like the taste of chemically treated water freshness referred to water that was frequently changed in water jugs at worksites several female participants described water that is clean… and …changed daily as the most desirable water to drink at work location of water female participants noted that the location of water next to the bathroom at the worksite was problematic participants described that men would often urinate or otherwise contaminate the drinking water located near the bathroom water at work is next to the bathroom…i dont think its healthy…that you would be drinking this…the water container should not be exposed to a person who might want to do some bad…get…some trash dirt or wash their hands in it…or urinate…sometimes that is what the men do hri treatment prevention fluids electrolytes several male participants identified fluids such as water gatorade® lemonade with salt and intravenous fluids as treatments for hri one male participant advised giving electrolyte pills that dissolve in water as another treatment both male and female participants noted that beer or tea are not appropriate treatments for someone suffering from hri cooling treatments several female participants described placing ice packs on the forehead and neck or top of head…to refresh… workers suffering from hri in contrast several other female participants reported that they learned from their families that you should not put cold water on the body because it can cause headaches or you might also faint a male participant stated that he would not give a bottle of cold water to a person who is suffering from heat female participants noted that when you are… working in the sun moving your hands a lot…you can get arthritis if …you get home and you wet them and when the body is hot they say its bad to drink very cold water because you can develop blisters inside the mouth participants stated they would loosen tight clothing and remove excess layers as hri treatments fanning the person with air was also suggested to help a person suffering from hri to cool down other treatments participants recommended stopping work and sitting in the shade to treat someone who was suffering from hri several participants of both genders noted they would check the pulse call 911 and inform a supervisor employer or other coworker to get help for a person who might be suffering from hri several participants discussed the importance of not surrounding or agitating a person that may be suffering from hri if someone was unconscious due to heat stroke or heat syncope participants described how they would use smelling onions or alcohol to help reawaken the afflicted person strong coffee without sugar was suggested by one participant as a treatment for hri prevention in addition to hydration participants of both genders recommended wearing clothing that is light and not too thick to be comfortable while at work and not give off too much heat they also recommended that clothing should not be tucked in…to allow for more ventilation shade was mentioned several times as an important method of prevention of hri discussion in this qualitative study of latino farmworkers in the central wa usa area using pra focus group discussion methods potential barriers to hri prevention and treatment related to hydration certain hri treatments clothing use and the desire to lose weight were identified proposed strategies to address these potential barriers and the type and scope of these strategies are shown in table 3 although most participants reported an awareness of heat health effects and were able to describe hri risk factors reported practices were not necessarily consistent with reported knowledge for example workers identified dark tight clothing as a cause of hri and removal of layers as an hri treatment but female participants also reported wearing darker clothing to sweat to lose weight and wearing sweatshirts layered on top of shortsleeved shirts to induce sweating alcohol was recognized as a cause of hri and water as the healthiest beverage to consume at work but some participants noted bringing beer to work to help quench thirst and participants reported drinking highly caffeinated energy drinks to increase alertness and productivity these discrepancies may have resulted from certain attitudes and beliefs including cultural beliefs competing health priorities and workplace hazards and controls and a lack of perceived ability to exert personal control over certain hri risk factors 28 hri knowledge although the majority of participants in our study reported never receiving formal hri training most participants were aware that extreme heat can cause illness these findings are consistent with other studies including a study of migrant and seasonal farmworkers in michigan usa where heat exhaustion was identified as a commonlyperceived health problem by many participants 7 among 474 hired farm workers in the mexican immigration to california safety and acculturation study the majority of whom had received hri training over half of participants were at least a little bit concerned about the risk of hri at work 20 most participants in our study accurately described hri symptoms and causes participants mentioned feeling dizzy if they did not drink enough water decrements in vigilance and endurance during heat exposure have also been described 29 which could increase the risk of falls from ladders and other equipment several epidemiologic studies have suggested that there is a relationship between occupational heat stress and injury 3031 many participants correctly identified a lack of hydration with appropriate beverages wearing darkcolored clothing high exertion and certain personal factors as risk factors for exertional hri although we did not quantify hri risk factors in this qualitative study our findings are consistent with those previously reported hri knowledge assessed in the micasa study using a standardized survey instrument was moderate 20 participants in our study were able to correctly identify certain hri prevention strategies and treatments including hydration with appropriate beverages removing clothing layers resting in the shade and reporting and getting help for affected workers however participants also mentioned drinking alcohol to quench thirst and strong coffee as an hri treatment which are not recommended these behaviors and misconceptions could be addressed during worker and supervisor hri training which is required in certain states including wa 21 cultural beliefs cooling treatments some participants reported believing that headache fainting arthritis and oral blisters may be caused by exposure to cold immediately after heat failure to recognize and address beliefs such as these could lead to less effective heat stroke treatment which involves rapid cooling and reduction of core body temperature to prevent death 32 barriers to effective culturally sensitive education regarding hri treatment may include educators and trainers lack of awareness or negative reactions to workers cultural beliefs 33 to begin to address these barriers the following information could be added to trainthetrainer hri educational materials 1 a review of the potential role of cultural beliefs such as beliefs related to cooling treatments after heat exposure in the prevention and treatment of hri 2 recommendations for trainers to identify and if present acknowledge the role of cultural beliefs in a nonjudgmental and respectful manner 3 an explanation of rapid cooling treatments for workers with heat stroke and 4 recommendations for trainers to involve workers in developing effective and culturally acceptable strategies for treating workers with heat stroke competing health priorities participants raised two main health priorities that may interfere with hri prevention one health priority was weight loss although participants had an awareness that tight dark clothing could contribute to hri some participants particularly women noted that wearing dark clothing and girdles under their clothing led to sweating and weight loss while sweating can lead to a decrease in water weight it can also lead to dehydration and hri the relatively large diurnal temperature variation in wa may contribute to workers behaviors of wearing extra layers during earlier cooler parts of the work day in order to stay warm however workers reported that they often did not take all extra clothing layers off as the day became progressively warmer potentially increasing the risk of hri the second health priority was back pain prevention some male participants reported wearing back support belts to prevent back injury however there is little evidence for the effectiveness of back support belts in primary or secondary prevention of back pain 34 and the belts could contribute to trapping heat and preventing evaporative cooling directing workers to communitybased obesity prevention and fitness programs 35 if available or integration of elements of such programs into workplace health promotion activities may be one way to address healthy weight loss fitness and back injury prevention without increasing the risk of hri competing workplace hazards and controls participants reported several competing workplace hazards and controls that may serve as barriers to hri prevention first participants noted that wearing personal protective equipment to protect from dust allergens and chemicals could increase the risk for hri participants also noted that they preferred wearing thicker denim clothes to avoid being injured by tree branches although the wa agriculture heat rule does require worker education on the importance of removing heatretaining ppe during all breaks 21 development of ppe that is protective but retains less heat may be beneficial for example development and use of more breathable chemicalresistant suits for pesticide handlers could help address both hazards lightweight material with a repellent finish was evaluated during field trials as ppe for use in hot climates and may be appropriate when using certain pesticides 36 however further testing is needed finally some participants noted that they preferred to wear clothing with greater skin coverage to prevent ultraviolet light exposure resultant sunburn and darkening of the skin which is perceived as undesirable particularly by women however additional clothing can also trap heat and prevent cooling in addition to sunscreen lightcolored breathable clothing with integrated uv protection could be explored as a means to address this competing hazard although the us occupational safety and health administration already requires employers to pay for certain ppe clothing with uv protection is not currently included in the scope of this regulation 37 more practical approaches may include 1 frequent laundering and 2 addition of uv absorbent agents and detergents during laundering of white cotton garments which have been shown to increase uv protection factors by 1751 and 407 respectively 38 hydration workplace factors participants reports of hydration frequency suggested that they may not be drinking enough water to stay adequately hydrated several participants reported drinking when they became thirsty however thirst cannot be relied upon as a guide for the need for water 32 as 1 of the total body weight in water is already typically lost when an individual senses thirst low selfreported water consumption has been observed in other studies in us farmworkers and hypotheses regarding barriers to water consumption include lost wages from taking breaks among piece rate workers negative reactions from supervisors regarding water breaks and lack of nearby bathroom facilities 20 employer implementation of a standardized system of water break reminders at reasonable intervals location of bathroom facilities closer to workers and use of salaried or hourly instead of piece rate payment schemes may help address these barriers in our study participants reported that a clear appearance of water and regular changing of water are most important when deciding whether or not to drink water provided at work female participants suspected that water located near bathrooms was contaminated previous studies in latino farmworkers have indicated that water provided in opaque containers where the contents and cleanliness of water is difficult to determine is not trusted 17 although the wa agriculture heat rule does require employers to ensure that all employees have the opportunity to drink at least one quart of water per hour 21 workers may be more likely to stay adequately hydrated if 1 water is not located next to restrooms 2 water is provided in closed nonopaque containers and 3 basic field sanitation requirements are met another approach could be to encourage employers to have water delivered to employees at regular intervals by an employee who drives to work areas in an allterrain or other vehicle supplied with water this approach has been observed on an agricultural operation in central wa although it has not yet been assessed for effectiveness and acceptability among employers and employees participants acknowledged that water is the healthiest beverage to consume at work however they also reported drinking energy drinks to increase alertness and productivity although caffeine is not recommended for workers at risk for hri due to its diuretic and stimulant effects 39 this view is somewhat controversial 40 41 42 providing water in a manner that is desirable to workers or providing preferred recommended beverages may encourage workers to stay hydrated with recommended beverages including information on sleep hygiene and fatigue mitigation in education and health promotion activities may also reduce workers perceived need for energy drinks other worksite factors several participants noted a lack of shade in the crop areas in which they work although the california usa heat rule addresses shade 22 the wa agriculture heat rule does not 21 addition of workplace shade requirements to regulations should be considered employer involvement employers and supervisors in addition to workers should be involved in the discussion and development of acceptable hri prevention strategies for agricultural workplaces many hri prevention strategies including the strategies proposed in table 3 require employer support and involvement farmworkers likely realize that workers have minimal control of certain hri risk factors such as workplace shade availability and proximity to bathroom and water facilities at work engaging with employers in the discussion and development of hri interventions is likely to increase the chance of effectively addressing barriers to hri prevention and treatment such participatory approaches that include employers and workers have been successfully used to develop practical solutions for pesticide safety in agricultural settings 43 strengths limitations strengths of this study include the use of pra techniques which allowed for active participant involvement and enabled participants to generate much of their own data in addition employers were not present during these sessions giving participants a more open environment in which to participate leadership of sessions was conducted by the same research staff member using a facilitators guide which allowed for standardization and consistency across sessions another strength of the study was the use of multiple team members to code and interpret transcripts and field materials in spanish which increases the likelihood of valid findings both the pra session leader and one of the team members that participated in data analysis and interpretation are members of the latino community in the central washington area where our study took place and have personal experience performing fieldwork their participation contributed to effective engagement of our study population and to validation of study observations finally the study addressed not only participants knowledge and practices but also relevant attitudes and beliefs limitations of the study include the use of a purposive sample of participants which may limit the generalizability of findings over half of our study group reported living in the us for over 10 years our participants may therefore be more acculturated than latino farmworkers who have more recently moved to the us in addition the pra focus group discussions included sections of hri education which could lead to bias in participant responses however educational exercises always occurred after participants shared their comments about hri topics another limitation is that for most reported beliefs we did not delve into the underlying reasons for these beliefs our study was not designed to specifically compare male and female participant responses we also did not measure the amount of time working in agriculture or specifically address acclimatization the relatively large diurnal temperature variation in wa may contribute to suboptimal acclimatization and previous studies have suggested that poor acclimatization in the setting of a heat event or a sudden increase in exertion may increase the risk of hri in wa workers 11 finally in this qualitative hypothesisgenerating study we did not quantify participants responses or obtain objective data on practices and behaviors we did not validate reported practices using field observations conclusions we identified potential barriers to hri prevention and treatment related to hydration certain hri treatments clothing use and the desire to lose weight among latino farmworkers strategies to address potential barriers to hri prevention and treatment in this population may include engineering administrative and health education and health promotion strategies at individual workplace community and societal levels 444 evaluation of the effectiveness of these interventions is needed although latino farmworkers in our study were able to describe hri risk factors reported practices were not necessarily consistent with reported knowledge further study is needed to elucidate 1 why knowledge of hri symptoms and risk factors may not necessarily translate into such practices as adequate hydration with recommended beverages wearing optimal clothing in hot conditions and rapid cooling of individuals with hri and 2 how knowledgebehavior gaps may be influenced by certain cultural beliefs competing health priorities and workplace hazards and a lack of perceived ability to exert personal control over certain hri risk factors a better understanding of hrirelevant knowledgebehavior gaps among farmworkers may lead to the development of additional strategies for hri prevention additional file additional file 1 participatory rural appraisal focus group facilitators guide outline competing interests the authors declare that they have no competing interests authors contributions ml participated in pra focus groups led data analysis efforts and participated in manuscript writing and revision jk organized contributed to the design of and participated in pra focus groups and participated in manuscript revision pp led pra focus groups and participated in manuscript revision mn participated in pra focus groups data analysis and manuscript revision mp participated in pra focus groups data analysis and manuscript revision hmr participated in pra focus group design and manuscript revision jts participated in study design pra focus groups and manuscript writing and revision all authors read and approved the final manuscript

background heatrelated illness hri is an important cause of nonfatal illness and death in farmworkers we sought to identify potential barriers to hri prevention and treatment in latino farmworkerswe conducted three semistructured focus group discussions with 35 latino farmworkers in the central washington usa area using participatory rural appraisal techniques interviews were audio taped and transcribed in spanish three researchers reviewed and coded transcripts and field notes and investigator triangulation was used to identify relevant themes and quotes results although the majority of participants in our study reported never receiving formal hri training most participants were aware that extreme heat can cause illness and were able to accurately describe hri symptoms risk factors and certain prevention strategies four main observations regarding farmworkers hrirelevant beliefs and attitudes were identified 1 farmworkers subscribe to varying degrees to the belief that cooling treatments should be avoided after heat exposure with some believing that such treatments should be avoided after heat exposure and others encouraging the use of such treatments 2 the desire to lose weight may be reflected in behaviors that promote increased sweating 3 highly caffeinated energy drinks are preferred to increase work efficiency and maintain alertness and 4 the location of drinking water at work eg next to restrooms and whether water is clean but not necessarily chemicallytreated are important considerations in deciding whether to drink the water provided at worksites conclusions we identified potential barriers to hri prevention and treatment related to hydration certain hri treatments clothing use and the desire to lose weight among latino farmworkers strategies to address potential barriers to hri prevention and treatment in this population may include engineering administrative and health education and health promotion strategies at individual workplace community and societal levels although farmworkers in our study were able to describe hri risk factors reported practices were not necessarily consistent with reported knowledge further study of potential knowledgebehavior gaps may uncover opportunities for additional hri prevention strategies farmworkers and employers should be included in the development and evaluation of interventions to prevent hri

introduction sexuality is an integral part of ones personality it includes everything about maleness or femaleness that is thinking and behavioral reaction to person 1 sex is still a taboo subject in our society because it is equated with just a physical act or child birth but sexuality includes the process of growing up puberty adolescence marital post marital sexual relationship conception contraception childbirth menopause etc 1 early education on sex is a very sensitive subject that is still considered a taboo in indian society and this topic is not discussed so much so far even there is a growing recognition of the need to inculcate responsible reproductive behavior among the adolescents thus before formally introducing the topic of sex education it is extremely important to know the perception of people parents teacher and school children regarding sex education to avoid any adverse effects 2 adolescents tend to discuss sexuality with friends and classmates they gather information from friends servants neighbors throughout prints electronic medias etc often this information is wrong and unscientific this often leads to anxiety negative attitude phobia and misconception etc 3 parents are uncomfortable in talking about sexuality with children you dont have to tell them they know it all is what the new age parents think about their teens most parents in india are not aware of their role in imparting sex and sex education 4 sex education is about biology and the sexual act with need to be clarified 118 sex education looks at the total persona or understanding of our bodies of our motions of intimacy in relationship our evolution as sexual beings and our safety from sexual abuse and maintaining reproductive health 5 sex education is important because sexual phobia affect the physical emotional and academic growth of the child argues dr padmini prasad noted gynecologist and sexologist she spoke to deccan herald about the need for sex education in schools and colleges 6 a study was conducted on valuesbased sexuality education the teenage pregnancy rate remains high and more and more people are infected with sexually transmitted diseases and aids the most sex education is limited to anatomy and sexual abstinence most people approved of sexuality education in the schools including contraceptive information youth armed with knowledge about sex tend to delay first intercourse and use of contraceptives 7 the investigator was motivated to take puc students as a population for the study because the sex education is not included in their curriculum when the pu students learn they can impart sex education to their peer group even it can be utilized in their own personal life also thus sex education can be utilized by all objectives 1 to assess the knowledge and attitude regarding sex education among the students of selected pre university colleges 2 to find out an association between levels of knowledge regarding sex education among the students of selected pre university colleges and with their selected socio demographic variables 3 to find out an association between levels of attitude regarding sex education among the students of selected pre university colleges and with their selected socio demographic variables hypothesis h1 the levels of knowledge of pu students regarding sex education will be significantly associated with their selected personal variables h2 the levels of attitude of pu students regarding sex education will be significantly associated with their selected personal variables methodology research approach an quantitative research approach research design descriptive survey design study setting pre university colleges of vijayapura district karnataka population students of pu colleges sampling technique nonprobability convenient sampling sample size 60 source of data collection primary and secondary data will be collected from the students of pre university colleges method of data collection selfreport tools of data collection the tool for data collection was divided into 3 parts which consists of demographic data structured knowledge questionnaire and structured attitude scale  procedure of data collection after obtaining permission from concerned authority of selected pre university colleges vijayapura and consent from subjects the data was collected by 60 participants using structured knowledge scale and attitude scale approximately 45 minutes were spent for collecting data results section 1 description of selected personal variables of participants the data presented in the table 3 depicts the participants level of knowledge regarding sex education it reveals that majority 52 of participants were had moderate level of knowledge 7 of participants were had poor level of knowledge and remaining 1 of participants were had good level of knowledge level of knowledge c findings related association between levels of knowledge and attitude with selected socio demographic variables of participants knowledge the computed chisquare value for association between pretest level of knowledge of pu students regarding sex education is found to be significant for educational qualification of parents and not found to be statistically significant at 005 levels for age gender religion place of residence previous knowledge on sex education and source of knowledge regarding sex education attitude the computed chisquare value for association between pretest level of attitude of pu students regarding sex education is found to be statistically significant at 005 levels for religion and not found to be statistically significant at 005 levels for age gender place of residence educational qualification of parents previous knowledge on sex education and source of knowledge on sex education conclusion the findings revealed that pre university students were had moderate level of knowledge and favorable attitude towards sex education this suggests that there is a need for the education for the adolescent students for the prevention of sexually transmitted disorders and improves their knowledge attitude and practice related safe sexual life conflict of interest not available financial support not available

background sexuality is an integral part of ones personality it includes everything about maleness or femaleness that is thinking and behavioral reaction to person sex education is about biology and the sexual act with need to be clarified sex education looks at the total persona or understanding of our bodies of our motions of intimacy in relationship our evolution as sexual beings and our safety from sexual abuse and maintaining reproductive health methodology a quantitative approach with descriptive survey design was adopted for the study the samples from the selected pre university colleges of vijaypura district were recruited by using non probability convenient sampling technique the samples of present study comprises of 60 pre university college students the tools used for data collection was structured knowledge questionnaire and attitude scale results the participants knowledge mean was 1778 median was 17 mode was 17 with standard deviation 413 and score range was 20 and the participants attitude mean was 794 median was 815 mode was 79 with standard deviation 1117 and score range was 53 with regard to knowledge majority 52 867 of participants were had moderate level of knowledge 7 117 of participants were had poor level of knowledge and remaining 1 17 of participants were had good level of knowledge and with regard to attitude majority 47 783 of participants were had positive attitude 12 20 of participants were had favorable attitude and remaining 1 17 of participant were had non favorable attitudethe findings revealed that pre university students were had moderate level of knowledge and favorable attitude towards sex education this suggests that there is a need for the education for the adolescent students for the prevention of sexually transmitted disorders and improves their knowledge attitude and practice related safe sexual life

topics in language disordersjanuarymarch 2017 barriers to or facilitators of communication for people with aphasia however this research is focused on understanding how the environment impacts the present communication and participation of people with aphasia the chronic nature of aphasia necessitates that researchers and clinicians also consider how peoples circumstances and therefore their communication needs and participation needs change over time this in turn requires clinicians to consider the many different environments that impact the communication and participation of people with aphasia in the long term and the consequences on their future health and wellbeing the importance of exploring the interplay between aphasia the environment and longterm health and wellbeing was highlighted when the first author met hank 1 they were both members of a volunteer aphasia advocacy group that met once every two months to develop services and provide a support network for people living with aphasia during the four years they worked together hank gave several presentations to community groups and to students about his stroke and living with aphasia through listening to these presentations as well as through social conversation with hank the author got to know him well his story raises important questions about the cumulative impact of the environment on the communication participation as well as health and wellbeing of people with aphasia over time hanks story may cause clinicians to reconsider how they conceptualize the impact of aphasia over time questions about longterm impacts of environmental factors are explored in detail later in part 1 of this article with hanks permission the first author recalls his story and how his life changed and evolved in the 15 years since the onset of aphasia in part 2 the authors explore how two different conceptual frameworksthe icf and the social determinants of health model 1 pseudonym account for the changes to hanks health and wellbeing over time finally part 3 includes a review of the research literature to explore the evidence for a relationship between aphasia and the sdh part 1 hanks story hank a white australian man was in his 40s and married with four children at the onset of aphasia he worked fulltime for a large national company negotiating complex sales and contracts and his wife beth worked parttime in retail although he often travelled interstate on business he was working in his home town of melbourne when he suddenly collapsed and was rushed to the nearest hospital subsequently hank was taken to one of the large publically funded tertiary hospitals that serve melbournes population of 45 million people his recollections of those days in hospital were vague however he recalled the doctors telling him that he had had three strokes in that first week his only other memories were that he could hardly talk or walk after several months of inpatient rehabilitation he was discharged home at the time he had an expressive and receptive aphasia and a persistent rightsided weakness but was able to walk with a stick despite the improvements he had made his aphasia meant that he could not go back to his former job as a result he lost the enjoyment and challenge of work that he loved he lost contact with work colleagues and he lost his substantial income the financial implications were serious all four children were attending a private school the eldest child finished her final year of high school but the family could no longer afford the school fees for the younger children who had to move to the local governmentfunded secondary school thus they lost contact with families they had known in the school community for years hank reported that the stress of all the changes was terrible and he and his wife separated within 2 years hank moved into the consequences of the consequences 87 a private rental on his own he was offered work through a disability employment agency which entailed packing envelopes in a mailroom alongside people with intellectual disabilities he reported attending for a while but ultimately he found it too depressing so he left with only a disability pension as income hank found living on his own too expensive so he moved into accommodations where the costs of rent and bills are shared he said he did not like living in a shared house and the house was not adapted to suit his needs as there were no rails on the stairs or in the bathroom furthermore he said his aphasia made it difficult for him to find the right person to live with and he was worried that his housemate would take advantage of him as he was living on a disability pension he was eligible for public housing he was looking forward to having his own place but there was a fiveyear waiting list around that time hank was diagnosed with depression in talking about how he managed every day hank said that he was okay but that he still needed occasional help with communication for example when his car needed to be fixed he reported that he did not really understand what the mechanic was talking about therefore he did not really know what the problem was with his car and was worried that he had been charged too much to get it fixed he also said he needed help with his computer his email often did not work and he could not work out how to fix it after hank did not attend the aphasia group for two months the author learned that he had fallen on the stairs at home and broken his ankle he was admitted to hospital and had another short period of inpatient rehabilitation back in his share house he said his mobility was worse but he was now the highest priority on the public housing list the following month he moved into his own singlelevel onebedroom unit reflecting on the events that occurred in the 15 years following hanks stroke provides a unique insight into one australian mans experience of living with aphasia the immediate consequences of his stroke and aphasia such as being unable to return to his former job would be familiar to clinicians and researchers but hanks story suggests that there are longterm consequences of aphasia consequences of aphasia in other words there are secondary consequences of the initial consequences of aphasia that are not immediately apparent in hanks case one could speculate that the stroke and aphasia contributed directly to his economic challenges and indirectly to the demise of his marriage both of which in turn contributed to his depression furthermore it is probable that his financial difficulties and separation meant hank had to live in a shared house where he felt unsafe one could even surmise that these consequences contributed to the deterioration of his health culminating in his broken ankle hanks story is unique but it is not an isolated example it raises questions that have broader implications including the essential question addressed in this article is there a conceptual framework that can explain the sequence of challenging events that can follow stroke and aphasia in cases like hanks in the following sections the authors explore how two different conceptual frameworks could account for hanks story and the implications each might have for reducing barriers to longterm health and participation for people with aphasia part 2 applying different conceptual models to hanks story applying the icf to hanks story helps to understand the current consequences the icf is a biopsychosocial framework of health and healthrelated conditions it has been used in speechlanguage pathology to describe communication and swallowing disability the icf consists of four components body functions and structures activities and participation environmental factors and personal factors all of which contribute to a persons experience of functioning disability and health the icf provides a way to conceptually understand the different factors that influence a health condition such as aphasia a speechlanguage pathologist working with hank could apply the icf to hanks situation to capture the wideranging factors influencing his aphasia for example the clinician could describe his language deficits or describe the consequences of the language deficits in terms of his communication activity limitations and participation restrictions these might include the range of communication activity limitations related to his interpersonal relationships such as difficulty expressing feelings difficulty understanding intent and difficulty adjusting to a change in topic furthermore the slp could consider how these different communication activity limitations combine to result in participation restrictions such as difficulty in maintaining his spousal relationship the icf framework also provides a useful framework to think about how the communication environment might be creating barriers to or facilitating hanks ability to communicate and participate consideration of environmental factors might prompt the slp to wonder if hanks important communication partners such as his wife and daughters have the knowledge and skills to communicate with hank finally the icfs personal factors component might prompt the slp to consider if hanks personality his knowledge of stroke and aphasia and his ability to cope with such a dramatic loss might also be influencing his ability to communicate some of these factors are depicted in figure 1 the icf framework can be applied to explore the factors influencing hanks aphasia at any point in time after his stroke figure 2 provides a hypothetical example of the factors that may have influenced hanks experience of aphasia many years after his stroke in summary the icf provides a conceptual framework to describe hanks functioning and disability at a particular moment in time however it does not provide a way to conceptualize how current level of functioning and disability such as difficulty participating in relationships or difficulty reading complex information may influence health and wellbeing over time is there another conceptual model that functioning disability and health by world health organization 2001 geneva switzerland author offers guidance in regard to potential longterm consequences applying the sdh to hanks story helps determine the possible longterm consequences the social determinants of health the sdh model provides a different conceptualization of health one that identifies the social factors that influence health and wellbeing in the long term the sdh may provide a better account of the factors contributing to hanks dramatic change in circumstances from being a successful executive living with his wife and children with financial means and several social networks to being an unemployed recipient of a disability pension living in shared accommodations where he does not feel comfortable or safe the sdh model as depicted in figure 3 states that social factors directly influence a persons material social psychological and biological circumstances which in turn influence a persons health and wellbeing according to the sdh it is not simply that disease or injury causes poor health and wellbeing rather it is the complex interplay of social factors that determine the likelihood that an individual will experience disease or injury that leads to poor health and wellbeing a wealth of evidence world wide demonstrates how different social factors influence population health and wellbeing for example mortality rates for both men and women steadily increase as poverty increases this pattern is evident both within individual countries and across different countries mortality rates are related to ethnicity education and income for example indigenous australians live approximately 16 years less than nonindigenous australians in the united states men with a low education live on average 65 years less than men with university degrees similarly women on low incomes live on average 5 years less than affluent women as davidson states some differences in population health such as health differences due to genetic factors may be unavoidable these differences are called health inequalities however if the variations are avoidable like the variations in health described earlier then they are no longer considered to be health inequalities but health inequities health inequities occur because of the way society is structured and the the sdh model proposes that there are structural determinants of health such as the socioeconomic and political context that influence social position in society the socioeconomic and political context is proposed to influence a persons access to education income and occupation the socioeconomic and political context may also have differential impact on people depending on their gender and ethnicity these structural determinants are hypothesized to effect intermediary determinants of health such as a persons material circumstances psychosocial factors and behaviors the health system in which an individual finds himself or herself is also considered an intermediary determinant of health because it influences a persons access to health services such as the specific criteria around access to health care and health care resources apart from an individuals behaviors and biological factors all the other factors in the sdh model are environmental factors some factors such as material circumstances and psychosocial networks are part of a persons immediate environment whereas factors such as the socioeconomic context the political context and the health care system are part of a persons broader environment can the sdh model be applied to individuals such as hank to explain the series of events that occurred to him after his stroke and aphasia applying the sdh to hanks story the sdh is a cyclical model that depicts how an individuals health and wellbeing are influenced by structural and intermediary determinants of health therefore in applying the sdh to hanks story the authors acknowledge that there were structural and intermediary determinants of health already operating that had influenced hanks health and wellbeing prior to his stroke these included copyright © 2017 the authors published by wolters kluwer health inc the consequences of the consequences 91 the prevailing australian socioeconomic and political context at the time as well as hanks prestroke social position his preexisting material circumstances the degree of social cohesion psychosocial circumstances behavioral circumstances and biological factors the application of sdh to conceptualize the consequences of aphasia over time begins at hanks discharge from formal rehabilitation services approximately 3 months after his stroke and consider the possible interplay of social determinants of health from this time on although all social determinants influence health and wellbeing the particular social determinants thought to play a key role in influencing hanks health and wellbeing are highlighted in figure 4 how might structural determinants influence hanks longterm health and wellbeing the sdh leads to reflection on how structural determinants of health may have influenced hanks health and wellbeing after his stroke subsequent aphasia and reduced mobility that is were there any factors in the environment related to government and reflected in australian macroeconomic social andor health policies that impacted hanks health and wellbeing did australian cultural and societal norms and values regarding stroke and disability affect hank two structural determinants that influence a persons social position income and occupation are considered later hanks stroke aphasia and reduced mobility meant that he could no longer participate topics in language disordersjanuarymarch 2017 in a highstatus highincome job his inability to resume his prestroke occupation had many consequences including a dramatic reduction in income however government policy did play a role although considerably less than the income he had previously received hank received some income through a governmentfunded disability pension this pension also entitled him to a concession on the cost of some essential services such as electricity the overall value of this pension would determine the extent to which it served as a protective factor for hanks health and wellbeing there was also a government service to support people with acquired disabilities to find employment however it is important to consider whether there were any environmental factors operating within these government services that created barriers for hank given his aphasia specifically did the people responsible for finding hank employment after his stroke understand what aphasia is were they able to communicate with him in a way that revealed his competence it is unknown if the disability employment staff had an understanding of aphasia and provided hank with a supportive communicative environment or not instruction in aphasia and supportive communication may have benefited their assessment of his capabilities and the work opportunities he was offered how might intermediary determinants influence hanks longterm health and wellbeing the sdh proposes that social position indicated by occupation and income has a direct bearing on intermediary determinants of health such as psychosocial factors material circumstances and access to health care the sdh may be useful when considering the longterm impact of these environmental factors on hanks health and wellbeing the authors aim to initiate a conversation within aphasiology regarding the longterm impact of aphasia that can inform future research service planning and delivery and resource allocation psychosocial factors the sdh model suggests that the fall in hanks social position as a result of his loss of occupation and income may have resulted in a range of negative psychosocial consequences these might include living with the stress of debt the loss of his workrelated social network the loss of the school social network and the breakdown of his marriage it is also important to consider the interactions among aphasia the environment and these psychosocial consequences whereas the environmental supports provided to hank were unknown the sdh can prompt clinicians to consider what they might need to be for example if there were a communicatively accessible financial counselling service hank and his wife would have been able to get financial advice and support in a way that hank could understand this support might have been in the form of supporting hank to continue to be involved in making financial decisions andor giving him the opportunity to be involved in appointing someone to assist with these decisions similarly as hank and his wife experienced their relationship deterioration communicatively accessible relationship counselling services might have meant that they would have been able to get the psychological and emotional support that they needed the consequences of losing his job and his income also meant that hank lost important social networks environmental factors related to the knowledge skills and attitudes of family friends school colleagues as well as work colleagues become critical having communication partners with the skills and knowledge to support a person with aphasia in conversation and having opportunities to develop new social networks may have provided hank with a communicatively supportive social network the loss of social networks alone can be detrimental to feelings of belonging and overall health and copyright © 2017 the authors published by wolters kluwer health inc the consequences of the consequences 93 wellbeing material circumstances another important intermediary determinant of health is a persons material circumstances such as housing this prompts a number of important questions around how a range of environmental factors such as the accessibility of legal services and the availability of advocacy services may have contributed to hanks financial situation and the quality of his housing although hank did not mention it explicitly in his story thinking about the relationship between aphasia and the social determinants of health may prompt clinicians to consider what if any communicative support hank received during the complex legal process of divorce and how this might have affected the amount of money he received as part of the financial settlement this is important because it would have had implications on many aspects of his life including the quality of rental accommodation he could afford a better financial settlement might have made the difference between living in a place where he felt safe or in a place where he did not feel safe another environmental factor relates to the presence of advocacy services there are no advocacy services for people with aphasia in melbourne if hank had had access to an advocate he might have been able to find affordable and acceptable accommodations for himself alternatively an advocate might have been able to help him find a shared house where he felt both physically safe and psychologically comfortable an advocate might also have supported hank when more complex communication situations arose such as understanding his rights and responsibilities as a tenant negotiating with his housemates on bills negotiating with the landlord about getting stairrails in place and negotiating car repairs with the mechanic the health care system another intermediary determinant of health is the health care system itself the sdh provides a way of explaining how access or a lack of access to the health care system can serve to protect a persons health or further compromise it health care policies determine who is able to access health care and the cost of this access given that hank was in receipt of a disability pension and living in australia he would have received free transport to hospital free hospital care and free inpatient rehabilitation a publically funded health care system facilitates access for all australians to basic health care however on his admission to hospital with a broken ankle the sdh model prompts clinicians to consider whether there were any environmental factors that could have influenced hanks access to this health care given that he had a preexisting aphasia a recent metasynthesis of the environmental factors that influence health care for people with communication disabilities based on observations in melbourne hospitals identified that there are no systems in place to detect patients with preexisting communication disabilities and there are no systems in place to equip health care providers with the knowledge skills and resources to support people with communication disabilities to participate in their health care it is possible that health care staff were not aware that hank had aphasia that the slps were not aware of hanks admission and that staff did not modify the information they provided him about the assessment and treatment of his broken ankle ineffective communication might have placed hank at risk of a preventable adverse event in hospital and might have undermined an optimal recovery in summary the sdh model prompts consideration of the effect of aphasia and the environment beyond communicating in a particular activity or participating in a certain event it encourages consideration of how aphasia as a chronic condition may make an individual more vulnerable to a set of conditions such as poorer housing and fewer social supports which in turn place him or her at topics in language disordersjanuarymarch 2017 greater risk of poorer health and wellbeing over time for clinicians and researchers the sdh identifies some environments that may be particularly important to target in order to enhance and protect the longterm health and wellbeing of people with aphasia these include government policies employment income education psychosocial networks and health care environments the sdh also prompts new questions in terms of how aphasiologists define and measure the success of aphasia interventions finally it highlights the need for support services for people living with aphasia when life circumstances change below the authors review the research evidence to explore the relationship between aphasia and the structural and intermediary social determinants of health part 3 is there evidence of a relationship between aphasia and sdh this section provides an overview of the research evidence in relation to aphasia the communicative environment and sdh the authors have not identified any studies that apply the sdh model to aphasia and its consequences however as described later some literature exists examining aphasia and these health and wellbeing determinants exploring the structural determinants of health and aphasia within the sdh model structural determinants of health refer specifically to interplay between the socioeconomicpolitical context structural mechanisms generating social stratification and the resulting socioeconomic position of individuals as such the authors begin by discussing the evidence regarding the citizenship experiences of people with aphasia and the environmental factors that influence their access to government services the structural determinants of health both influence and are influenced by an individuals socioeconomic position the most important indicators for socioeconomic position are occupational status level of education and income level to further illustrate the impact of aphasia on these indicators of socioeconomic position the following provides an overview of the literature in relation to the influence of aphasia and the environmental factors that influence access to education aphasia civic engagement and access to government agencies citizenship is a concept which encompasses connection to wider society rights and responsibilities and the capability for exerting power and influence people with aphasia largely define citizenship in terms of community involvement although some suggest a broader definition involving dealing with government agencies findings from interviews with people with aphasia suggest that their desire for civic involvement is driven by a wish to engage in activities beyond the home and by a desire to act as agents for change for both themselves and others in the populations they represented an investigation by howe et al found that the environmental factors that influenced the community participation of people with aphasia included awareness of aphasia opportunity for participation familiarity availability of extra support for communication communication complexity message clarity and time available for communication however little is known about the relationship between environmental factors and participation or the impact of environmental level interventions on the participation of people with aphasia the ability of people with aphasia to engage with government agencies has been reported to be fraught with challenges as an example people with aphasia have been found to experience difficulties accessing services through centrelink the public interface of the australian governments department of human services responsible for the provision of social security payment to among copyright © 2017 the authors published by wolters kluwer health inc the consequences of the consequences 95 others people with disabilities in interviews about their experiences with this government agency people with aphasia reported that additional time accessible interactions information and processes and service relationships with individualized approaches were needed to facilitate their engagement but that none of these things was currently being provided aphasia and access to education the notion of access to education is important in addressing both equity within the education system and opportunities that seek to grant equal opportunities in employment beyond course completion there has been very little research on the environmental factors that influence access to education for people with aphasia the number of people with aphasia who make the decision to either enter or return to higher or further education following the onset of aphasia is unknown existing literature on the experiences of people with aphasia in the educational sector describes both experiences in which the challenges of trying to access education lead to withdrawal and those in which academic success was achieved despite these challenges that is in addition to the persons language impairment the findings reported in the literature revealed environmental barriers experienced by people with aphasia in the educational setting these barriers can grossly be categorized into two areas poor awareness of aphasia and its consequences within the education sector and a lack of responsive and flexible systems to support the needs of people with aphasia in educational settings these categories are explored in further detail later poor awareness of aphasia and its consequences within the education sector to meet the needs of people with aphasia in an educational context their needs must first be understood clearly by the educational provider when staff have a lack of awareness or understanding about a students disability students are more likely to have negative educational experiences facilitating an understanding of aphasia within educational settings is likely to be made difficult by a poor public awareness and understanding of the aphasia in the community the invisible nature of aphasia may mean the obligation of disclosure and seeking accommodations lies with the student with aphasia a process that has been reported as difficult for individuals with a variety of disabilities and may be made more difficult for people with aphasia as a result of their linguistic deficits lack of responsive and flexible systems to support the needs of people with aphasia in educational settings because of the highlevel language demands in educational settings and the communication difficulties inherent to aphasia people with aphasia may be limited in their capacity to participate in formal education without learning support aphasia can restrict a persons ability to engage with the process of education which is normally conducted in the spoken and written language modalities including their ability to meet linguistically focused outcome assessment requirements parr et al identified a number of specific teaching methods that contribute to educational success for people with aphasia however it has been reported that these methods are not commonly employed exploration of education service provision to people with aphasia by jordan and kaiser in the united kingdom identified a number of smallscale examples of collaboration between slp services and adult education providers to meet the needs of people with aphasia however challenges related to conflicting philosophies were identified despite this the value of collaborations between slps and academic staff was also identified by bruce et al they suggest that the topics in language disordersjanuarymarch 2017 model and location of slp services should enable people with aphasia to seek support from slps as their educational circumstances and needs change exploring the intermediary determinants of health and aphasia the structural determinants of health for people with aphasia as discussed earlier operate through a series of intermediary determinants of health those structural determinants can be considered to influence these intermediary determinants the main categories of intermediary determinants of health as outlined in the sdh model are material circumstances social cohesion psychosocial factors behaviors and biological factors the following section reviews the evidence regarding environmental factors that influence access to interpersonal relationships for people with aphasia and access to the health care system for people with aphasia aphasia and interpersonal relationships without the speed or ease of prestroke verbal output are people with aphasia able to maintain and create new social relationships language has been described as the currency of relationships thus the loss of language with aphasia deprives the individual of one of the fundamental ways to maintain relationships there is substantial evidence to support the assertion that aphasia has a profound impact on interpersonal relationships described as a psychosocial factor within the sdh the effects of aphasia have been described in regard to many different kinds of relationships including intimate relationships relationships with children and relationships with friends there are no data available on the number of marital relationships that break down following one person acquiring aphasia there are some limited studies on the perceptions and experiences of spouses of people with aphasia that suggest that aphasia impacts spousal relationships in positive and negative ways recent research also indicates that many spouses of people with aphasia experience third party disability that may further compromise their ability to support the relationship for example family members of people with aphasia are at risk of developing depression deterioration in their own health changes to their own social relationships and recreational activities positive and supportive intimate relationships are a powerful contributor to living successfully with aphasia access to supportive and meaningful relationships was one of the seven themes identified in a qualitative metaanalysis of interview data from people with aphasia family members and slps the authors concluded that their study reinforced the idea that living successfully with aphasia can only occur within the context of love acceptance friendship and support from others this research supports the idea that access to and participation in meaningful personal relationships may serve to buffer people with aphasia against some of the negative impacts of aphasia relationships with children appear more resilient to the impact of aphasia in a study of 83 people with chronic aphasia 71 reported that they had the same amount of contact with their children following the stroke this is in keeping with evidence from the broader stroke population however less is known about the relationships between younger children and their parents when parents still have caring responsibilities outside family relations evidence suggests that aphasia affects the nature and quality of interactions between people with aphasia and their friends this manifests in reduced social networks andor reduced quality of social relationships hilari and northcott found that 64 of 83 people with aphasia interviewed reported reduced interactions with friends and 30 reported having no close friendships whatsoever this loss of friendship is uniquely attributed to the presence of aphasia rather than the stroke more generally a survey of people with aphasia in the united states found that 75 felt others avoided them because of their communication difficulty the evidence to date creates a picture of shrinking social networks while the nature of aphasia further restricts opportunities and ability to seek emotional and informational support it is still possible for people with aphasia to develop and maintain friendships but this requires the two way hard work of friendship as well as creativity and resourcefulness aphasia and access to health care recent research has addressed the factors that influence the success and failure of communication between patients and health care providers across the continuum of health care when patients and health care providers manage to establish shared meaning positive health care outcomes are likely conversely communication breakdowns within the health care sphere lead to negative health outcomes increased length of hospital stay higher rates of readmission increased costs an increase in negative events and a reduction in patient satisfaction without access to appropriate and relevant communication support people with aphasia may experience a reduction in their capacity to express their health care needs and actively participate in decisions regarding their own health care poor communicative access within health care can lead to damaging and negative experiences for people with aphasia including a reduction in the reported satisfaction with the health care experience an increased risk of inappropriate or inadequate service provision and an increased likelihood of the occurrence of adverse events conclusion the sdh model offers clinicians and researchers a way to conceptualize the cumulative effect of inaccessible environments on the longterm health and wellbeing of people with aphasia the authors are not suggesting that hanks story is typical for people who acquire aphasia nor is his story rare aphasiologists have much to learn regarding how sdh can enrich approaches to aphasia assessment decision making around the aims and type of the interventions offered and measurement of intervention effects for slps the sdh may challenge traditional views of the clinicians role in the lives of people with aphasia viewing the impact of aphasia decades after the onset emphasizes the importance of understanding the impact of many different environments on people with aphasia the sdh suggests that slps need to work beyond the level of the individual with aphasia in formal rehabilitation settings to address the vast range of systems services and policies that have the potential to damage or enhance the longterm health and wellbeing of people with aphasia hanks life following the onset of aphasia is one example of how many different facets of the environment appeared to influence his health and wellbeing for the long term his story illustrates the disconnect between how an individual might present initially in a health care setting and the foreseeable and unforeseeable impacts that aphasia may have on that persons health and wellbeing in the future indeed hanks story serves to highlight the powerful topics in language disordersjanuarymarch 2017 domino effect that can result from changes in one aspect of the model which turns a presentday health condition into a longterm social problem that impacts all aspects of life given the chronic nature of aphasia and that limited public health care resources are typically frontloaded to acute care and rehabilitation within the first year poststroke the sdh poses interesting questions on how clinicians might serve the needs of people with aphasia by recognizing and reducing the environmental barriers to full participation in life to optimize health and wellbeing for the long term

understanding the impact of the environment on the participation of people with aphasia depends on ones perspective a longterm perspective provides a unique insight into the myriad of ways in which the environment can influence the participation of people living with aphasia over decades in this article the authors present the reallife story of hank who has lived with aphasia for more than 15 years the authors consider how 2 different conceptual frameworksthe international classification of functioning disability and health and the social determinants of healthaccount for hanks experience the international classification of functioning disability and health is useful to conceptualize the range of factors that influence living with aphasia at a particular point in time in contrast the social determinants of health is useful to conceptualize the cumulative impact of living with aphasia on longterm health and wellbeing viewing aphasia as a social condition that impacts social determinants of health has potentially wide ranging implications for service design and delivery and the role of speechlanguage pathologists

background cannabis is the most commonly used illicit drug worldwide 1 and spain has one of the highest consumption rates in europe 2 in 2019 105 of the population had used cannabis in the past year in total 8 had used cannabis in the past 30 days and 29 used it daily 3 research has found that daily or neardaily users account for almost 80 of total cannabis consumption 4 5 6 their use patterns require more detailed analysis because they consume larger doses and take it several times during the waking day 7 8 9 10 therefore they are more vulnerable to acute and chronic health or psychological harms associated with cannabis use including impaired psychomotor and cognitive functioning memory deficits dependence respiratory impairments onset or amplification of psychosis in predisposed individuals and driving impairment with risk of traffic injuries 11 12 13 14 15 daily use in adolescents and young adults is also associated with early school leaving increased risk of using other illicit drugs and cognitive and psychological deterioration 12 13 14 15 experts agree that standardized tools for measuring cannabis exposure are necessary to unify the evidence on the antecedents correlates and consequences of use 16 surveys tend to distinguish people who use cannabis heavily based on frequency of use and rarely ask about average daily intake however dnd users consume remarkably diverse amounts of cannabis for instance gamella and jiménez 17 found that the number of joints smoked monthly by a sample of 81 spanish daily longterm cannabis users ranged from 10 to 300 similar findings were reported internationally 1018 therefore it seems that a more accurate assessment of cannabis use requires assessing both frequency and quantity indeed tomko et al 19 have shown that the sum of the quantity of cannabis used and the frequency of use in the past 30 days significantly improves the prediction of urine cannabinoid level and cannabisrelated problems this study aimed to analyze groups of heavy users according to their use patterns and whether their consumption and its consequences varied we hypothesized that the heavy use category comprises a variety of use patterns associated with different vulnerability for cannabisrelated problems we chose latent class analysis a modelbased clustering methodto uncover these groups in a sample of heavy users this method allows to identify different groups accurately characterizes membership and predicts which case is likely to belong to each group previous studies have utilized lca to identify cannabis user types according to several sets of variables craft et al 20 identified seven classes of pwuc characterized by the probability of using different products herbal cannabis sinsemilla and hashish were associated with increased dependence whereas the consumption of concentrates was associated with diagnosis of mental health disorders davis et al 21 distinguished four groups in a sample of twins and siblings based on the concurrent and simultaneous use of cannabis with tobacco alcohol and other illicit drugs simultaneous use of cannabis and tobacco was associated with the most problematic outcomes including depression illicit drug use and cannabis use disorders two studies found four and five subgroups respectively of persons who use cannabis based on the products they used and their pastmonth use frequencyintensity 2223 heaviest users who consumed plant products concentrates or both frequently and spent more time high were more susceptible to experiment adverse consequences another two studies uncovered four and five classes of users respectively according to consumption frequency quantityintensity and cannabisrelated problems 2425 both studies identified three groups among heavy users with increasingly more negative consequences to conduct our lca we included only variables affecting the magnitude of exposure to cannabis and its effects we excluded consumption method because all our participants principally smoked cannabis in joints smoking combusted cannabis is the predominant method among pwuc in spain in 2019 98 of pastmonth cannabis users reported smoking it in a joint 87 mixed it with tobacco 3 we chose for the postlca analysis variables describing social health or behavioral characteristics or outcomes of cannabis use relevant to public health we followed the previous literature to select these indicators sociodemographic factors settings and sources of cannabis use other drug use and health outcomes 26 this study aims to contribute to the knowledge of pwuc heavily in spain their demographics use patterns and experienced consequences we applied lca to 1 identify classes in heavy users according to their cannabis exposure magnitude 2 examine if there were associations between class membership and other variables and 3 identify which of the examined variables remained as predictors of class membership in a multinomial regression model methods participants and procedure we recruited 380 individuals who had consumed cannabis ≥ 3 daysweek in the past 12 months the dutch cannabis dependence study employed the same eligibility criterion 27 participants were recruited through chain referral and cannabis social clubs in spain from january 2017 to may 2019 involvement was voluntary and anonymous participants were informed about the research aims the institutions responsible and the funding body they provided consent to respond to a paperandpencil selfadministered questionnaire in total 142 participants were members of cannabis clubs these clubs are registered nonprofit associations that organize the production and distribution of cannabis among their adult members we invited members of some cannabis clubs to participate with the help of some of the clubs staff they sent us back the completed questionnaires other club members appeared in the networks of users found by snowball sampling various collaborators help us to follow these networks and to contact participants in different settings variables we selected four variables describing the intensity of cannabis use for lca • the number of weekly cannabis usedays • the number of joints typically smoked in a useday was estimated by responding to the following questions how many joints did you smoke the last time you smoked alone how many joints did you smoke the last time you smoked with others with how many individuals did you share each joint for example smoking one joint alone and three with another individual gives a total of 25 joints if the last consumption day was atypical participants responded to the same questions regarding a regular cannabis use day • cannabis dosage was estimated by selfreport of the number of joints made with one gram of cannabis this method has been previously validated to better estimate average doses per joint at group level compared to other methods such as using a prompt card with realsize pictures of a ruler and different dosages 28 the estimated median in our sample was 028 g per joint very near the 025gram standard unit joint 28 • allday consumption finally individuals had to report if they usually consumed cannabis throughout the waking day or only at specific times the variables selected for the postlca analysis were • 33 34 35 which assesses the frequency of the following events in the past 12 months have you smoked cannabis before midday have you smoked cannabis when you were alone have you had memory problems when you smoked cannabis have friends or family members told you that you should reduce or stop your cannabis use have you tried to reduce or stop your cannabis use without succeeding have you had problems because of your cannabis use all items are answered on a fivepoint scale from 0 to 4 total scores range from 0 to 24 the cutoff points used according to dsmiv criteria were 9 for cud and 12 for cannabis dependence 36 • use of other substances use of tobacco and alcohol in the last month use of inhalants cocaine amphetamine ecstasy lsd sedativehypnotics synthetic cannabinoids and mushrooms in the past 12 months a dummy variable was created to classify individuals that had taken one or more noncannabis illicit substances in the past year statistical analysis we applied lca to cluster participants according to the intensity of their cannabis consumption lca is a statistical procedure used to identify latent groups within a sample by sharing some characteristics the latent groups are inferred from patterns of the observed variables used in the modelling we conducted different lcas to identify classes of pwuc heavily based on patterns of cannabis use we selected four variables to develop the lca number of weekly cannabis usedays number of joints smoked on a typical useday number of joints made from one gram of cannabis and cannabis use throughout the waking day then we explored several solutions beginning with the most parsimonious and increasing the number of latent classes by one to determine the model that featured the best data fit for reasons of interpretability and parsimony we did not use models where the smallest class proportion was 52 37 the first model with this characteristic was the 4class model to determine the number of classes that have the best fit we considered the akaike information criterion consistent aic bayesian information criterion samplesize adjusted bic approximate weight of evidence criterion lower values indicate better fit and parsimony 38 the lomendellrubin test was also computed to compare k1 class and k class models higher p values suggest that the k class model does not fit the data significantly better than a model with one less class finally we estimated the entropy where values 080 indicate a successful classification of individuals into classes after deciding the number of latent classes and using the latent class posterior probabilities individuals were classified in their most likely class in the next step anova and chisquared tests were used to compare continuous and categorical variables respectively in the case of multiple comparisons holmbonferroni correction was performed finally we applied multinomial regression to identify the factors associated with latent class membership this regression only included statistically significant variables from the previous step all analyses were conducted in stata results latent class model comparisons of the lca modelfit statistics suggested that the threeclass model provided the best fit figure 1 presents the predicted mean of all variables used in the lca analysis by class the three latent classes show a clear division according to cannabis use intensity • bivariate associations sociodemographics differences among classes for sociodemographic variables are presented in table 2 there were significant intergroup differences regarding agefrom youngest to oldest moderately heavy heavy and very heavy education levels were similar between classes 1 and 2 however the percentage of respondents with education below university level was significantly higher in the very heavy group similarly unemployment was significantly higher in the very heavy group and there were more inactive people among the moderately heavy users the proportions of being employed and monthly income were similar between the three classes there was no difference in the proportion of being married or having a partner characteristics of cannabis use motives for use factor analysis of the five potential motives for cannabis use suggested enhancement motives predominated for all classes followed by coping expansion and social motives conformity motives were rare several significant intergroup differences emerged regarding motives for cannabis use coping motives significantly increased through the classes supply sources table 3 panel c presents the distribution of supply sources among groups typically cannabis was purchased in all classes obtaining cannabis for free was more common in class 1 there were substantial significant intergroup differences in the proportion of users who had obtained cannabis from a social club only 9 of respondents had grown their cannabis plants class 2 included 116 cultivators in contrast with only 24 and 53 in classes 1 and 3 respectively adverse outcomes table 4 panel a provides the bivariate associations between the three subgroups and selfreported adverse outcomes in the past year psychological and social troubles were more prevalent than physical problems across subgroups intergroup differences emerged concerning the proportion of individuals who had experienced psychological disorders family disputes financial problems or received a fine there were considerable significant intergroup differences regarding cast scores overall 592 of users reported cud and 366 dependence significant intergroup differences emerged regarding the consumption of inhalants amphetamine lds and synthetic cannabinoids in the last year use of other substances multivariate associations we conducted a multinomial regression model with all the variables that were statistically significant in the previous bivariate analyses almost all the individuals who had consumed cannabis in a club in the past month had also acquired it there therefore we excluded the variable club as use setting in the regression model and kept only club as a supply source in adverse outcomes we included cast scores instead of the cutoff points for cud or dependence table 5 shows the resulting model compared to the moderately heavy group the heavy group comprised more individuals in the 2130 years age cohort it was less probable that they obtained cannabis for free and more likely that they acquired cannabis in a club compared to the moderately heavy group those in the very heavy group showed a lower proportion of university graduates more years of cannabis use and used it outdoors more it was less probable that they obtained cannabis for free and more probable that they had bought it in a club and had higher cast scores compared to the heavy group subjects in the very heavy group exhibited a lower proportion of university graduates and more years of cannabis use it was more probable that they purchased cannabis in a club and had higher cast scores it was less probable that they had drunk alcohol in the past month in summary age education number of years of use using outdoors obtaining for free buying cannabis in a club cast scores and alcohol use were associated with cannabis use intensity discussion the present study identified three latent classes of pwuc frequently characterized by consumption intensity age education years of use and buying cannabis in a club emerged as correlates of class membership no significant intergroup differences were observed regarding other factorsgender unemployment mode of administration motives and other substance use the prevalence of cud and dependence increased through the classes at least two previous lcabased studies have shown that pwuc are a varied population with dnd users comprising three main groups or categories pearson et al 24 conducted lca on data collected from a sample of college students who had used cannabis in the past f 307 p 0047 coping 27 24 27 29 f 374 p 0024 conformity 1 f 126 p 0285 enhancement f 077 p 0464 medical 29 and whether users consumed cannabis throughout the waking day resulted in clear distinct patterns of use and consequences the heaviest users may be intoxicated throughout the waking day however for some dnd users especially if they consume lower doses at specific times intoxication may not interfere much with their daily life in our study the heaviest users were older had used cannabis use for more years and were less educated older users may have had more time to develop more heavy use patterns since there were no significant intergroup differences in terms of the age of cannabis use onset former research has interpreted earlyonset and prolonged cannabis use as predictors of poorer educational outcomes and unemployment 39 40 41 42 we only observed intergroup differences regarding education future studies should examine correlates between the three groups and other demographics such as gender or employment in larger samples of heavy users for instance in our research 79 of the heaviest users were male but the intergroup gender differences were not significant many studies have reported associations between intensity of cannabis use and consumption is the most significant predictor of cud even when controlling for different products and modes of use 2246 additionally nearly one in three pwuc frequently develops dependence 47 although using multiple products and modes of administration is not common in spain some users are under the effects of cannabis most of the day consumption intensity is a complex category that must reflect the number of hours under the influence of the substance consistent with previous research 24254849 enhancement coping expansion and social motives were the most prevalent cannabis use reasons across classes we did not observe significant intergroup differences regarding reasons for use in the multinomial logistic regression these findings are consistent with those of pearson et al 24 concurrent use of other substances except opioids was common in our sample tobacco and alcohol use in the past month was prevalent across classes and more than half reported having used at least one illicit drug other than cannabis in the past year the prevalence of alcohol use in the past month was significantly lower in the very heavy group other studies have observed this polydrug use in daily users 50 according to the literature tobacco and cannabis seem to be complementary 51 it is less clear if alcohol is a substitute for cannabis 52 more research is needed to clarify the relationships between cannabis and other substances spanish cannabis clubs may have become a principal supply source for the heaviest users in spain we found significant and broad intergroup differences regarding accessing cannabis clubs to obtain and use cannabis on their premises two previous studies of spanish cannabis clubs 5354 found 77 and 68 of their members were daily users respectively most members were longterm cannabis users and they did not change their use pattern after joining the club some authors have pointed out that cannabis clubs could play a relevant role in implementing harm reduction practices 5556 the preference of the heaviest users for this source of supply might support this proposal however in general cannabis clubs have to fill some crucial gaps to implement a harm reduction policy providing information on risks and harms offering health support services for members performing lab tests on the cannabis they supply etc 57 additionally cannabis clubs must reconsider the maximum quantity of cannabis distributed monthly to each membercurrently between 60 and 90 g 56 conduct followups with frequent users advise them to reduce their doses and frequency of use and help problematic users access treatment and health advisory services based on our findings clinical treatment interventions should also pay special attention to the use patterns of pwuc heavily since they are diverse and related to cud further research will need to identify more correlates of class membership which will enable more specific interventions for each heavy user class limitations the study has several limitations firstly we cannot know the representativeness of the sample network sampling is widely used to reduce biases in gathering samples of hardtoreach and hidden populations such as the one targeted in this study 58 this study was not intended to provide prevalence estimates of different user groups that might exist among pwuc but rather to characterize dnd cannabis users and identify correlates of class membership secondly all data were selfreported measures which must be considered when interpreting the results although selfreport is an accepted method for obtaining population behavior information individual bias and memory issues can compromise data accuracy 59 nonetheless we have confidence in the validity of our main findings which are consistent with former studies we believe the set of questions assessing the quantity of cannabis used is reliable we have more reservations about the results related to use of other substances future research will benefit from combining interview assessments biological controls of cannabis use and behavioral tasks to assess more accurate constructs thirdly we could not measure thc content and other cannabinoids in the cannabis herb and resin used by participants which are paramount to assessing the intensity of consumption and its consequences however a previous study 29 did not find large average differences in the potencies of these products in spain nonetheless future research will need to identify the potency of cannabis products to have better control of the study variables conclusion this study suggests that pwuc heavily form three welldifferentiated classes class membership was related to outcomes associated with cannabis use including increased cud and dependence these findings are coherent with former research and highlight the necessity of considering the differences among heavy users to implement harm reduction policies particularly in cannabis clubs and clinical treatment of cud data availability the datasets used andor analyzed during the current study are available from the corresponding author on reasonable request cannabisrelated problems 102425 43 44 45 our participants did not widely acknowledge cannabisrelated problems a third reported psychological and financial difficulties and only 10 health damage in contrast the average cast score was high and notable intergroup differences emerged the proportion of individuals with scores ≥ 9 in the very heavy group was more than two times higher than in the moderately heavy group this difference increased to more than three times when considering scores ≥ 12 these findings are consistent with former research indicating that frequency of competing interests the authors declare that they have no competing interests

background people who use cannabis daily or neardaily vary considerably in their daily dosage and use frequency impacting both experienced effects and adverse consequences this study identified heavy cannabis user groups according to consumption patterns and factors associated with class membershipwe conducted a crosssectional study of 380 spanish residents 618 male average age 303 years who had used cannabis ≥ 3 daysweek throughout the past year participants were recruited through chain referral and cannabis social clubs we applied latent class analysis lca to cluster participants according to use intensity lca indicators included frequency of weekly cannabis use joints smoked each day cannabis dosage and if cannabis was consumed throughout the day or only at specific times associations between class membership and sociodemographics use patterns motives supply sources adverse outcomes and use of other substances were measured using anova and chisquared tests multinomial regression identified the factors associated with latent class membership results three latent classes moderately heavy 218 heavy 682 very heavy 10 had average weekly cannabis intakes of 24 55 and 183 g respectively very heavy users were older χ 2 1777 p 001 less educated χ 2 3680 p 0001 and had used cannabis for longer f 462 p 001 cast scores f 2651 p 0001 increased across the classes the prevalence of pastmonth alcohol use was lower among the heaviest users χ 2 595 p 005 cannabis was usually obtained from a club by very heavy users χ 2 2095 p 0001 conclusions people who use cannabis heavily present three groups according to frequency and quantity of cannabis consumption use intensity is associated with increased cannabisrelated problems differences among heavy users must be considered in harm reduction interventions in cannabis clubs and indicated prevention

background multimorbidity is one of the largest challenges facing health systems worldwide 12 multimorbidityusually defined as experiencing two or more chronic conditionshighlights the limitations of existing health care systems which are often illsuited to meet the needs of those affected traditionally medical practice has focussed on diagnosing and treating single health conditions in isolation 34 multimorbidity is common in the general population 5 6 7 8 and increases with age 59 but it is not limited to the older population since often a greater number of people affected are aged under 65 years 59 socioeconomically disadvantaged populations experience a greater burden of multimorbidity and are affected from an earlier age 57 preventionbased approaches often focussing on wellestablished risk factors such as smoking diet and physical activity are being prioritised by health policy to both improve population health and address inequalities 1011 however the importance of these risk factors for multimorbidity across the lifecourse and their contribution to socioeconomic inequalities are unknown we aimed to describe the development and social patterning of multimorbidity over the lifecourse and quantify the contribution of behaviourrelated risk factors methods data source we used data from the west of scotland twenty07 cohort study which was started in 1987 to investigate social processes that produce or maintain health inequalities study details have been previously published 1213 twenty07 employed a twostage stratified random sample of respondents from three cohorts born in the early 1930s 1950s and 1970s and residing in the west of scotland comparison with census data showed that the sample was broadly representative of the area 14 respondents were recruited from 62 sampling units there were 4510 respondents at baseline and there have been four followup waves 19901991 19951997 20002004 20072008 respondents were aged approximately 3555 and 75 at the final data collection wave which included 67 of the baseline sample who were still alive all cohorts and data collection waves were used in the analysis except for the 1970s cohort at wave 1 as risk factor information was not collected in a comparable way at this age we therefore analyse data on individuals aged across the adult lifecourse from 18 to 75 years ethical approval was obtained at each wave from national health service andor university of glasgow research ethics committees respondents are flagged for routine followup for mortality through the health service registry 674 had died prior to the final data collection in 20072008 measures outcomes multimorbidity is typically characterised by the presence of two or more chronic conditions 5 but the actual conditions included vary we defined chronic conditions on the basis of those used by barnett and colleagues in their landmark study 5 whose work was informed by a previous systematic review of multimorbidity indices 15 selfreported conditions were coded based on the royal college of general practitioners morbidity classification 16 the exact coding process was discussed and agreed on by two clinically qualified members of the research team respondents who had two or more of the 40 relevant conditions were classed as having multimorbidity further details on the diagnostic coding are provided in additional file 1 table s1 socioeconomic status areabased deprivation categories were calculated using carstairs scores for postcode sectors carstairs scores provide an index of deprivation based on census results for four indicators of socioeconomic status for residents of each postcode sector 17 the seven categories from twenty07 were collapsed into three least intermediate and most deprived household income was used in supplementary analyses to compare associations with an alternative measure of socioeconomic status to make the income variable comparable across households it was weighted for number and age of people living in the household using the mcclements equivalence scale 18 to take account of period effects tertiles of income were created separately for each cohort and wave relative indices of inequality were used to investigate the potential contribution of risk factors to socioeconomic patterning of multimorbidity 19 participants from each cohort at each wave were ranked from lowest to highest deprivation score with the midpoint of each deprivation category in the cumulative distribution used these rankbased measures were then standardised to produce an index that ranged from zero to one and then regressed on the outcome with 95 confidence intervals obtained from estimation of the regression coefficient risk factors risk factors were obtained through surveys administered using standardised protocols with the exception of body mass index which was nursemeasured diet was classified on the basis of frequency of fruit and vegetable consumption in the 7 days prior to interview into ate fruit or vegetables every day ate fruit or vegetables some days had not eaten fruit or vegetables exercise was estimated by number of days per week of activity lasting at least 20 minutes which made the respondent out of breath or sweaty categorised into none 13 and 3 days for smoking status respondents were classified into never smoker exsmoker and current smoker bmi height utilised standard thresholds underweight normal range overweight obese and morbidly obese respondents were asked about alcoholic drinks consumed in the week prior to interview and units of alcohol were calculated based on amount and type two measures of alcohol intake were created exceeding existing weekly recommended maximum guidelines and exceeding daily recommended maximum guidelines in the previous week males exceeded weekly guidelines if they consumed more than 21 units of alcohol a week and exceeded binge drinking guidelines if they consumed more than 10 units in one session equivalent figures for females were 14 and 7 respectively daily units of alcohol intake were not available for all cohorts at all waves and were therefore used only in supplementary analyses lastly a count score was created by adding up the number of adverse risk factors statistical analyses the data structure was hierarchical multilevel logistic regression models were used to assess the relationship between multimorbidity and potential socioeconomic and healthrelated risk factors models were constructed in stata version 13 using three levels measurement points within individuals and within sampling units estimated using the adaptive gausshermite quadrature option in the melogit command to understand how multimorbidity prevalence has changed over time we modelled prevalence across the lifecourse by predicting the probability of having multimorbidity using our main statistical model described below modelled rather than crude prevalence was assessed to account for potential bias arising from attrition for the main longitudinal analysis the outcome at each wave was modelled based on deprivation and risk factor predictors from the previous wave effectively modelling change over time for example multimorbidity outcomes at wave 5 were modelled using deprivation and risk factor predictors measured at wave 4 the first set of models examined multimorbidity at waves 25 with explanatory variables age sex cohort and multimorbidity at the previous wave in the second set of models deprivation and each risk factor were added separately to model 1 risk factors were then added jointly to determine whether they showed independent associations with multimorbidity all models were adjusted for age sex cohort time between waves and multimorbidity at the previous data collection point odds ratios and 95 cis were obtained the modelling strategy meant that each wave was conditional on data being available at the previous wave hence outcomes at baseline were not modelled each participant could be included in the model up to four times if they participated in all five waves interactions between cohort sex and age and with all risk factor and socioeconomic status variables were tested using the global wald test final models included significant interactions there were no significant interactions between risk factors and age sex or cohort however interactions between sex and cohort were statistically significant and are included in all analyses the best fitting function of age was cubic which was included in the model in addition to linear and quadratic age terms to illustrate the results we present predicted probabilities for developing multimorbidity across the lifecourse statas margins command was used and for these graphs only the sample was restricted to those who were not multimorbid at the prior wave and the fixed part of the regression models used for prediction separate curves were drawn for each covariate lastly we investigated how much each risk factor mediated socioeconomic inequalities in multimorbidity by assessing the percentage change in the coefficient for deprivation after adding each risk factor using the approach of stringhini et al 2021 ie comparing the coefficients for the magnitude of inequalities across different regression models to minimise potential bias arising from missing data we used multiple imputation with chained equations to address both item and wave missingness imputed data for covariates were not used when there was attrition from the study imputed outcome data were used when covariates were available at the previous wave we included auxiliary variables that were correlated with the outcome when imputing data we conducted 24 rounds of multiple imputation the regression models and the calculation of relative indices of inequality are based on the multiply imputed data a complete case analysis yielded similar findings given that there were similar findings between imputed and complete case data predicted probabilities were calculated using complete case data we conducted supplementary analyses to check the robustness of our findings as results were similar using complete case and imputed data we used complete case data for the supplementary analyses to further explore alcohol intake guidance on daily recommended units was used to calculate binge drinking and this was added as a risk factor as a different measure of socioeconomic status the associations with household income were compared to those of areabased deprivation given the potential for death introducing survivorship bias experiencing death or multimorbidity was defined as a secondary outcome in sensitivity analyses a further definition of the outcome multimorbidity as three or more conditions was also used we also implemented an alternative mediation modelling approach using statas khb command which overcomes some methodological concerns about traditional approaches to mediation analysis 22 in particular the limitation that regression coefficients from different logistic regression models should not be compared results prevalence of multimorbidity baseline prevalence of multimorbidity differed substantially by age multimorbidity prevalence increased substantially over the 20year period in all age groups figure 1 shows the predicted prevalence of multimorbidity over the lifecourse for each cohort accounting for attrition younger cohorts experienced higher prevalence of multimorbidity when at the same age as older cohorts for example men born in the 1950s experienced a 59 higher prevalence of multimorbidity at the age of 60 years compared to men born in the 1930s at baseline the most prevalent health conditions were pain depression hypertension respiratory conditions and dyspepsia as expected there were large differences by cohort with the most common conditions in the youngest cohort being depression anxiety and respiratory conditions predictors of developing multimorbidity females had higher levels of multimorbidity in all three cohorts at baseline and throughout the followup period an interaction between gender and cohort indicated that gender differences in the development of multimorbidity increased in the 1970s and 1950s cohorts compared to the 1930s cohort the null models and interaction effects are shown in additional file 1 table s5 fig 1 predicted prevalence of multimorbidity across the lifecourse by cohort and sex when added to the regression model separately deprivation and all risk factors except for physical activity were significant predictors of multimorbidity the more risk factors present within an individual the higher the odds of developing multimorbidity those with three or more risk factors had almost double the odds of developing multimorbidity compared to those with no risk factors figure 2 shows the relationship between deprivation and developing multimorbidity those in the least deprived areas had a lower predicted probability of developing multimorbidity than those in the most deprived areas the inequalities gap was most apparent between 50 and 70 years but was found in younger and older adulthood as well figure 3 shows age trajectories of developing multimorbidity by smoking bmi physical activity diet alcohol and risk factor count there were clear differences in probability of developing multimorbidity for those who were overweight current or exsmokers those with poor diet and those reporting no alcohol consumption a similar pattern was apparent when investigating the risk factor count as with deprivation absolute differences between multimorbidity for each bmi diet alcohol and smoking category were most apparent in later midlife with smaller absolute differences seen in young and older adulthood for example at age 59 current smokers had a 30 predicted probability of developing multimorbidity over 5 years compared to 22 for never smokers whereas at age 23 the respective probabilities were 11 and 7 lastly the extent to which the five risk factors attenuated the relationship between areabased deprivation and multimorbidity was investigated by comparing the magnitude of inequalities before and after adjusting for different risk factors the rii which summarises the extent of inequality in the development of multimorbidity was 174 there was modest attenuation of inequalities when adding risk factors to the regression models with smoking followed by diet making the greatest contribution to inequalities accounting for differences in all five risk factors resulted in a total of 408 attenuation indicating that the majority of inequalities in the development of multimorbidity remained unexplained by these five risk factors supplementary analyses with household income instead of area deprivation daily alcohol rather than weekly alcohol units and different definitions of multimorbidity showed largely similar patterns of findings inequalities by income were slightly greater than by deprivation and the risk of developing multimorbidity was clearly increased amongst binge drinkers in contrast to the greatest risk amongst nondrinkers within the main analysis using a combined outcome of multimorbidity or mortality showed almost identical findings as those seen in the main analysis suggesting that survivorship bias did not account for the findings limiting the main analysis to complete data also yielded similar findings risk factors were stronger predictors of multimorbidity when it was defined as being three or more conditions rather than two for example in the most deprived group the or for developing multimorbidity was 204 for 3 chronic conditions compared to 146 when 2 conditions were used with multimorbidity defined as three or more conditions the rii was 252 in the null model with 337 attenuation when adjusting for all risk factors lastly using the alternative statistical approach the karlson holm and breen method to investigate the mediation of five behaviourrelated risk factors on socioeconomic inequalities in multimorbidity led to similar results discussion socioeconomic status predicts the development of multimorbidity throughout the adult lifecourse with inequalities greatest between 50 and 70 years modifiable risk factors for several chronic conditions are important predictors of developing multimorbidity while these risk factors appear to partially mediate the relationship between deprivation and multimorbidity the majority of the relationship between deprivation and developing multimorbidity remains unexplained efforts to reduce these known risk factors at any point across the lifecourse could contribute to addressing the growing burden of multimorbidity with the greatest potential impact when changing behaviour before age 50 however behaviourrelated risk factors only mediate the association between deprivation and multimorbidity to a limited extent most of this association is unexplained it is essential to also focus attention on addressing the underlying causes of fig 2 the independent contribution of area deprivation to the predicted probability of developing multimorbidity over a 5year period in the twenty07 study deprivation to reduce health inequalities 23 the most socioeconomically disadvantaged experience the greatest burden of multimorbidity and in addition to the imperative to tackle such inequality health systems also need to be responsive to it effective health care that is based on a collaborative comprehensive patientcentred system is required to deal with such patient complexity 24 25 26 a starting point is universal coverage of health care especially primary care however even in such systems the inverse care law fig 3 the independent contribution of risk factors to the predicted probability of developing multimorbidity over a 5year period in the twenty07 study persists affecting patients of low socioeconomic status with complex multimorbidity the most 2728 our study has several important strengths we investigate a wellcharacterised longitudinal cohort designed to cover the entire adult lifecourse furthermore the sample is representative of the general population and we collected social variables in a standardised manner however some limitations should be noted first multimorbidity was defined on the basis of selfreported health conditions which may lead to bias in outcome ascertainment 29 however health conditions were coded using standardised criteria by trained health professionals second most risk factor information was selfreportedlikely to be particularly problematic for physical activity a related issue is that the measures capture behaviour at a particular time point with reverse causation likely to explain the findings related to alcohol in addition the measures of diet and physical activity only captured specific aspects of these behaviourrelated risk factors aspects of diet other than fruit and vegetable consumption which may be associated with development of multimorbidity could not be included likewise further details on physical activity could not be included third there are other potentially important dimensions of socioeconomic position which we have not been able to investigate future investigation may provide a greater level of understanding and afford opportunities for intervention for example low education has been linked to multimorbidity 30 and is also closely linked to health literacy thereby highlighting a potential target for intervening to influence health behaviour fourth all cohorts experience attrition although given the diverse socioeconomic population studied in the twenty07 study this is relatively modest fifth our variables have some missing data which we addressed through multiple imputation conclusions our study demonstrates the existence of substantial socioeconomic inequalities in the development of multimorbidity throughout the adult lifecourse while common risk factors predispose to the development of multimorbidity a key finding of this study is that the relationship between deprivation and the development of multimorbidity is only partially mediated by lifestyle factors future research is required to identify other factors that mediate the relationship between deprivation and multimorbidity furthermore there is a need for further research to distinguish the relative importance of mental and physical health conditions 31 as well as investigate combinations of specific health conditions in greater detail 3233 irrespective of the biological pathways policies and interventions focussing on the social determinants of health may be the key to reducing the prevalence and severity of multimorbidity social determinants include access to highquality health care with the continuing existence of the inverse care law likely contributing to excess multimorbidity in deprived areas a recent exploratory cluster randomised controlled trial which supported general practitioners and practice nurses working in deprived areas to deliver holistic personcentred care to patients with multimorbidity led to costeffective improvement in wellbeing 3435 beyond this a focus on addressing nonhealth sector determinants including income employment housing and the social and physical environment is necessary 36 37 38 additional file additional file 1 supplementary analyses table s1 classification of multimorbidity table s2 descriptive characteristics of study participants table s3 number and proportion of sample with each condition by wave table s4 proportion of sample with each condition by cohort at baseline table s5 tests of statistical interaction table s6 summary of missing values for imputed variables table s7 comparisons of area deprivation and income table s8 comparisons of weekly alcohol consumption and binge drinking table s9 odds of multimorbidity or death table s10 complete case analysis table s11 odds of multimorbidity based on 3 conditions table s12 relative indices of inequality based on 3 conditions table s13 relative indices of inequality according to karlson holm and breen method abbreviations 95 ci 95 confidence interval bmi body mass index kg kilogramme m metre n number within sample or odds ratio rii relative index of inequality authors contributions svk conceived the idea for the study and led the study design ks led the analysis with input from svk and they jointly drafted the paper all authors contributed to the study design and interpretation of findings and critically revised the manuscript all authors approved the final version of the paper competing interests the authors declare that they have no competing interests

background multimorbidity is a major challenge to health systems globally and disproportionately affects socioeconomically disadvantaged populations we examined socioeconomic inequalities in developing multimorbidity across the lifecourse and investigated the contribution of five behaviourrelated risk factors methods the twenty07 study recruited participants aged approximately 15 35 and 55 years in 1987 and followed them up over 20 years the primary outcome was development of multimorbidity 2 health conditions the relationship between five different risk factors smoking alcohol consumption diet body mass index bmi physical activity and the development of multimorbidity was assessed social patterning in the development of multimorbidity based on two measures of socioeconomic status areabased deprivation and household income was then determined followed by investigation of potential mediation by the five risk factors multilevel logistic regression models and predictive margins were used for statistical analyses socioeconomic inequalities in multimorbidity were quantified using relative indices of inequality and attenuation assessed through addition of risk factors results multimorbidity prevalence increased markedly in all cohorts over the 20 years socioeconomic disadvantage was associated with increased risk of developing multimorbidity most vs least deprived areas odds ratio or 146 95 confidence interval ci 126168 and the risk was at least as great when assessed by income or 153 or when defining multimorbidity as 3 conditions smoking current vs never or 156 136178 diet no fruitvegetable consumption in previous week vs consumption every day or 157 95 ci 133184 and bmi morbidly obese vs healthy weight or 188 95 ci 142249 were strong independent predictors of developing multimorbidity a doseresponse relationship was observed with number of risk factors and subsequent multimorbidity 3 risk factors vs none or 191 95 ci 157233 however the five risk factors combined explained only 408 of socioeconomic inequalities in multimorbidity development conclusions preventive measures addressing known risk factors particularly obesity and smoking could reduce the future multimorbidity burden however major socioeconomic inequalities in the development of multimorbidity exist even after taking account of known risk factors tackling social determinants of health including holistic health and social care is necessary if the rising burden of multimorbidity in disadvantaged populations is to be redressed

introduction in the context of our countrys long history of social injustice the issue of systemic racism in higher education has recently gained a lot of attention constantly african american students have suffered injustice that has reach a tipping point the call to action for combating systemic racism has sparked a cultural phenomenon that has made inroads in all walks of life consequently this study seek ways to explore compare and contrast the factors or reasons linked to the systemic racism that influences african american students decisionmaking when deciding to join an institution of higher education the african american students experiences in the us are unique most importantly there are many factors that are beyond students control that have shaped it such as historical and economic issues however this is a top priority in respect to students college choice historically the academic journey from early school for african american students has not been straightforward in schools african american students are more likely to be labeled mentally challenged or learning disabled and overrepresented in special education programs in addition they are less likely to appear in talented or gifted programs such as honors classes or advanced placement courses furthermore they are subjected to expulsions and suspensions and the retaining rate is alarming one out of five african american students received an outofschool suspension and they are 35 times more likely than their caucasian peers to be suspended or expelled consequently many african american students lack adequate opportunities to develop positive classroom experiences they are often berated for minor classroom behavioral issues that become magnified by teachers and administrators over the years researchers have identified three major problems that have emanated for african american men before they enter into higher education such as lack of quality teachers in k12 education overrepresentation of african american male students in special education programs and a lack of african american male students as well as other students of color in advanced placement courses at the secondary education level according to bottiani bradshaw and mendelson students perceptions of differential treatment exclusion and discrimination by teachers and other adults in school appear to play a significant role in the poor outcomes among youth of color however there are lot of barriers when it comes to admitting more black students to the nations selective universities the climate change surrounding racial issues and the us economic downturn have had a significant impact on the commitment of students of color in respect to higher education historically black colleges and universities have played a significant role in expanding educational opportunities in the united states this study attempts to answer the overarching research question how does systemic racism play a role in african american students college choice decisions and the factors affecting the decision theoretical framework to lead this study this study is grounded in critical race theory and college choicedecision theory the conceptual framework for this study was provided by the critical race theory this is because crt explores and analyzes the experiences of students of color which can inform crosscultural inclusivity practices in a number of ways however crt was appropriate for this study because it presents practical techniques that can be used by academic advisors and other higher education administrators when working with students of color crt can also serve as a theoretical framework through which a person can understand various ways on advising interactions and practices with students of color in order to offer help or exert harm this study applied crt because it challenges the status quo and examines racial difrences in myriad contexts such as the many ideologies and norms embedded in educational institutions furthermore crt has been used to normalize and analyze racialized experiences in research and practice by challenging traditional paradigms methods texts and discourses on race gender and class based on the different models within each of the college choice and decision theories there is an understanding on why african american students might choose to attend an hbcu or predominantly white institutions models by iloh glasser hasen and litten and freeman provide an explanation of college selection and decisionmaking aspects within each example to support the study objectives methodology the present study is a nonexperimental qualitative comparative case study analysis this study will use qualitative research which entails collecting and analyzing nonnumerical secondary data in order to understand concepts opinions experiences and phenomena the aim is to gain indepth insights into the problem answer the research question or generate new ideas for future research qualitative researchers engage in naturalistic inquiry and explore realworld settings by inductively developing rich narrative descriptions of the cases they are investigating inductive analysis across case studies yield patterns and themes which is the fruit of qualitative research the purpose of this study is to analyze data for insights within across and between cases therefore this comparative case study design involves comparing contrasting analyzing and synthesizing the similarities differences and patterns across three selected case studies that share a common focus goal or phenomenon this study also used secondary data sources from all three cases which includes documentation archival records interviews physical artifacts direct observations and participant observation the researcher has collected and integrated data within the case study research which is unique to other qualitative approaches this has help in facilitating a holistic understanding of the phenomenon being studied data collection this qualitative research is designed to reveal the meaning that informs the action practices or outcomes using rigorous and systematic transcribing coding comparing analyzing and interpreting the trends and themes with a focus on retaining the true meaning however such research is used to understand how people experience the world qualitative researchers often consider themselves instruments in research because all observations interpretations and analysis are filtered through their own personal lens this case study analysis involves intensive analysis of the following three selected case studies to understand and gain an indepth holistic view of the research problem i consequently these three research studies conducted within ten years were selected through extensive database searches using specific words the titles and research questions from the selected case studies were extracted and compared using a colorcoding method to show internal consistency data analysis procedure the researcher extracted the relevant data from the selected case studies and utilized this data for secondary data analysis the selected case studies were semantically coded to assess their interrelatedness understand the text data label the emerging sections with codes examine the codes for similarities and then combine the codes into broad themes to initiate the data analysis the following preliminary themes were developed student college university african american black racism and identity the selected studies were uploaded to atlas ti9 to arrange and code the major themes a word cloud was assembled by ordering the importance of the phrases from all three case studies next a hierarchical network was constructed where the coding revealed an emerging themes furthermore the codes were arranged into themes or categories to create a database of topics that were widely discussed in the case studies this process give room for the researcher to observe the density comprehend indepth understanding to answer the research questions and ensure the credibility of the data analysis subsequently themes were developed by utilizing the sixstep processes suggested by caulfield results findings on theme one systemic racism in higher education in analyzing the three case studies the first theme that emerged was systemic racism in higher education in case studies 1 and 2 the findings of these research studies displayed an acknowledgment of racism as a factor in african american students choosing to attend an hbcu or a pwi findings on theme two african american students decision making in case studies 1 and 3 the process of choosing a college to attend was another theme that emerged the decisionmaking factors of african american students are prominent themes in each case study in this theme three small subthemes have been discovered college choice and decision factors reasons for choosing hbcus and reasons for choosing pwis findings on theme three experiences of african american students in hbcus and pwis in study 1 recent high school graduates from hbcu and pwibound have a high expectations of college life that are typical of experiences that will duplicate high school in a larger community in study 2 the students at the historically black colleges and universities reported a better psychological and functional faculty support levels than their pwi counterparts findings on theme four minority students stress and anxiety in hbcus and pwis in case study 2 the report from african american students at pwis were more stress related and exposure to racial discrimination are being underrepresented on these campuses as codes emerged the researcher could see linkages between the factors influencing college choice and the selected theoretical frameworks of college choice decision and critical race theory in this study crt was used in analyzing how race and privilege play a major role in society and also how it plays a role in higher education specifically in this study college choice and decision theories were used in addition several college choice and decision theories were used to analyze how college students think and arrive at their decisions to attend a college or university however the findings in case study 1 helped the researcher to connect the case findings to other cases utilized in this study in case study 1 the theme of systemic racism in higher education was also discovered this is connected to the findings and other themes from other case studies in case 1 african american students use racial climate and the significant presence of a diverse or samerace student body to validate their final selection in case study 2 there were discussions about how african american students have more positive perceptions at an hbcu and also how the experiences of black students at pwis were negative these findings have helped in discovering minority students stress and anxiety at hbcus and pwis as a key theme emerging from the analysis of case study 2 african american students on an hbcu campus would report lower minority status stress levels than their counterparts on a pwi campus collectively the current analysis suggests that institutional racism affects african american students college choices conclusion while answering the research question the findings of this study have revealed that the role that systemic racism plays in college choice decisions of african american students is displayed in critical race theory this is because it is a crucial factor in the analysis of choice theory in the context of systemic racism the critical race theoretical lens that affects the college choice decisions of african american students shows that race is an embedded factor in college choice decisions because of a deeply rooted and racist normalized traditions the crossanalysis of the studies confirms that african american students use racial climate and the significant presence of a diverse or samerace student body to validate their final selection this research confirms that racism and many other factors play a crucial role in the college choice decisions of african american students in attending predominately white institutions of higher education it is apparent from this studys findings to note that racism is an issue for african americans in their college choice decisions consequently the students decisionmaking for higher studies or deciding on their careers is a complex process however there is still much to learn about how african american students choose a college education for themselves it is instructive to engage in a racial analysis of the access and choice processes to better understand the oppressive structures encountered by collegebound african american students contrarily the college enrollment decisionmaking process for students can on the surface appear fair and inclusive across racial lines although this is not the case conflict of interest the author reported no conflict of interest data availability all of the data are included in the content of the paper funding statement the author did not obtain any funding for this research

a lot of attention has been given to the problem of institutionalized racism in academia lately from a young age the road to success in school has not always been an easy route for african american students according to bottiani bradshaw and mendelson 2016 students perceptions of differential treatment exclusion and discrimination by teachers and adults in school appear to play a significant role in the poor outcomes among the youth of color the climate change surrounding racial issues and us economic downturn have had a significant impact on students of color as regards to their commitment to higher education karkouti 2016 this paper attempts to answer the overarching research question such as how does systemic racism play a role in african american students college choice decisions the results from this paper are displayed in critical race theory as it is a crucial factor in the analysis of choice theory

introduction the american psychologist james mckeen cattell published the first university ranking in november 1910 his calculation of the scientific strength of institutions listed american universities in descending order depending on the number of eminent scientists employed some hundred years later university rankings have become increasingly important devices for assessing the quality of higher education and research ever since the arrival of the first international university ranking in 2003 the academic ranking of world universities developed by shanghai jiao tong university rankings are an integral part of discussions regarding the role and impact of universities the emergence of university rankings is often understood as resulting from a drive for more accountability and transparency in the governance of higher education this demand or pulldriven explanation is common in current research on rankings and the same line of reasoning is also found in earlier studies according to hazelkorn four main drivers of university rankings can be identified the positioning of knowledge as the foundation of economic social and political power increasing demographic pressure in many countries higher education seen as a vital component for an industrious nation and the emergence of the student as a savvy consumer these drivers might indeed be viable explanations for the popularity of university rankings and their presence in discussions on the issue of quality assessment in the governance of science and scholarship however as principal reasons for the development of rankings they put too little emphasis on the ranking practices and methods employed rather when scrutinizing their history we find that university rankings local as well as international often were initiated for completely different reasons than transparency and accountability strategic considerations of the institutions using the ranking as well as the availability of more data about research and teaching performance have resulted in the perception of new rankings as reputational and management tools but the emergence of rankings is also strongly intertwined with the advancement of research in fields such as statistics and bibliometrics consequently we argue that the emergence of rankings can only partly be understood as an answer to pulldriven demands and developmentsinternationalization globalization and economizationin higher education furthermore the popularity of university rankings cannot solely be explained by increasing topdown governance in neoliberal academia because the practice of ranking ties in with deeply engrained cultural repertoires around competition and performance arguably to rank comes natural for professions that have become highly competitive of themselves the history of rankings the epistemological logic behind them and their disciplinary background are crucial elements often overlooked in contemporary research in this sense we agree with marginson that surprisingly little critique is directed towards rankings as social science although the methods of ranking are taken from disciplines such as sociology psychology economics and information science thus the current study supplies a muchneeded push perspective on a phenomenon usually explained by pull mechanisms an explanation for the success of rankings originates from their ability to make heterogeneous characteristics of universities comparable through classification normalization and standardization thus allowing universities to take part in a global higher education market driven by a competition for expertise reputation students and money here our main interest lies not so much in the conceptualization but in the concrete enactment of comparability we will show that rankings as a social technology make highly diverse entitieslike universitiesmeasurable through quantitative methods or in other terms rankings make universities calculable this practice or ability of making calculable is the main topic of our study calculation is defined as a process of making distinctions between actors and to determine possible actions and consequences associated with these actors as argued by callon and muniesa such a broad definition is useful in avoiding a sharp distinction between judgment and calculation drawing on latour and his concept of centres of calculation the framework formulated by callon and muniesa also highlights the movement of materials which allows for a detailed analysis of the material practices of ranking in order to develop a better understanding of how universities are made calculable through rankings we focus on the construction of eminence in the sociotechnical context in which the first university ranking emerged in particular we adopt the notion of calculative devices to demonstrate the interaction between the ways in which scientific eminence was defined and the means and methods to measure it the process of making calculable is then exemplified by the first university ranking in this part of our paper we link the epistemological rationales behind the construction of cattells first ranking to the sociopolitical context in which he operated an era in which the field of psychology became institutionalized against the backdrop of the eugenics movement and the rise of statistics as a legitimate means to assess innate eminence secondly the scientific and sociopolitical context in which the first ranking emerged enabled a redefinition of universities and scientists as commodities on an international market for eminent institutions and scholars this market afforded space to an intricate valuation system for scientists and institutions on the basis of their respective status third we demonstrate how this measurement practice not only reflects contemporary social values and scientific norms but is also generative of particular forms of the social itself the ways in which cattell combined certain measurement practices with peer evaluation among eminent men also created highly novel ways of valuing scientific institutions these novel understandings of eminence arose in tandem with the new ways in which eminence was recognized and measured in fact the act of measuring eminence defined what would henceforth count as eminence as a result the concept lost the ambiguity it could still retain when it was not yet stabilized by the process of measurement comparable processes of definition and social construction can now be seen around contemporary enactments of excellence and quality in a concluding section we relate the history of the first university ranking to contemporary developments by showing how the operationalization of excellence is shaped by epistemological concerns methodological choices and the availability of instruments background though global university rankings are a quite recent phenomenon the literature on the topic is immense hazelkorn estimates that there are over one thousand papers and books on the theme of rankings and the number of publications has surely increased since the publication of her book to even begin to review this vast literature is a daunting task but a few strands in the literature can be outlined here generally we find three types of studies on the topic critical studies methodological studies and studies of influence and effects these literatures rarely overlap critical studies usually focus on the ideological level and rankings are discussed as an indication of a more general development described under headlines such as marketization commodification academic capitalism or neoliberalism usually these studies have their origin in research focused on developments in higher education more generally and they tend to focus on the phenomenon of university rankings rather than on methodology used or construction of rankings the second strand of research tests university rankings empirically here the methodologies of university rankings are in focus indicators used and calculations made are scrutinized an early example is van raan who pointed to several problems in the arwuranking bias towards us journals bias towards sciences wellcovered in web of science and bias towards english language journals indepth methodological studies and criticisms pertaining to technical aspects have pointed to the many problems associated with calculating the quality of universities and attempts of replicating rankings are common the third line of research focuses on the effects of university rankings using concepts such as performativity and reactivity to describe how rankings influence behavior these studies often build on interviews or questionnaires targeting various stakeholders or analysis of rankings in popular media the history of university rankings is a less developed line of inquiry compared to the major directions outlined above cattells role as the creator of the first proper university ranking was noticed already by webster but it was godin who firmly connected these efforts to francis galton and the eugenics movements this study latches on to these accounts of the development of university rankings and we point to parts of the history that have been overlooked in earlier research such as cattells early use of doctorates to measure scientific strength and how the ranking was reported in the press most importantly however we introduce the concept of calculability in order to align the practical construction of the ranking with the historical context in which it was produced ranking and calculability our conceptualization of university rankings as calculative devices which contribute to the establishment of a market fits well with a contemporary debate on commodification and academic capitalism ideas concerning a market for universities and academics might appear as more farfetched in the context of the early 20th century and the enactment of the first university ranking yet markets both for students and scientists were not only explicitly discussed but were also an important reason for constructing a ranking in the first place a narrow focus on market devices might however restrict our analysis to the use or intended use of rankings we show that rankings are also fundamentally grounded in contemporary practices of knowledge production we think it is crucial to consider this particular register and the concomitant regimes of valuation in accounting for the omnipresence of rankings callon and muniesa explain calculability in three steps first the entities supposed to be calculated are detached from their original context this can be understood through the process of singularization described as follows the entity is detached from its production a process made possible through the objectification of the good then it is adapted to the world of the buyer which in turn is arranged to receive it finally it is integrated in the social and technical networks of the buyer the citation is a fine example for showing how detachment takes place in the case of rankings the referencesupplied by the producerauthoris turned into a citation through its inclusion in a citation index and becomes entangled in a citation infrastructure where it eventually comes to represent scientific impact the reduction of more complex valuation practices into numerals is here an important part of the process as numbers are both transferable and easily communicated to a large audience furthermore quantification is one of the most effective strategies for turning social arrangements credible objective and impeccable their abstractness also reduces the need for specific indepth knowledge and enhances the universality of measurement furthermore numbers are both easily decontextualized and recontextualized which allows for them being used for new purposes in novel contexts in the second step things are sorted out and related to each other thus detached items such as citations publications the number of nobel prizes external grants received and so forth are now compared and linked with each other callon and muniesa describe this as … a process of classification clustering and sorting that makes products both comparable and different finally a result has to be produced and presented for a calculation to be completed in this step the different indicators are integrated to form a descending list of entities deliberations and calculations used to reach this particular order are blackboxed and presented as a uniform ranking of universities hence the production of university rankings can be divided into three distinct practices using this theoretical framework detaching sorting and presenting this arrangement allows us to deconstruct the first proper university ranking and describe the necessary steps needed for its production the artifacts or the calculative spaces through which rankings are produced is here of particular interest and directories paper slips and lists are examples of devices used by cattell furthermore our analysis underlines how ideological underpinnings technical procedures methodological considerations epistemic criteria as well as dissemination channels came to shape the first university ranking the theoretical structuring we adhere to also demonstrates how alternative approaches were gradually abandoned for example how the method of measuring scientific strength using the number of doctorates was discarded at each of the three steps choices were madeon method scope and presentationand the final published ranking was the product of these considerations a decisive reason for adopting a theory of calculability is also its potential for analyzing rankings more generally with a few modifications the structure and theoretical framing used in this study can also be applied to the construction of contemporary rankings james mckeen cattell and his work on american men of science james mckeen cattell was an american psychologist and longtime editor of science cattell was trained in europe and held a lecturing position in cambridge where he came into contact with the eugenics movement and the famous statistician francis galton before he became a professor at columbia university in 1889 the scientific methodology of the eugenics movement provided cattell with the tools for imagining classifying and acting on eminence differently by linking novel forms of measurement to new ways of valuing scientific performance this eventually resulted in the invention of the first university ranking the main problem for cattell and many contemporaries interested in eminence and greatness was a perceived decline in great men compared to earlier periods a fear of a biological degeneration of the population was an important motivation for the eugenics movement as inheritance of mental abnormalities was believed to result in a larger proportion of the weak and insane a general anxiety regarding the decline of the british empire further intensified the interest in heredity 1 the fate of the nation was dependent on the overall quality of men and the measurement and promotion of eminence was deemed as an important task late 18thcentury interest in great individuals should also be viewed in the light of one of the major anxieties of the time the fear of the masses the advent of industrialism democratization and growing working class were all contributing to this fear influential thinkers such as the french physician gustave le bon claimed that human beings lost their ability to think independently in the crowd as their individual selves were absorbed by a crowd soul 2 the eminent freethinking individual thus became increasingly important as a protagonist of rational thinking and human advancement furthermore the preoccupation with great men was accompanied by a growing interest in the role of the scientist in a time when scientific work to an increasing degree became an occupation among others in his early work cattell supported the notion that greatness is inherited rather than acquired the little scientist can doubtless be made but probably the great man of science must be born however he quite rapidly changed his view on the naturenurture debate and just three years later cattell interprets his own studies of scientists as proof against the hereditary view3 thus the eugenics movement and the ideas associated with it were highly influential for cattell and his work on the distribution of eminence but gradually he began to question some of his initial beliefs cattells change of position from nature to nurture also meant a shift in the focus of his study where the institutions of science came to take center stage the work of galton spurred cattell to study differences between humans with regards to intellectual ability he started with a brief study on exceptional ability where he listed the thousand most eminent men based on the space they occupied in dictionaries and encyclopedias these investigations were later developed and published under the title a statistical study of eminent men in 1903 in this work cattell examined six biographical dictionaries and encyclopedias using the length of the bibliographical note as an indicator of eminence he admits that the selection of men having attracted the eyes and ears of the world is a crude measure the most eminent man napoleon was according to cattell neither a genius nor a great man 4 instead of providing a definition of eminence a priori cattell trusted that his objective and impartial method would guide him thus the methodology of taking the length of the note as a form of value made sense for cattell because he treated eminence and reputation as interchangeable as galton had done before him with the first edition of american men of science a biographical directory cattell once again followed in the footsteps of francis galton who had published his english men of science in 1874 according to cattell an important reason for publishing this reference work was to … make men of science acquainted with one another and with one anothers work women were almost absent in the discourse on eminence the directory instigated by cattell changed its name to american men and women of science as late as 19715 for galton the main contribution of women was as able mothers of eminent men cattell is clearly misogynist in his early work where he finds a biological explanation for the lack of women among eminent scientists women depart less from the normal than mana fact that usually holds for the female throughout the animal series in many closely related species only males can be readily distinguished also in later studies cattell tends to explain the poor representation of women 18 out of 1000 scientists as a result of innate differences between the sexes however in his later writings cattell pondered on the unrealized potential that women offered for science especially where he suggests that it is possible that the lack of encouragement and sympathy is greater than appears on the surface and he considers the prospect of a future in which womens contribution to science matches that of men the four editions of american men of science that cattell edited became his main material for studying science 6 the essay that accompanied the directory tells us a lot about the background including data on birthplace city age and most notably the college or university attended by researchers and the methodology he used the directory of eminent men also served other purposes for example the analysis of the distribution of scientific eminence across cities and universities was a primary goal …we can tell whether the average scientific standard in one part of the country at a given university etc is higher or lower than elsewhere we can give quantitatively the men being weighted the scientific strength of a university or a department according to godin statistics were collected to address this problem and to contribute to the progress of science what cattell was aiming for was nothing less than a … natural history or ecology of men of science making universities calculable the construction of the first university ranking when studying the ecology of scientific men cattell found that one particular institution the university played an important if not crucial role for the advancement of science in this respect he clearly distanced himself from galton who had had little praise for universities and their role in fostering eminence in his english men of science 7 their departing view was partly due to differences in their positions in the nature or nurture debate where cattell eventually came to downplay the role of inherited giftedness in this context universities became a natural point of departure when studying the distribution of scientific men eventually his interest in the institutions of science came to result in a ranking where the overall scientific strength of american universities was presented as noted above three proceduresdetachment sorting and presenting were needed before a calculation of institutional eminence could be performed although we find it useful to structure the analysis according to these three steps it is important to stress the blurriness of these practices initial categorizations of researchers are presented already in the detachment stage as names are presorted based on disciplinary affiliations and all three procedures are present throughout moreover the process is not in any way linear cattell presented his results continuously and the assumptions underlining his project and the aim of his undertaking changed over time in an iterative process detachment reputation was cattells preferred indicator in measuring scientific merit and this becomes apparent in his attempts of ranking institutions still this choice was not obvious and he considered several other indicators of eminence of note are the early attempts of measuring institutional performance based on output of doctorates cattell states that the number of doctorates can be seen as important output the american university is definitely a place for research where both teachers and students are engaged in research or in learning the methods of research the results of the work of the students is in large measures summarized by theses for the doctorate and it is interesting to know what is the outcome of the past years research thus more than ten years before the publication of his 1910 ranking cattell presented an order of universities based on doctorates from 1898 onwards he published a list of the number of doctorates awarded in the us the current history of cattells work and the construction of the first university ranking has mostly ignored these earlier attempts of measuring institutional performance based on output it could be argued that the list of universities building on the number of doctorates awarded in fact was the first ranking of universities the list of doctorates conferred was published annually results from earlier years were reproduced and compared in subsequent editions and results were presented in descending order thus it allowed for comparing the output of universities over time in 1903 cattell explicitly discusses the position of different institutions it will be noticed that five universities are distinctively in advance and that a large majority of the degreesfour fifths are conferred by seven universities there has been no considerable change in the positions of the universities during the years covered by records though there is apparently an increase at columbia and michigan and a decrease at johns hopkins and clarke in his work on eminent men cattell realized that his data could be used to rank universities and the same applies to the counting of doctorates in the 1909 article on doctorates conferred by american universities he not only explicitly refers to the change of position of the leading universities but he also uses the number of scientific men as an additional indicator to substantiate his findings cattell gradually understood that the number of graduates or the reputation of individual scientists could be detached from their original context and be used as indicators for the ranking universities he also envisioned that these indicators could be combinedalthough he never formally did so in a proper ranking in the 1910 article introducing the first known ranking cattell also discusses the possibility of using the number of doctorates as a proxy for scientific strength we may perhaps assume that the relative strength of a university in different departments tends to be proportional to the number of research degrees conferred the cautious words may perhaps used by cattell are one possible explanation as to why he never used doctorates to construct a proper ranking it might be that he saw mere counting of heads or number of published papers as crude indicators of scientific strength in fact he published several lists of the number of scientists doctorates and scientific papers produced at american universities but these were never presented as measures of overall strength it was not until he was able to add and calculate the qualitative factor of peer judgments that he proceeded to construct a ranking hence although cattell in many instances hints at doctorates or papers being an indicator of strength he never advertised these lists as actual rankings the same applies to earlier lists of universities based fig 1 order of universities by the number of doctorates awarded from doctorates conferred by american universities for scientific research reprinted with permission from aaas on the eminent men attending them which were produced by scholars working in the eugenicist tradition making lists involves a process of decontextualization they enforce boundaries and create hierarchies and making a list thus marks an important step in the construction of a ranking a ranking is however something more than a list as pointed out by webster a university ranking should be arranged based on a specific criterion that the compiler believes to reflect the academic quality of the institution in question thus the doctorate lists come close to being a ranking in a formal technical sense but they were not constructed nor presented as such instead cattell came to construct his ranking based on his study of american men of science crucial for this undertaking was the qualitative judgment made on the relative standing of scientists made by peers building on his initial list of prominent scientistsderived from university rosters scientific journals and bibliographical dictionariescattell asked ten prominent representatives from 12 disciplines to rank individuals according to merit these representatives were then presented with an initial list of men known to have carried on research work of any consequence according to cattell the number of preselected names was proportional to the total amount of researchers within a given field ranging from 175 in chemistry to 20 in anthropology the representatives were provided with slips containing names and addresses of scientific men being ranked the instructions for ranking describe the procedure in detail in case there is noted the omission of any scientific man from the list who should probably have a place in the first three quarters a slip may be added in the proper place with his name and address in case there are names on the list regarding which nothing is known the slips should be placed together at the end the slips as arranged in order should be tied together and returned to the undersigned the list as a technique for ordering information was of great importance for this maneuver as it allows judgments on the quality of individual researchers to be stabilized and visualized this operation is a prerequisite for calculation as it transforms mainly oral statements into visual ones in this case stabilization is enacted through slips that are arranged and tied together to form a ranked list of notable scientists in each field cattell understood that this operation was not straightforward and his instructions point to two complications that also remain troublesome in contemporary rankings the first concerns how to deal with interdisciplinarity … an eminent astronomer might also be a mathematician but in ranking him as a mathematician only his contributions to mathematics should be considered making disciplines comparable was another difficulty encountered when arranging the order of scientists cattell notes that a scientist falling between the disciplines is … likely to receive a lower position than he deserves 8 he also discusses the problem of selfevaluation and found that scientists were equally inclined to overrate as to underestimate their own contribution moreover respondents were likely to overestimate the importance of close colleagues and to give higher ratings to researchers working on topics closely related to their own field of inquiry the thousand leading men of science ranked according to this method would be the basis for his statistical studies cattell continued with further categorizing the most eminent scientists into groups with a hundred men in each when comparing the difference between the groups cattell found that the distribution of merit was highly skewed where the first hundred had a scientific merit equal to the second and third hundreds together cattell then proposed that his ranking of men could be converted into a ranking of institutions the points given to individual scholars were aggregated at the level of institutions to produce a number indicating scientific standing hence the relative ranking of individual researchers was detached from its original use and was employed for the purpose of ranking institutions yet this maneuver was not a straightforward operation as numbers had to be sorted before the actual ranking could be produced the sorting into cohorts based on overall position made researchers both different and comparable which in turn allowed cattell to develop a scientifically based ranking sorting building on his findings regarding the relative distribution of researchers cattell decided to award universities points depending on the position of their scientists among the top thousand the development of a weighting system with points awarded according to the position of the scientists employed allowed him to produce a ranking of universities this weighting was developed from the overall and highly skewed distribution of eminence that cattell found in his studies hence there was a scientific argument for assigning more points to highly ranked scientists support for this arrangement is given already when cattell presented his 1906 study of eminent scientists summarizing his findings cattell writes the first hundred men of science cover a range of merit about equal to that of the second and third hundreds together and this again is very nearly equal to the range covered by the remaining seven hundred however the decision to award researchers higher up the list significantly more points than those positioned further down was also based on actual salaries within universities in fact cattell asserted that salaries on average increases with distinction and roughly measures it the pay structure within universitieswhere distinguished professors generally earned three times as much as assistant professorsprovided further arguments for this arrangement thus both previous findings on the distribution of merit and the current pay structure within universities came to influence the methodology used for ranking presenting on 11 november 1910 cattell presented what he saw as the actual first ranked list of universities in science for the first time not only the number of eminent men but the quality of these men was presented in a ranked list of universities cattell argued that these numbers told us more than simple counting of men t hey take account not only of the number of men gained or lost but also of the rank of these men and of the changes which have taken place through men improving their standing or failing to maintain it thus the ranking did not only present a weighted number of scientific strength but it also indicated if a university was losing or gaining in the ranking cattell claimed that his ranking provided a fair estimate of the relative standing of the institutions on his list and envisioned several possible uses he believed that institutional rankings could inform students in their choice of university this view resonates well with the present discourse on the topic another of cattells concerns was international competition which obviously also relates to current discussions in cattells case he discusses the standing of us science in comparison to europe however his aim was not primarily that of national prosperity rather he suggested that the us should contribute more to the global advancement of science thus cattells urge for international comparison was not primarily based on an assumption that american science should be better for the sake of the country but rather that it should promote science as such cattells third argument for using rankings is less visible in todays debate he suggested that university rankings could be used for raising the status and the salary of scientists scientists were underpaid compared to other qualified professions and this was in cattells view a major hindrance to science as otherwise talented men would choose other careers one strategy of achieving this was through the production of rankings of both men and universities thus he started to calculate price tags for scientific strength a university can obtain a man of the first rank for from 5000 to 7500 or a man in the lower hundreds of the list for from 2000 to 2500 clearly cattell imagined a market for academics where universities could invest in highly ranked scientists in order to boost their strength and position in the ranking he also suggests that competition for highly ranked scientists could be an important factor for the promotion of local universities first of all rankings could thus be used to empower researchers in the university system which according to cattell was increasingly run by administrators thus his aims were linked to political purposes emancipating university professors and elevating their status in university administration as such there is an obvious link with cattells fierce campaign played out in university control and many pieces in science on problems of university administration and in particular what he perceived as a lack of authority and the right of say of university professors this is fascinatingly similar to todays debates where universities increasingly are seen to be managed by administrators and where rankings are presented as tools that could serve scientists and students cattells critique of the politics of his time targeted the manner in which universities were run9 he fig 2 the scientific strength of leading institutions from a further statistical study of american men of science ii reprinted with permission from aaas particularly focused on the low status of the scientist in terms of freedom and in terms of monetary awards it seems to me that scientific men suffer in character because they are employees rather than free men the tension between viewing the ideal scientist as an independent curiositydriven free individual and advocating science as a respected and well paid occupation among others were ever present in cattells thinking and it related to a larger question of the time can independent and eminent men be grown in a dependent situation eventually cattell aimed for a compromise in which scientists were indeed employed but with a high degree of autonomy his ideal was the german research university of the 19th century secondly cattell introduced ranking as a means to calculate and classify eminence this novel classification and calculation enabled a differentiation between distinct classes of merit resulting in fundamentally novel forms of being great with their own distinctive forms of value attached to them moreover the classes of merit and the salaries that should be based on them were grounded in cattells scientific studies of the distribution of scholarly merit similar to earlier studies of the distribution of eminence cattell found this distribution to be highly skewed 10the legacy of the first university ranking the journal science was cattells main channel for advertising his study of american scientists including his ranking his biographical work american men of science was continually reproduced and he also frequently published shorter notices on the number of doctorates awarded at major us institutions however cattell did not reproduce his table comparing the scientific strength of universities a probable explanation for this is the lack of data though the biographical directory continued to be published the method of letting peers rank researchers in their own field employed in 1903 and 1909 was not used in later editions the sheer number of entries growing from 4000 in 1905 to 10000 in 1921 also greatly enhanced the labor and cost of producing the directory as callon andmuniesa also note detaching objects grouping classifying and presenting them are actions demanding considerable effort and calculative power it may have been too much for cattell he did continue to follow the distribution of scientific men across universities and in an article introducing the 1927 edition he discusses changes in the distribution of scientific men yet due to lack of data only the total the number of esteemed scholars is counted and no calculation of overall scientific strength was presented the 1933 edition the last one edited by cattell included a list of institutions where three or more of the starred scientists were employed again harvard is on top followed by california and chicago but the list is not said to be representative for the overall quality of institutions and no ranked list of scientific strength was presented the tradition of comparing universities based on american men of science was later taken up by stephen s visher who published a short piece in science where the numbers for the institutions employing most of the leading scientific men are given he did not produce a descending list but noted that harvard ranks highest on the list of universities when it comes to young starred scientists the attention received by cattells ranking is hard to estimate and it may not have drawn the same relative amount of media coverage as todays global rankings however cattells study was reported by news outlets and the implications of his study were discussed in a major piece in the the new york times sunday magazine the article americas great scientists rapidly decreasing was overall very supportive of cattells efforts calling his study one of the most interesting documents the educational world has seen for many a day an article published in the evening star titled on the down grade also focuses on the general decline of great men a cultural motif of the time … the present generation is decidedly below the mark set by its forerunners the same that is true in literature he says will be found true in science if the test is applied throughout the world thus the general theme of a declining civilization which cannot match the greatness of previous periods is repeated cattell was not the only one that took an interest in comparing universities at the beginning of the 20th century in 1910 edwin e slosson published great american universities in which 14 leading universities were compared on several criteria although slosson did not present a uniform ranking of universities his endeavor came close to current multidimensional rankings 15 years later raymond hughes was accredited with being the first to rank graduate programs in 1925 these early attempts had in common that they originated from the sciences themselves and although they claimed to be of relevance for students their audience mainly consisted of fellow scholars what makes cattells ranking standout compared to previous attempts of measuring scientific quality and to the rankings that followed it was not only that he was first in presenting a hierarchical list that was explicitly said to reflect overall scientific strength cattell also pioneered two major approaches for quantifying academic quality outputmeasures and reputational surveys furthermore he utilized three main indicators used in university rankings today manpower reputation among peers and number of papers cattell also aligned measures of manpower with reputational measures in order to corroborate his findings moreover the construction of the ranking grew out of a much larger scientific effort to understand the nature of scientific eminence ranking for cattell was not only a way of presenting his results but it was also a method used for studying and influencing the scientific community discussion cattells notion of eminence derived from the eugenicist tradition influenced his choice of methodology and was like contemporary rankings shaped by current conceptualizations of excellence and research quality cattells ranking built on the same basic idea about distribution as galton in his hereditary genius only a small subgroup of all scientists covered in american men of science were really considered to be outstanding and of these an even smaller subgroup were truly eminent cattell arrived at two main and to some extent contradictory conclusions on the basis of these findings first he argued that his study could be used to discover factors and environments that are likely to foster eminence with the overall goal of increasing the proportion of great scientists in making this argument he clearly sees nurture as a more important factor than nature yet some of the proposed solutionsie better salaries for married professors to encourage them to get more children and stipends for the children of professors are in line with the idea of scientific eminence largely being innate second he argued for better conditions for these eminent men they should be better paid have more autonomy and better working conditions the notion of a chain of institutionsfrom a world university where the truly outstanding scientists should be employed a countrywide university for the nationally distinguished ones and a local one for the less talentedis also part of the idea that the distribution of eminence among scientists should be reflected in institutional arrangements these visions correspond not only to galtons thoughts on the distribution of geniuses where only a selected few are truly great but it also capitalizes on the idea of a meritocracy where every scientist is given a fitting position based on abilities and performance in many ways this line of reasoning echoes the rhetoric of excellence that surrounds current day discussions on universities and their role in society the ranking that cattell presented effectively plotted the units of assessment on a scale with variable positions this had important performative effects though the ranking clearly builds on the eugenicist idea that only a few people can be eminent universities could from this point onwards hypothetically work themselves into a better position on the ranking in effect this new topography of eminence had a builtin potential to nurture eminence at the time cattell and contemporaries came to argue that the social nurture was more important than was first assumed in the right environment eminence was within reach even for those that were not born into it this builtin potential to improve we argue is an important intellectual linkage between these ranking practices and the social science of the time the ideas that motivated cattells ranking are crucial for understanding why and how the ranking was constructed however the role of instrumentationlists directories surveys and slipsused to produce the first university ranking should not be underestimated similarly citation databases websurveys and algorithms used in contemporary rankings play a significant role in the construction of excellence the directory american men of science was not developed to measure institutional strength nor was the science citation index designed for ranking journals or institutions rather they were instruments designed to facilitate communication in science quite soon however the information these instruments provided was used for comparison and ranking hence the availability of data determined to a considerable degree how rankings were constructed cattell pondered over the possibility of using the number of papers as an indicator of scientific strength he considered and made an attempt to produce an international ranking of countries and institutions he also had plans to reproduce his 1910 ranking but the lack of adequate instruments for these purposes hindered him the rationale of the first university ranking was based on theoretical and methodological considerations from a long tradition of measuring eminence in the eugenicist tradition the emergence of universities as the central hub of research as well as cattells involvement in science policy and university politics came to redirect his focus from individuals to institutions the eminent man shaped foremost by heredity and upbringing came to be replaced by the excellent university as the emblematic symbol of scientific and intellectual strength the image of the researcher was highly unstable in the early 20th century as older notions of the gentleman researcher driven by intrinsic motivations were juxtaposed with science as a paid profession cattells study of the ecology of scientific men and his subsequent ranking of universities was deeply rooted in this larger debate about the role of the scientist similarly the current preoccupation with university rankings can be related to a discussion regarding the multiple roles and instable identities of contemporary universities as we have seen an important characteristic of rankings is the ability to define make comparable and stabilize heterogeneous objects through processes of detachment sorting and presenting furthermore the concept of calculative devices also questions a common separation of judgment and measurement as two distinct processes as the example of the first university ranking shows judgment is often a prerequisite for measurement these elements are often overlooked in discussions that focus mainly on methodological issues or on the role of rankings in relation to increasing competition in the academy we show in this study that deliberations at each stage were dependent on how excellence and scientific strengths were conceptualized when cattell developed his ranking at the detachment stage for instance the crucial question was which entity would have to be deattached to come to represent eminence cattell deliberated between number of papers or number of doctorates but eventually decided that reputation among peers was the best indicator for eminence the peer evaluation was then detached from its original use of studying the distribution of eminence among individual scientists and employed for the purpose of measuring the scientific strength of institutions in current rankings a range of proxies can be singled out as representing qualities of a university and each of these is based on specific perceptions of what these proxies represent then the next question arises how should these numbers be sorted so that they come to represent the combined quality of a university as we have seen cattell developed a calculation procedure for this purpose based on the overall distribution of scientific men today algorithms are used to weigh and normalize outputs in similar fashion finally the results are presented either as a definite descending list of institutions as in cattells case or in a more multidimensional and less fixed manner thus notions of what constituted scientific strength underpinned each of the decisions made by cattell in ways very similar to how contemporary conceptualizations of quality and excellence are informed by current social values and scientific norms the idea that men and universities could be positioned on a single ranked list is apparent in the method used by cattell scientists were asked to produce a single list from the most prominent scientist downwards based on a selection of names provided beforehand the methodology chosen by cattell latched on to existing ways of measuring eminence developed in the eugenicist tradition of galton and his disciples however the basic statistics available from american men of science was not enough for judging the strength of institutions the mere production of scientists or papers could not be an indicator of eminence rather he saw reputation among peers as signaling true eminence hence a detailed ranking of scientific men based on observations of the distribution of scientific merit among scientists became the preferred approach as a ranking neglecting the highly skewed distribution of eminence could not be just consequently his ranking was in many respects a byproduct of his larger studies into the distribution of scientific men thus the first ranking of universities in 1910 originated from an academic setting where the approach taken and methods chosen were supported by current research findings similarly the first global university ranking was produced by researchers at shanghai jiao tong university for the purpose of studying and improving the relative position of chinese universities the reputation and influence of commercial rankings largely rests on the use of scientific methods thus both the first national and the first global university ranking were not primarily produced for outsiders but for academics themselves their development was not mainly driven by demands for external accountability and transparency that is advocated today but by a more fundamental curiosity regarding the growth and progress of science

global university rankings have become increasingly important calculative devices for assessing the quality of higher education and research their ability to make characteristics of universities calculable is here exemplified by the first proper university ranking ever produced as early as 1910 by the american psychologist james mckeen cattell our paper links the epistemological rationales behind the construction of this ranking to the sociopolitical context in which cattell operated an era in which psychology became institutionalized against the backdrop of the eugenics movement and in which statistics of science became used to counter a perceived decline in great men over time however the eminent man shaped foremost by heredity and upbringing came to be replaced by the excellent university as the emblematic symbol of scientific and intellectual strength we also show that cattells ranking was generative of new forms of the social traces of which can still be found today in the enactment of excellence in global university rankings

introduction in todays era of globalization we cannot escape from global life the wave of globalization brings both positive and negative values such as divisions disputes and disharmony in society by looking at this phenomenon indonesian education must be sensitive to the currents of globalization industrial revolution 40 leaves new problems related to the loss of social humanities values the millennial generation born in the 1990the 2000s has shown symptoms of mental degradation the consumerist lifestyle unlimited freedom lack of social care intolerance difficulty in interacting with issues and the loss of ethical behavior on social media are a series of examples of this degradation education is a human need or society the basis of life to be better physically mentally and in character education plays a role in various aspects so there is no life without education education is like food for the human spirit throughout its life also in line with king butler multicultural multiracial and multireligious societies have great potential for conflicts between groups races religions and ethnicities problems arising because of diversity have become inherent facts in various countries built on such variety in the development of society 50 most of the information came from the internet and then in the physical space thus the role of humans in activities cannot be replaced by technology there are 4 forms of change in technological development in the concept of society 50 namely health mobility or transportation facilities infrastructure and smart management although the origination of the era of society 50 came from japan which adapted to the conditions of the country in some respects it was also by the conditions in other countries in this evolutionary world society 50 is an information society built on society 40 which aims to prosper poor communities the link between education and multiculturalism is a solution to diverse cultural realities as a process of developing all potentials that respect plurality and heterogeneity due to cultural ethnic ethnic and religious diversity so the role of multicultural education is significant in overcoming or minimizing the negative impacts of the 40 revolution era so that students will be wise in using social media and be careful not to let their words writings and tweets have the nuances of blasphemy and intolerance the impact that the industrial revolution 40 will have on economic growth is a problem that divides economists on the one hand technology pessimists argue that the critical contributions of the digital revolution have been made and their impact on productivity has ended on the opposite side technology optimists claim that technology and innovation are at the point of infection and will soon unleash a wave of higher productivity and economic growth according to there are ten signs of human behavior that indicate the direction of the destruction of a nation namely 1 increased violence among adolescents 2 cultured dishonesty 3 increased disrespect for parents teachers and leaders 4 peer group influence on violence 5 increased suspicion and hatred 6 use of abusive language worsening 7 decreased work ethic 8 decreased sense of social responsibility of individuals and citizens 9 increased selfdestructive behavior 10 increasing loss of moral guidelines thus based on thomas lickonas theory which is a problem to revive in this digitalization era many social factors can threaten the younger generation including the emergence of violence and incompatibility that often occurs in the media and the real world strengthening character is needed to instill a solid foundation in building diversity in this country in addition the most important thing is that students come from various circles in this institution some students come from outside the region then from multiple statuses ranging from children of kyai teachers officials farmers traders and others this will cause a barrier between one group and another character education is the most important part to realize the formation of a generation with superior quality and is the key to making indonesian children have good quality so that they can be implemented in everyday life through this character education students will not only learn to distinguish which behavior is right or wrong good or bad behavior but will familiarize students behaving by the existing character values so that it is embedded in them to always do good habits that are by the character values character values if character values have been embedded from an early age students will be able to fortify themselves against things that are not good so they are better prepared to face the 40 era technology was created to facilitate human tasks in living their lives as well as social media as part of technology made according to their respective characteristics that aim to reduce peoples social life such as connecting and facilitating interaction between individuals groups groups or those who have the same views however the presence of social media can also be used as an arena for debate and even a place of endless insults between users for this process to run as expected all parties must accept the multicultural concept that is socialized and disseminated through educational institutions and ideas that can be set as models of the academic curriculum at various levels of institutional education implementing multicultural education in indonesia is considered relevant to the conditions of the indonesian people with cultural diversity and complexity recognition of the various cultures of the indonesian people is the primary key to respecting cultural diversity implementing multicultural education in indonesia is considered relevant to the conditions of the indonesian people with cultural diversity and complexity recognition of the various cultures of the indonesian people is the primary key to respecting cultural diversity this paper aims to include multicultural education in shaping the social character of children and the implications of multicultural education in schools in the era of digitalization the research conducted by with the results of the study stated that in building the character of the nations children a solution was needed one of which was through multicultural education centered on the character of indonesian which was done by forming a mindset attitude action and habituation so that the emergence of national awareness of character a great nation is realized through a strong human character if national values are not continuously instilled they will potentially become a source of division and conflict against a nation therefore multicultural education emphasizes the importance of accommodation for the rights of every culture and society to maintain and maintain the identity of the national culture and society so that later the indonesian nation has a good character and an honorable nation the difference from the research lies in the aspect of the digitalization era which provides a very fast flow of globalization and changes the character of children research conducted by the results of the study show that the implementation of multiculturalbased character education is carried out through the following programs a school management commitment b through school rules c integration into intracurricular programs d integration into extracurricular programs e school culture and f network program the school develops character values religious values independence care for the environment achievement tolerance democracy national spirit competitiveness and peaceloving supporting factors include a good commitment and cooperation between school principals teachers students and the involvement of parents and guardians b support from the government and the private sector in the network inhibiting factors include a the habits and culture of the environment from which students are different b the community environment c peer environment and electronic media e incomplete infrastructure f evaluation of character education programs that have not been optimal thus affecting the process of character building this research is only on the aspect of the character education program but not on character cultivation from the digitalization aspect during the industrial revolution 40 while in research the existence of multiculturalism education will be able to help to better appreciate differences with a very high tolerance so that it can form a personal character that is by islamic religious education in social actualization in society multiculturalism education will make students become more characterized and find an identity that is by the scientific fields they have studied especially in islamic religious education which is the main character trait of muslim behavior the gap from this research is to shape the character of local wisdom by the uniqueness of each region so that it does not eliminate the identity of children in the era of digitalization in addition multicultural education is basically to find and explore the common values contained in various types of cultures and the development of tolerance towards individuals creating a management system that does not discriminate against students backgrounds will help create harmony in cultural diversity through the efforts of staff and managers schools must become a cultural environment and a place for cultural exchange between ethnic groups so that each ethnic group can enrich each others cultural heritage through the introduction of cultures thus important issues in multicultural education need to be built based on the diversity of different ethnic groups races and ethnicities in a single unit this difference will naturally lead to innate diversity for students in the life of the nation and state based on the results of this study found that the development of multicultural character in salafiyah islamic boarding schools is explicitly planned for the aspect of integrated moral education the organizational culture of salafiyah islamic boarding schools allows the development of the multicultural character of students leaders clerics and teachers always show behavior with values of respecting others especially guests and respecting differences method the type of research used in this research is library research the author uses a descriptive normative research approach emphasizing the strength of data analysis on existing data sources data sources can be divided into two categories namely primary and secondary data sources the primary data source in this research is the book multicultural education a source book second edition the data collection technique in this study was carried out with documentation techniques this technique is used to track documents data and information in books magazines scientific journals articles and so on that are relevant to this research to analyze the data the author uses content analysis as content analysis is a research methodology that utilizes a set of procedures to draw valid conclusions from a book or document graphic 1 method results and discussion implementation of multicultural education in shaping childrens social character multicultural education in the digital age this diversity must be accepted as a reality for people with a complete view of life it must be difficult to accept this fact when suddenly a group of unknown people come and live in their ancestral land in general the challenge faced by education in the digital era is how education can present itself whether it can educate and produce students who have high competitiveness or are even barren in the face of the onslaught of various advances in the global era multicultural which is full of competition in various sectors both natural and monetary sectors in this case the current development of the digital era will lead to cultural uniformity efforts this uniform ideology will undoubtedly threaten the existence of a multicultural society so people need to know about multicultural society sholahudin siahaan argues that a multicultural society is a society consisting of several kinds of cultural communities and all aspects of their advantages with slightly different conceptions of life a system of meaningful values forms of social organization historical differences customs and habits according to niota sonia and according to sonia multicultural education must be embedded in the curriculum and teaching strategies including interactions between teachers students and families and the overall teaching and learning atmosphere this type of education is a critical reflective and actionbased pedagogy for societal change consequently multicultural education can develop democratic principles in social justice hanum explained that the implementation of multicultural education can be done through a contribution approach in the classroom one of which is by introducing the diversity of forms of traditional clothes and houses introducing the vocabulary of each region introducing calls for men and women according to their respective regions it has the aim of expanding the knowledge of students through the diversity of indonesian customs and culture schools play an important role in instilling multicultural values in students if students have values of togetherness tolerance love of peace and respect for differences then they will be reflected in their daily behavior because they are formed in their personalities if our young generation successfully owns this then the future life can be predicted to be relatively peaceful and full of respect for each other can be realized multiculturalism is a reality that must be accepted by humanity therefore this fact does not have to make people from different cultures divided and hostile to each other according to farid ari fandi quoted in the journal sapendi multicultural education programs have several hopes first for the embedded attitude of pluralism culture is not only tolerated but embraced together in harmony second multicultural education recognizes the importance of socializing children with other people who have different cultures and backgrounds from themselves with the multicultural character in the childs personality the child can mix well with each other even though they have different experiences third multicultural education provides the ability to develop a sense of self that is multicultural education gives confidence to every student this trait is especially true for students who have economic disparities and live in a minority world in other words multicultural education can be an alternative means of solving sociocultural conflicts apart from being an alternative means of conflict resolution khoirul mahfud juga menjelaskan bahwa pendidikan multikultural juga signifikan dalam membina siswa agar tidak tercerabut dari akar budaya yang dimiliki sebelumnya tatkala yang berhadapan dengan realitas sosialbudaya di era globalisasi related to this education has a role in instilling character values including character building is one of the main tasks in education the main task of education is not only providing knowledge and skills but character building character building will give birth to someone superior in character so that it will produce students who are wise in dealing with the problems and challenges they face changing bad habits through character education a student will be able to understand and be able to distinguish between what is good and what is bad so that way students through student education can change the bad habits that they did before step by step character is a character that is stored in a persons soul and through that character it will be seen easily how a person will behave to others through character education students are formed to have good character the character of students can be said to be good and can be known through the way they behave and how they treat others character is a trait that is created within a person to show commendable behavior and has an element of virtue implications of multicultural education on social character in schools in the era of digitization multicultural values emphasize an open attitude and respect for the entity including cultural aspects so with multicultural awareness it is hoped that it will develop an attitude of mutual tolerance solidarity and respect for each entity of diversity multicultural values emphasize an open attitude and respect for the entity this includes cultural aspects so with multicultural awareness it is hoped that it will develop an attitude of mutual tolerance solidarity and respect for each entity of diversity multicultural education is an educational program that provides multiple learning resources for learners to students academic and social needs multicultural education as a substitute for intercultural education is expected to foster an attitude of caring and understanding of the existence of political recognition of the culture of human groups such as tolerance ethnocultural and religious differences discrimination human rights democracy and plurality universal humanity and other relevant subjects automatically this multicultural awareness will build the character of tolerance in each learner multicultural education if it has been internalized and owned by students from an early age will be able to create future generations of the nation with superior character schools play an important role in instilling multicultural values in students if they have values of togetherness tolerance love of peace and respect for differences then what happens is that these values will be reflected in their daily behavior because it is formed in their personality if our younger generation successfully owns this then future life can be predicted to be relatively peaceful and full of respect for each other can be realized according to mahfud there are several approaches to the multicultural education process first it no longer equates the view of education with schooling or multicultural education with formal school programs second avoiding the idea that equates culture with ethnic groups meaning that there is no need to associate culture solely with ethnic groups as has been the case so far third because competency development in a new more clearly that efforts to support ethnically separated schools are the antithesis of the goals of multicultural education fourth multicultural education increases competence in several cultures which culture will be adopted is determined by the situation and conditions proportionally fifth it is possible that education increases awareness of competence in some cultures such understanding will then distance us from the concept of biculturalism or the dichotomy between natives and nonindigenous people although it has been explained the competencies that teachers must possess in reality there are still obstacles to implementing multicultural education in schools meanwhile zakiyuddin baidhawy states that multicultural education is a process of teaching a respectful sincere and tolerant way of life towards cultural diversity that lives amid a plural society thus the study of character education in multicultural education is an education that offers an alternative through the implementation of educational strategies and concepts based on the utilization of the diversity that exists in society especially those of students such as ethnic plurality culture language religion social status gender ability age and race this educational strategy aims to make it easier for students to understand the lessons they are learning and to increase their awareness to always behave in a humanist pluralist and democratic manner the characteristics of multicultural education are principles of democracy equality and justice oriented toward humanity togetherness and peace and developing an attitude of acknowledging accepting and appreciating diversity social in a pluralistic society according to mughni state that multicultural education is education that respects differences from this definition it can be concluded that multiculturalism education teaches about respecting all students regardless of their background gender social class ethnicity race religion and culture all students have the same opportunity to study at school a concept idea or philosophy is a set of beliefs and explanations to recognize and assess the importance of cultural diversity in shaping lifestyles social experiences personal identities and educational opportunities for individuals and groups through 6 factors that become sources of consideration namely a gender b race or ethnicity c social class d religion e exceptionality and f other variables multiculturalbased learning seeks to empower students to develop respect for people of different cultures and provide opportunities to work directly with people or groups of people of other ethnicity or race multicultural education also helps students recognize the appropriateness of diverse cultural views assists students in developing pride in their heritage and culture and makes students aware that value conflicts often cause conflict between community groups in a broad context multicultural education tries to help unite the nation democratically by emphasizing the perspective of a plurality of people in different countries ethnicities and cultural scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 scaffolding jurnal pendidikan islam dan multikulturalisme vol 4 no 3 162174 groups thus school learning is conditioned to reflect the practice of democratic values the curriculum exposes other cultural groups in society language and dialect where students are better off talking about respect among themselves and upholding the importance of cooperation rather than talking about competition and prejudice among several different students in terms of facing the challenges of childrens future nation in the era of the industrial revolution 40 education as a conscious and planned effort in creating an active learning atmosphere from every learning process will try to stun the young generation of this nation to be able to develop their potential and make the learning process a means to understand develop understand and know something and be more critical in thinking conclusion the importance of multicultural education in the digitalization era has an impact on childrens character education the multimedia era provides a rapid flow of globalization in character inequality so multicultural education is needed in educational institutions the impact of multicultural education will give a social character with a different cultural frame from the various ethnic cultures that exist in indonesia this will contribute to aspects of the values of togetherness tolerance love of peace and respect for differences that will be reflected in their daily behavior because it is formed in their personality if our young generation successfully owns this then the future life can be predicted to be relatively peaceful and full of respect for each other can be realized abdullah a numan a zamroni z wahyuni d i arbaiyah a bibliography

the purpose of the study was to find out the implementation of multicultural education studies in the digital era and the implications of multicultural education on the formation of social character in the digitalization era with the rapid development of technology today it certainly has an impact on the condition of education including the study of multicultural education the method used in this article is a qualitative method with a literature review data collection techniques are carried out with a conceptual approach the data collection technique in this study was carried out with documentation techniques this technique is used to track documents data and information in books magazines scientific journals articles and so on that are relevant to this research the author uses content analysis content analysis to analyze the data the results of the study show that the condition of the rapid progress of information and communication technology has a negative impact therefore multicultural education in this case seeks to provide understanding to the community especially students to know about multicultural values namely the attitude of accepting appreciating and respecting all forms of difference to avoid unwanted conditions such as radicalism racism discrimination and so on

as more and more political candidates include a social media presence in their electoral campaigns the impact of applications such as facebook and twitter on youth engagement has become an increasingly relevant question the 2010 mayoral race in calgary canada constitutes a rich case study for this relationship with these elections an independent and virtually unknown candidate rose to fame and won the mayoral seat in what appeared to be a social medialed electoral campaign the story has been quickly labeled a success in terms of both youth engagement and voter turnout where scholars have deplored decreasing voter turnout rates and chronic disengagement of canadian youth from politics this election advanced the seductive promise that social media may put such worries to rest this promise however rests on an ideological construction of democratic politics and citizen engagement as a function of new media social media it is argued enable a more efficient information exchange and a more egalitarian structure of communication between politicians and citizens the ability to successfully campaign online becomes envisaged as the new winning card in electoral races discursive constructions of technologically enabled democracies are indeed part of larger modern discourses on the alleged capacity of information and communication technologies to alleviate the social problems such discourses argues vincent mosco prey upon unfulfilled and unfulfillable collective hopes and dreams of equitable social structures the myths of cyberspace work partly because people genuinely want power and community people desperately want to control their lives and want to inhabit a larger social totality that provides them with emotional and intellectual support yet the ideological dimension of these discourses works precisely by effacing the structural inequalities characteristic of our late capitalist societies the relationship between engagement through social media and socioeconomic class for instance completely disappears as new media become positioned as universally available accessible and convenient furthermore these discourses reproduce a civic culture where technological determinism continues to legitimize proposals for social action and modes of explanation of social phenomena and identities when technology comes to be regarded as the solution to the woes of democracy our attention is lured away from a critical interrogation of the problems intrinsic to democratic decisionmaking mechanisms leaving us unable to recognize the impact of structural inequalities on the ability to join the field of politics and unprepared to deal with the conflictual nature of democratic processes this article engages in a critique of the discursive articulation of social media and civic engagement using the case of the 2010 mayoral elections in calgary the goal here is to map the ideological dimension of young peoples talk about political engagement through social media young people describe social media such as facebook and twitter as technologies of engagement where engagement is seen as a result of the perceived features of these technologies suggesting that the source of engagement resides in the use of technology rather than the individual citizen participants unrestrained enthusiasm for the alleged power of social media to improve politics remains a twoedged sword on the one hand it is clear that young people understand and challenge the inequality of contemporary politics particularly the perception that politicians remain inaccessible and aloof from citizens concerns on the other hand the faith in social medias ability to improve politics is simplistic and fails to critically investigate both the impact of existing power relations on democratic configurations and the very idea of democracy as a form of collective selfgovernment social media and engagement this article starts from the assumption that the ways in which we come to imagine engagement through social media illustrate unspoken yet shared expectations of politics framing our relation to democratic decisionmaking arrangements rather than focusing on the details of social media use in the 2010 electoral campaign in calgary the focus here is on the discursive construction of these technologies in relation to political engagement this approach is not common in the literature dealing with new media and engagement in the tradition of political communication engagement is often a priori defined as consisting of a limited set of actions through which citizens seek to influence the course of politics one of the most influential definitions of engagement goes back to the study of electoral participation undertaken by sidney verba and his colleagues by political participation we refer to those legal acts by private citizens that are more or less directly aimed at influencing the selection of governmental personnel and or the actions that they take this view is heavily skewed toward voting behavior along with campaigning communal activities and contacting elected officials and politicians studies in this tradition often try to identify the demographic and subjective factors most likely to influence engagement their interest in social media focuses primarily on their effects on political participation or on their potential to predict electoral participation with this notion of engagement in mind the question of the relationship between media and engagement becomes more complicated two different approaches robert d putnams argument of the dilution of social capital as a result of media consumption and jurgen habermas model of communication and media as sites of democratic praxis have attempted to clarify it following putnam some scholars have looked into how icts affect social capital the rapid popularization of myspace facebook or twitter effectively renders mundane social networks more visible researchers are now able to observe not only the formation but also the everyday use of the bridging and bonding social ties a common way of studying these ties and their relation to political participation is by measuring the statistical correlation between social media use and other factors such as political knowledge trust in others participation in civic life and political cynicism studies in this theoretical tradition often find that the use of social media has various facets from leisurely to political consumption social media appear as an important source of information as well as a site of political discussions and some forms of participation finally online political involvement seems to be correlated to political engagement offline thus far the empirical research on social media does not seem to support putnams suggestion that the internet consumption leads to social isolation and disengagement in the public sphere model the emphasis is placed on the existence of communicative spaces where citizens can engage in rational deliberation over matters relevant to the common good the question asked of social media is to what extent they are able to provide that ideal communicative space zizi papacharissi argues that the distinction publicprivate is no longer tenable as social media blur the boundaries between these spheres mixing personal lives and politics people are immersed in their everyday lives yet by being networked seemingly banal personal conversations and actions on social media come to have political power this power is directly connected to the aggregation and public visibility that social media add to these quasiprivate spaces chadwick calls these spaces granular suggesting that they encourage small scale forms of political engagement through consumerism and propagation of political content across multiple applications for bennett these forms of political engagement are part of a wider social transformation where personalized politics is on the rise personalized politics involves an understanding of engagement as consisting of personal choices and lifestyle values often shared with an individuals social network consequently it is important to understand just what these new forms of political engagement consist of the corollary of course is whether these forms of political engagement are indeed significant in terms of their capacity to affect politics overall however empirical research has been ambivalent on the issue of impact suggesting that researchers need to recognize that at least some online spaces are in fact capable of hosting salutary democratic communication attention to these granular public spheres also brings under scrutiny habermas emphasis on rational debate dahlgren points out that political engagement requires cognitive but also affective involvement from this perspective we need to recognize the role of protopolitical or latent political activities things such as liking a politician on facebook retweeting the link to a newspaper article or commenting on a friends wall may coalesce into political engagement on the other hand an array of practices of use and of structural constraints shapes these latent political activities involving social media one of the most discussed emergent practices of use is that of homophily if indeed social media users tend to relate to likeminded people 1 then we may be faced with isolated perhaps even ideologically antagonistic public spheres it remains unclear whether homophily is indeed widespread and whether its impact is as severe as it may appear lincoln dahlberg reminds us that these online spaces are permeated by a culture of consumption which may result in a population generally disinterested in politics or engaged in a consumerist form of participation he concludes that the marginalization of online rationalcritical deliberations will occur as long as consumerism and other noncritical private modes of interaction dominate cultural participation and individualized interaction dominates politics yet again although consumption culture and a neoliberal ethic emphasizing individual action are indeed important structural constraints of participation through social media their significance is not at all straightforward we may consume politics through social media thus prompting new forms of engagement but at the same time our own practices of social media use position us as both citizens and consumers within particular networks of power controlled by commercial interests whose goal remains the monetization of our online lives participation through social media argues greg goldberg remains thorny because it takes place within the confines of profitoriented spaces that is this marriage of convenience between participation and profit may not always work toward the same democratic goals espoused by habermas the chatter and clutter of social media may be seen as part of the civic culture of our times understood as the taken for granted orientations factual and normative as well as other resources for collective life in a similar vein mark deuze speaks of the expectations embedded in the current digital culture that is the possibility of remixing different forms of cultural texts our roles as bricoleurs engaged in the assembly disassembly and reassembly of mediated reality and the necessity of participation participation he concludes is what people have come to expect from those aspects of society they wish to engage in this may not be the form of participation that political scientists have envisaged but a messy and dispersed mode of engaging with the routines and confines of everyday life where resisting the facebooks changes to the interface faking politicians twitter accounts or making online cultural texts available by translating them in other languages becomes inseparable from politics the form of this participatory civic culture needs to be further investigated examining the ways in which we imagine the role of social media in spurring political engagement helps us bring to the vocabularies and the systems of evaluation through which we make sense of our own relation to politics yet attention to the ways in which our civic responsibilities and technology become articulated in everyday life is surprisingly missing from the literature such everyday understandings are the sites of ideological struggle where our individual meaningmaking processes relying on the existing civic culture reinscribe or resist contemporary structures of power canadian youth and electoral engagement the case of the 2010 calgary municipal elections in canada youth turnout has often been described as worrisome the numbers indicate a sharp decline in the number of young people casting their votes in federal and provincial elections on average around 37 of people in the 1824 agegroup and around 46 of those in the 2529 agegroup have participated in the federal elections held between 1997 and 2008 importantly this marks a 40 decline in the number of firsttime young voters since the 1960s various explanations have been attempted for this phenomenon the impact of television youth mobility rising cynicism decline in political knowledge and socialization effects have all been invoked as factors contributing to the turnout decline among young people adsett has argued that this decline may derive from the marginalization of youth in politics as a result of the shift of the canadian state toward neoliberal ideologies and of the decline of the welfare state on the other hand the investigation of the alleged decline in youth turnout is limited by the same a priori reduction of political engagement to voting noted previously in her review of literature focused on youth engagement in canada oneill remarks that rather than being indifferent or apathetic canadian youths engagement is merely different young canadians are involved in volunteering activities and tend to prefer individualized resultsoriented political action research on social media and youth political engagement in canada remains scarce the few published works take a political communication approach to the role of the internet in party politics focusing on electoral campaigns this may be a result of the fact that the use of social media in elections is of recent origins and its efficacy as an electoral campaign tool remains unclear at least for politicians previous research on the potential of the internet to affect electoral outcomes in canada was skeptical in one of the few studies of social media in local elections in canada verville and giasson note that the use of social media by politicians tends to remain envisaged as a oneway message transmission system however as political parties increasingly devote resources to online campaigns the use of social media to encourage political engagement is likely to change similarly taras and waddell note that in spite of the excitement of journalists and political junkies with the role of social media in the 2011 federal elections the limited number of people who are active social media participants the narrow range of issues those people highlighted during the campaign the lack of impact on the issues they raised and the paucity of uses that were found for social media during the campaign call for a sober evaluation of the role of twitter and facebook in electoral contexts in this context the case of the 2010 municipal elections in calgary alberta is particularly interesting the fact that social media have been rhetorically constructed as the winning card may indicate a shift in the way social media are imagined as an electoral tool this however should not be taken as saying that social media were the winning card a young and booming city calgary has traditionally been characterized by political and cultural conservatism in recent years calgary has experienced a dramatic demographic change with ensuing cultural tensions over the struggle of the city to define itself the demographic dynamics have resulted in the second youngest metropolitan populations across canada in 2010 calgarys median age was 358 ahead of toronto ottawa vancouver and montreal politically however ever since the first provincial elections of 1905 the governing parties in alberta have obtained the bulk of the votes and have stayed in power for lengthy periods of time in calgary the previous two mayors have stayed in power for 11 and 9 years respectively furthermore voter turnout in municipal elections has been generally low upon the announcement that the longstanding mayor of calgary was retiring from politics all eyes turned toward the most wellknown incumbents entering the mayoral race among the 15 mayoralty candidates was naheed nenshi whose candidature was initially ignored 2 by the end of the race however journalists had become increasingly interested in nenshis online presence consisting of a twitter account a facebook profile and a series of videos uploaded on youtube they compared the number of facebook followers for each of the candidates suggesting a direct relationship between nenshis success and his ability to capitalize on social media 3 these elections were marked by one of the highest turnouts in the history of the city although precise data are missing many speculated that the increase was the result of nenshis ability to use social media to engage young people on the other hand it should be acknowledged that nenshi ran on a nonpartisan and generally positive campaign focusing on the idea of urban change against the background of worries about voting turnouts in general and about the perceived political apathy of young people nenshis campaign brought along the promise that youth disengagement could in fact be addressed simply by making use of the latest icts methodology this article presents the results of a thematic analysis of 59 student essays engaging with the following question in your opinion what was the role of social media in the 2010 mayoral elections in calgary the essays have been contributed by undergraduates at the university of calgary as part of their course assignments in three different courses in the department of communication and culture informed consent to use the essays as research data was done by an independent third party the essays were introduced as the opinion section of a more comprehensive assignment and students were instructed that no further research or integration of course material was required or expected in this context in addition they were told that the grade for this section depends solely on their ability to make their opinions and the thought process behind them as explicit as possible the use of student essays as data for qualitative research is more common in the field of education where researchers are interested in bringing to light the specific discursive repertoires through which students talk about specific topics in approaching data qualitative researchers are interested in three things data should provide indepth and emic accounts data should be generated by people who are part of the phenomenon under study and data are understood as coconstructed by the researcher and the participants the essays used here match these expectations they are indepth personal accounts of students opinions in response to a topic introduced by the researcher several methodological implications of this type of data should be recognized here first general expectations of academic writing as a genre impacted the structure of these contributions although not necessarily in a way that disqualifies them as data academic writing is seen as reasoned measured argument students try to explain their position and to anticipate counterarguments yet this is what often happens in the context of any conversation interview or public statement an essay may be more thought through and elaborate than an oral contribution as students naturally draw from the course material but also from other sources to provide a detailed account of the event under discussion as with other qualitative contributions such data are taken here not as a reflection of students inner beliefs or content knowledge but rather in terms of the interpretive repertoires on which students drew to explain themselves not unlike an interview setting classrooms have to be understood as ecologies that involve social and cultural forces exemplified by students and teachers the development of these ecologies are not entirely predictable in other words just as in everyday exchanges there is no reason to assume that a communicative interaction is entirely determined by the institutional setting within which it takes place in using student essays as data this article subscribes to roth and lucas description of student talk as reflective of communities and language games while students draw from the material they learn through their coursework theres little reason to assume they only do so within assignments furthermore while student contributions are tailored by the expectation of a grade we cannot assume that the assignments will simply mirror the instructors views or teachings collyer acknowledges that students writing is often shaped by the anticipation of the teacherreader consequently students seek to persuade and to reconcile with the reader by explaining their positions however the nature of the studentteacher interaction in this context provides students with a feedback loop which makes available to the writer an increased interlude with which she may deliberate more deeply before producing utterance again this is in no way radically different from the context of communicative interactions traditionally seen as legitimate qualitative data in all cases as researchers we are dealing with coconstructed accounts whose context of production needs to be acknowledged in all cases both researchers and participants select from available linguistic resources participate in language games and make contextdependent choices when speaking or writing about something the crucial assumption in the methodological approach of this article is that such choices are also indicative of and contributive to wider discourses about social media and democratic politics thus the student essays in this sample were analyzed in terms of how students talked about engagement mobilization or participation the researcher first identified the paragraphs in which students referenced these words these paragraphs were subsequently reread and coded thematically the researcher did not seek to link a specific statement with the demographic details of the speaker as this was seen as less relevant the focus was on how engagement and social media were temporarily brought together the ability to generalize from the discursive analysis of these essays remains however limited this sample consists of undergraduate students talking about engagement in a specific context although no further demographic data was collected the fact that respondents are part of the higher education system uniquely positions them as part of the new professional elite this i argue is significant this group is not only proficient in using icts but to a great extent student life in canada inevitably makes icts a central part of the everyday life of these participants students like the ones included in this sample will go on to become the next political communication specialists journalists politicians computer engineers as well as citizens the discursive construction of engagement through social media in this project participants talked about engagement as driven by three factors namely the feeling of being part of a community the ability to access and share information and the possibility of engaging in personal communication with politicians and other citizens within this frame social media were described as both an engagementspurring technology and a social space where this engagement unfolds the influence of friends communities lead to engagement for the participants in this study facebook and twitter were social spaces where they interacted with others the feeling of being part of a community made political endorsements within a network of facebook friends compelling i did find myself looking up nenshis facebook page due to the amount of facebook statuses that i saw regarding his campaign all of the hype that was created heightened my level of curiosity and pushed me to become more engaged in the political race in line with the social capital literature political engagement appears to be driven by strong social ties that is the respondents online network of friends spurred their curiosity and interest in politics that also means however that engagement becomes a consequence of social practices fashions social media buzz drives the individuals assessment of the issue in question as important when it comes to youth electoral politics can be to a large extent an entirely new thing and many of the participants in this sample were firsttime voters in these elections it is clear that their social networks attention to the elections opened up their appetite as well ones friends often have a strong influence on an individual throughout the 2010 election many people were posting and tweeting their thoughts on the election platform issues and candidates for many individuals seeing that it was important to their friends made it important to them this vision of social mediaenabled engagement suggests that tapping into networked communities is useful in mobilizing young people yet it also casts youth engagement as a result of technologically driven mobilization processes rather than the result of the internalization of civic duties in other words engagement becomes understood as a consequence of processes exogenous to the individual rather than a personal commitmentresponsibility that the individual assumes as part of herhis civic identity this is further problematic as the notion of community depicted here consists mainly of the respondents online friends and acquaintances reminiscent of the literatures emphasis on the dangers of homophily who is part of this social media network and what is the relation between its nodes respondents did not bring up this question as for them social media represent a connection to a larger global society when on social media young people felt connected not only to their friends but to their friends friends or even complete strangers brought together by the features of the technological platform this framing of social media satisfies the cosmopolitan element of canadian identity cementing the belief that the internet allows ones community to escape the confines of parochialism perhaps it is relevant here that most respondents readily resorted to habermas public sphere as a metaphor for social media 4 reminiscent of chadwicks granular spaces of engagement created through the consumption of political content respondents felt that networked individuals are within two degrees of separation from each other thus social media appeared to them as organic spaces of global interconnections as respondent 13 explains the interaction with people that you do not personally know but are somehow connected to your network gives a sense of community yet not everyone is online and citizenry cannot be simply reduced to the social media fan base a pervasive belief that everyone in calgary is present on social media ran across the sample although more data on canadian social media users are needed the question to be asked here is whether the marginalized or excluded from democratic decision making are indeed present on and able to contribute to social media trends recuperating the question of who is excluded or absent from social media is important the respondents in this sample imagined social media as intrinsically egalitarian spaces on the other hand respondents were silent on the question of disagreements or conflicts within social media while the 2010 elections in calgary gave off the sense of a community galvanized by nenshis candidature the apparent consensus on the role of social media in these particular elections has less to do with the politicians platform and more with the perception that he recognized the importance of youth in politics for respondents social media were the quintessential youth hangout and nenshis presence in this space was decoded as a longawaited recognition of the important political role of youth the powerful articulation of social media on the one hand and community cosmopolitanism equality and recognition of youth on the other effectively invests technology with meaning social media become positioned as the solution to the problems of political disenfranchising of youth and of social inequality at large the conflation of social media with strong community ties and democratic politics works however ideologically first what happens when the issues or candidates that become popular online are not necessarily factually correct or liberal second under what conditions can a candidate mobilize social networks is this mobilization in fact reflective of widespread sentiments offline third how can peer pressure and critical thinking be reconciled so that individuals still have room to make up their own minds particularly when going against the prevailing norm among friends and family fourth in the context of democratic decision making what are the consequences of a social mediadriven agenda setting for if citizens become engaged as a result of the electoral buzz on these platforms what happens when such spaces remain silent on crucial political matters become manipulated or reach saturation with electoral matters popularity and relevance information breeds engagement access to information was the second frame used in talking about the role of social media in spurring engagement as the social capital literature suggests social media become an important source of information for political discussions respondents spent a lot of time explaining the importance of social media as sources of information yet they rarely engaged in an explicit way with the question of what this information consists of anything that was shared through social media appeared to be information such as retweets shares friends telling friends about political positions messages from campaign teams and politicians to some extent the increased personalization of politics has further expanded the notion of politically relevant information as the details of a politicians life are an expected political action spurring citizens affective involvement in the elections two major meanings of information emerge from the data first information referred to the content shared by ones social media network second information referred to online content circulated by the politician and his team on social media actions such as liking the politicians facebook page or updates endorsing the politician were often depicted as information made visible by the technological platform itself respondent 13 explained that the mere act of joining a facebook group is instantly made known to his friends which in turn lets everyone on my friends list know every interest of mine i post on facebook doing this makes the campaigns page more noticeable to my friends and therefore increases their chances of them joining and participating in the community respondent 15 describes this as a process whereby friends keep their friends informed and involved respondents typically emphasized the trustworthiness of this type of information this information was objectively rendered visible to the individual courtesy of the algorithm of the platform respondents did not feel that they were pressured or persuaded by others but rather that they were merely provided with the facts about the political choices and comments of their online social network importantly respondents were completely silent on the mechanisms through which facebook and twitter make information visible to users it is this perceived objectivity of technology that leads one respondent to argue that social media had a gatekeeping effect on electoral campaigns voters can go on sites like facebook and twitter and see how other voters feel about the candidates their ideas and their policies this can reveal both positive and negative qualities of these policies that one would not see if they were to read about it without discussing it further this ease of access to information forces the candidates themselves to run a cleaner smarter as people are more likely to expose their flaws and weaknesses people will also not be so easily swayed by the false slander and mudslinging of the candidates information was also used to talk about messages originating from the politicians social media accounts the convenience of accessing this information through social media was often highlighted as an important aspect of engagement social media has become one of the most affluent forms of transmitting information with the majority of calgarians having a facebook and twitter account the information regarding nenshis campaign was readily accessible people constantly check and update their facebook using mobile devices promoting transport and relay of information many people have access to the information published on these forms of social media and it is easily spread if indeed students get their political information mostly from the internet then the question of what this information actually consists of becomes crucial interestingly enough almost none 5 of the respondents indicated that they had relied on expert commentary or analysis to make their decisions however the fact that in their own essays students did rely on news stories to develop their arguments may indicate that such sources have not necessarily been rendered obsolete however throughout the sample traditional news media were depicted as biased and manipulative this is interesting as reposting and retweeting news editorials or other expert contributions is common practice among facebook and twitter users when considered in conjunction with the quote above the information posted by a politician and his campaign team on social media appears as not only honest but also directly relevant to social media users this view of social media use resonates with the vision of the internet as a space of personalized information where the burden of sifting through massive amounts of information is alleviated by picking and choosing the news sources that one considers valid but how should we assess content we consume through social media the articulation of information and personal networks or direct communication between citizen and politician is easily conducive to the conclusion that we now possess all the relevant political information relevance in this case stems out of the nature of social media allowing for the filtering of information through ones networks interestingly unlike the literature respondents do not recognize this behavior as a form of homophily consequently they do not seem to worry over the consequences of selectively exposing oneself to sources of information that merely reinforce ones own attitudes values and views furthermore respondents emphasized the convenience aspect of information retrieval through social media information was not only at their fingertip but it was already distilled and reliable by virtue of coming from ones friends or from politicians themselves this in turn spurred political engagement casted here as a lack of access to relevant information but what exactly does this type of information consist of what sets of norms and rules make it relevant for instance what happens with information that is relevant to groups that are not part of ones social network what skills do we need in order to assess the credibility and usefulness of this information in a manner that recognizes the conflictual nature of democratic negotiations for instance respondent 13 swiftly moved from talking about political parties marketing their values and ideas through social media to explaining how these social media profiles inform voters about the politicians political position in this discursive slippage the thorny question of intent and agenda particularly in the context of electoral communication becomes effaced but if democracy is conflictual then intent and agenda are crucial as they advance specific interests while ignoring others in this sample for instance although some respondents recognized that nenshis presence on social media was part of an electoral campaign aimed at swaying voters to your cause only very few actually engaged with the candidates position on policy issues 6 it is hardly news that emotional involvement leads to engagement but how do we move from such latent forms of engagement to more nuanced understandings of democratic politics unmediated communication recalibrating the balance of power the ability of social media to enable an allegedly unmediated relation between citizens and politicians was the third theme through which social media were constructed as tools fostering democracy among this sample nenshis success was often depicted as a consequence of his presence on and availability through social media interaction through social media was often depicted as horizontal communicative links between voters and candidates as well as between voters the personal nature of political communication became the ultimate form of gatekeeping as respondents believed that it is fairly easy for them as technologically savvy individuals to assess the authenticity of a politician respondents thus saw themselves as in control of their own opinions about politicians as respondent 14 explained the allegedlyunmediated interaction with a politician via facebook or twitter means that people have the ability to take the message and redirect it in different paths in other words the public interprets it the way it sees fit respondent 51 added that by retweeting or commenting on a politicians facebook or twitter updates citizens felt empowered by this movement and i believe this led to decreased voter alienation the articulation of social media and direct communication advances however a simplistic view of the problems of democratic decisionmaking mechanisms as merely barriers in the transmission of information between political elites and citizens however as already mentioned the real hardships of democracies have to do with reaching decisions in cases of conflicting interests in a manner that is equitable at least in some respects to most groups and particularly to the ones most affected by these decisions furthermore the image of direct communication needs to be further unpacked as the previous section shows we need to question exactly what is communicated by the politician and for what purposes the politician engaging with social media users like them appeared to these respondents as a quintessential democratic practice citizens express concerns politicians address them it engaged them emotionally creating the opening for political engagement yet it is important to differentiate between the act of answering a citizens social media question and the act of policy making with which politicians are entrusted via the electoral process overall respondents were more enthusiastic about the first while remaining oblivious to the latter for instance respondent 34 argues on facebook voters were able to become friends with mayoral candidate no longer was that particular candidate just a figure in a suit standing behind a podium but they were now a friend who voters wanted to see win the same thoughts are echoed by respondent 33 since nenshi himself ran his own twitter account and carried a blackberry everywhere he went every citizen of calgary essentially had nenshis phone number any john doe could tweet him their own questions at their hearts content and it seems that he answered as many sic as possible the perception of befriending the candidate left respondents feeling empowered in turn this feeling of being taken into account of being heard led to greater interest in the campaign on the other hand without belittling the importance of this affective dimension of engagement we have to question the implications of this discursive articulation of social media and direct communication as with the preceding themes technology becomes envisaged as the mechanism that not only enables but also guarantees the genuineness of the relation between politicians and citizens however we should not conflate a politicians availability to citizens with the act of democratic decision making the fact that a politician engages with citizens does not mean the decisionmaking process is democratic while it is important for politicians to be in touch with citizens in order for the latter to remain invested in politics the question of who is represented on social media is also of uttermost importance so is the question of what a politician will do with citizens social media input discussion by looking at how a sample of undergraduate students discursively construct the role of social media in the 2010 electoral campaign in calgary this article explored the ways in which technology is imagined as the solution to the question of civic engagement in democratic electoral processes the discursive articulations explored here have been considered as sites of ideological struggle for social arrangements are sustained by a mobilization of meaning which legitimates dissimulates or reifies an existing state of affairs in other words while these articulations speak to respondents desire for a different form of democratic politics and suggest a salutary potential of using social media to spur civic engagement they are also problematic in terms of masking inequalities and reducing democracy to a simple message transmission act the stories of the role of facebook and twitter in the 2010 mayoral elections in calgary provided by participants constitute strategic meaningmaking efforts through which individuals draw from existing discourses to both make sense of the world around them and perform their identity as the new intellectual elite embracing and criticizing technology to talk about politics is one of the symbolic strategies through which these young people insert themselves into the social fabric performing the roles of responsible cosmopolitan and liberal citizens technology presents itself to respondents as not only a tool and a space of political engagement but also a guarantor of a better democratic setting where the distance between young people and politics is bridged yet this view of technology can equally be seen as a legitimizing mechanism the responsibility for and the capacity to address social issues is placed in the hands of technocrats technologists and technology users as respondent 28 asserts leaving no room for resistance to the reign of technology the digital age is upon us what exclusions are operated by such discursive articulations in spite of the widespread adoption of icts in canada the seamless embeddedness of new media into the fabric of everyday life remains a privileged middleclass experience many of the participants in this study often against some of the lectures and class discussions to which they had been exposed took for granted the power of social media to improve the relation between young voters and politicians for the young people in this sample new media are crucial to their daily existence and central to their professional life as such for this group new media may indeed open up new avenues for political engagement latent forms of engagement such as liking a candidate or retweeting a political statement may coalesce into engagement yet the conditions under which this happens as well as their political efficacy remain unclear within the case under discussion here and given the limitations of this data it is impossible to distinguish between the role of social media in spurring engagement and the mobilizing influence of the media coverage of these elections looking at the role of social media in the 2011 federal elections in canada taras and waddell suggest that traditional media found social media use for political communication purposes newsworthy but the evidence of the impact of social media on elections is hard to assess they point out that although around 16000 tweets were produced daily during this federal election this number is less impressive when compared to the 24 million canadians eligible to vote what can we make of the persistent belief that everyone is present on social media to a certain extent this discursive element encapsulates a genuine desire to be part of a community of friends to live in a democratic society where politicians are accountable to citizens and to have unmediated access to relevant information to put it differently this belief represents the much desired happy ending in the context of democratic politics motivated by such dreams and hopes the respondents hailed the revolutionary potential of social media to alleviate social imbalances and civic apathy there is as much wishful thinking as democratic ethos in such discursive constructions yet these discursive constructions legitimize a particular distribution of resources and of power if political engagement is spurred by and through social media then technology becomes the solution to voter apathy in the three themes discussed above engagement appeared constrained by convenient access to information lack of relevant and comprehensible information the absence of affective ties to politics and most importantly the lack of real opportunities to be heard and make a difference social media seem able to alleviate these problems as they promise convenience and connection as well as complete information as politicians migrate to these spaces there is also the promise that citizens will have an avenue to voice their opinions and be taken into account during the decisionmaking processes this of course is highly the issue of how decision making in a democratic setting can take place in the context of a plurality of interests and agendas remains largely ignored furthermore in these discursive articulations engagement appears prompted by either technology per se or its proper use this raises an important issue in legitimizing the distribution of resources for instance if we accept this premise then it makes sense to argue that resources previously devoted to fostering political engagement should be redirected toward developing technical skills and technical solutions with little attention to the role of civic education or of a democratic media system fulfilling a gatekeeping function as much as respondents rejoiced the opportunity to talk to politicians directly such encounters cannot produce the same knowledge outcomes as investigative reporting and political analyses taras and waddell echo this point when they argue that candidates political parties the media and even social media devotees all seem most interested in using the technology as a new instantaneous way to tell people what they think or what they should think in the 2011 federal election it was sometimes used to offer live tweeting playbyplay of speeches or events such as the leaders debates it is not clear though that such stenography with no context or analysis serves any broad purpose in enhancing the publics understanding of events or positions taken by politicians and parties in this project respondents were most enthusiastic about the possibility of directly talking to politicians yet although this use of social media was different from what taras and waddell discuss it nevertheless remains problematic to what extent does this personal connection helps us understand the broader context particularly when it remains an act of political marketing on the one hand it is important to remember that elections remain a game of gaining voters trust in this context one respondents confession is problematic i was unaware of the speeches nenshi gave or the ideas and opinions of the other candidates but i based my vote upon the tweets supporting him and what they said about him i actually did not follow nenshi on twitter until after he won the election so i was unaware of what he was saying about his views while this was not a wideshared view it raises important questions about the construction of social media as the solution to political engagement if our engagement with social media reproduces consumer politics by relegating citizens to the passive role of waiting to be courted by politicians within the comfort of their online social spaces then this type of engagement remains highly problematic on the other hand even this consumer politics needs to be recognized as part of a wider participatory culture the new forms of engagement through social media may often be incoherent and perhaps solely fueled by private interests but a priori judging them as useless or irrelevant does not work either the conditions under which our likes shares and retweets become part of processes of mass mobilization offline remain unclear and outside the scope of this article yet this recognition should not prevent us from questioning the discursive effects of this conceptualization of engagement through social media of interest here is the ways in which such discursive constructions of engagement through social media operate a simplification of the complex reality of the unequal setting of political environments befriending a political candidate online inevitably shapes our conceptualization of politics and politicians political engagement becomes an act of individual consumption consisting of disparate actions such as consuming facebook updates a politicians tweets or your friends likes of a particular candidate the linguistic and conceptual slippage from politician to friend can divert us from questioning how this politician actually protects and promotes the public good and whose public good shehe is actually representing as users our understanding of the social media landscape is inescapably shaped by our particular context we see the networks and their activities through the vantage point of our screen our list of friends our tweeter feed it becomes too easy i contend to lose sight of the structural inequalities of our societies it is even easier to evaluate everything in terms of individual choice control and will our discursive construction of social media as the solution through which power imbalances can be recalibrated resonates with our own experience as users failure to acknowledge what such discursive constructions make possible and what they marginalize remains a grave danger it is important that we question how these discourses about social media and political engagement prompt us to imagine technical spaces as sufficient in and of themselves for the realization of a democratic polis notes 1 yardi and boyds study indicates that this may not necessarily preclude engaging with those who disagree with you 2 in 2004 nenshi had been a candidate for a city councilor spot in calgary he was unsuccessful at the time nenshi was not completely unknown in some circles given his academic position at mount royal university in calgary and his involvement with the business community however i would argue that nenshi was virtually unknown outside of those circles 3 nenshi had over 11000 followers while the favorites stood at 74 and 1400 followers respectively yet these numbers are small when compared to the population of 665045 eligible voters in the city 4 habermas model of the public sphere was part of the course material covered in two of the courses from which students were recruited however students choice may also be indicative of the seductive power of the public sphere as a metaphor 5 only one respondent mentioned that people may get information from other sources not only social media however she concluded that social media are going to become more and more prominent in our lives 6 the word policy appears twice in the data analyzed here while the word issues is mentioned 30 times across the sample in most cases these words were used in general context such as local issues important civic issues issues which resonated with calgarians or platform issues the only explicit references were to things such as bylaws for renting basement suits property taxes and biking lanes author biography delia dumitrica is a visiting professor in communication at saint louis university madrid campus her research focuses on discursive constructions of new media with a focus on the ways in which new media are imagined in the context of politics civic activism and education she is also interested in cultural aspects of video games

the case of the 2010 municipal elections in calgary canada is used here to explore the discursive construction of social media in relation to political engagement this article examines the way in which 59 undergraduate students at the university of calgary discuss political engagement through facebook and twitter participants enthusiastically constructed a vision of engagement fostered by social medias alleged intrinsic features social media it was argued create a feeling of community provide access to information as well as the ability to share it and open up new means of building personal connections between politicians and citizens in this articulation social media appeared as both the tool that produced engagement and the space where this engagement unfolded the focus of the article is on questioning the implications of this discursive construction by asking what political possibilities are opened up or closed down in this articulation the construction of social media as the solution to the problems of democracy remains highly problematic yet also indicative of a deep preoccupation with the conditions of modern life and particularly the desire to find solutions to the increased complexity of the social systems

introduction cities attract economic agglomeration and population growth building on the benefits of density proximity and connectivity and the world is increasingly becoming urbanized as an estimated 14 million move into urban areas every week cities utilize 78 of the worlds energy and are responsible for the production of more than 60 of greenhouse gas emissions whilst urban areas account for 2 of the earths surface they are home to more than 50 of its total population the latter accounted for only 13 in 1900 and is estimated to rise to 68 by 2050 urban areas are more resourceefficient requiring less land and infrastructure to be sustainable however they generate a nucleus of additional challenges toward climate resilience such as diminished biodiversity air quality and flood resilience increased air temperatures resulting from the urban heat island effect and even poorer physical and mental health resulting from the lack of access to nature the climate crisis exemplified by the recent intensification of natural disasters including floods bushfires and storms as well as other climatic events like heatwaves and rapidly rising sea levels poses a profound existential threat to our cities and future generations for instance recent floods in pakistani cities florida in the us victoria and new south wales in australia and unprecedented fires on the nsw south coast have led to a loss of human lives and inflicted substantial damage to urban infrastructure the research evidence shows that time is running out to bend the curve of greenhouse gas emissions and prevent catastrophic global warming one in 25 australian properties will be effectively uninsurable by 2030 due to rising risks of extreme weather and climate change in the us more than 15 of properties in massachusetts are at risk of flooding over the next 30 years boston with the highest number of floodprone properties will see a 45 increase in flood risk by 2050 not only are climatic hazards expected to pose an increasing threat to citizens and livelihoods but cities vulnerability is also being exacerbated by the social stresses that pose increasing challenges to cities worldwide for instance communities worldwide concurrently endure intense social stresses due to unaffordable housing and social disadvantage affecting livability and equity in cities and urban regions and impacting their ability to cope or adapt to climate disasters city governments find themselves unable to provide basic services and manage risks from acute shocks and chronic stresses leading to poor living conditions and increased crime and violence in urban areas urban resilience has taken center stage amid these great challenges however policy discourse and media coverage have focused predominantly on natural disasters and community resilience particularly the resilience of infrastructure systems this is because investing in resilient infrastructure is considered critical for economic survival governments have a traditional and convenient instrument in infrastructure funding and the political popularity of infrastructure investments the world bank highlights that less attention has been given to resilient housing albeit housing has become even more important since the onset of the covid19 pandemic as we live learn work and spend more time in our homes some cities have observed the critical need for better housing and increasingly consider housing affordability as a key pillar of housing resilience moreover the interplay between social disadvantage and urban resilience is also pertinent to achieving effective resilience outcomes for example coaffee et al put emphasis on addressing vulnerabilities such as urban disadvantage that amplify crises and erode coping abilities individuals experiencing extreme poverty and those disadvantaged infrastructure is a visible and tangible investment compared to other investments and during elections political parties and politicians frequently commit to building new infrastructure the resilience discourse is skewed towards infrastructure residing in disasterprone urban areas become increasingly vulnerable due to their limited means to cope with or adapt to such calamities climate change generates multiple negative impacts for cities such as the urban heat island effect social stresses including housing unaffordability and social disadvantage then compound the poor living conditions of urban residents and make our cities less resilient however the previous analyses ignore the spatial variability of these processes and the spatial relationships between these indicators from an empirical viewpoint an aggregate citylevel analysis may hide smallarea differences in climate impacts and vulnerabilities and a citylevel policy may also respond to smallarea level climate events and social vulnerabilities differently we examine whether the small areas subjected to disruptive climate events also experience social vulnerabilities in so doing this paper combines three indicators measuring climate events and social stresses to explore urban resilience in sydney our findings shed light on the importance of the spatiality of these natural and social impacts by identifying 11 critical areas in sydney impacted by the highest levels of urban heat and urban disadvantage and two critical areas impacted by the highest levels of urban heat and housing unaffordability these findings have at least two policy implications first the overlapping of climate events and social vulnerabilities indicates the current siloed approach to urban resilience is ineffective in other words rather than implementing standalone measures to mitigate climate risks urban disadvantage and housing unaffordability integrated solutions that strengthen resilience are required for instance social protection programs for the disadvantaged should provide disasterresilient housing second the accentuation of smallarea differences in climate events and social vulnerabilities underscores the utility of placebased strategies advocating for the initiation of urban resilience policies and programs in disasterprone lowincome areas to prioritize urgent interventions and cultivate the development of more resilient cities the next section sets the scene by providing a background to urban resilience and urban resilience frameworks section 3 discusses urban heat as a climate event and housing unaffordability and urban disadvantage as social stresses that erode the coping abilities of city dwellers section 4 presents the methodology a pragmatic framework for building urban climate resilience considering the interconnections between climate events and social stresses this section also introduces the study area and data measuring urban heat housing affordability and urban disadvantage the key patterns and overlaps are examined in section 5 alongside illustrative maps showing the geographies of urban heat housing unaffordability and urban disadvantage in small areas are defined here as geographical units that carry inherent socially geographically economically or physically identifiable qualitieseg statistical area level in australia which has an average of about people placebased approaches target the specific circumstances of a place and use the best available resources to gain local knowledge and insight into planning frontiers in sustainable cities frontiersinorg sydney section 6 concludes the paper with a discussion of key findings and implications urban resilience definitions and frameworks definitions of resilience urban resilience is a contested concept according to the world bank group urban resilience is the ability of a system entity community or person to adapt to a variety of changing conditions and to withstand shocks while still maintaining its essential functions similarly douglas and philip define resilience as the capacity of a system to deal with changes and continue to develop further complementing that resilience thinking is based on the belief that humans and nature are strongly coupled and should be conceived as one socioecological system whether small or a large complex entity resistance is associated with a coordinated system that is responsive and adaptive to changing circumstances chandler explains that the view of resilience as a system or as processbased relates to a change to the classical interpretation in which resilience refers to internalized individual abilities to resist and bounce back and regain balance after conditions of stress contemporary or postclassical resilience thinking is based on the idea that resilience depends not only on individual internal qualities but on conditions that promote constructive interrelationships between individuals communities and the environment as such resilience is a systemic responsive process between internal and external factors that is why some scholars considered an ecological perspective to explain resilience likewise from an urban planning perspective newman et al claim that viewing cities as an urban ecology rather than separating their different social economic environmental structural and other elements is fundamental for resilience urban ecology is based on the understanding of cities through the interaction of all living organisms the environment they live in and the effect of these interactions on energy requirements information and other processes also important to the postclassical interpretation of resilience is that of an evolutionary process as such resilience implies not only bouncing back to regain balance as previously understood but it is about bouncing forward and evolving from the process of responsiveness and recreation chandler remarks that such transitional or metamorphic conditions are fundamentally dependent on attributes of selfreflection and adaptability to make the most of change or crisis as well as creativity flexibility innovation and responsive qualities of a system the analytical framework employed in this study builds on the definitions that explain resilience as the capability to adapt and withstand shocks it also aligns with the ecological perspective that identifies resilience as a system also including the environment and the evolutionary viewpoint that entails the significance of being futureready on the path to resilience the former is relevant here as we contend climate events and social conditions are part of a broader resilient system the latter perspective is forwardlooking in emphasizing the importance of addressing vulnerabilities and strengthening individuals and communities with coping abilities in the process of building resilience resilience frameworks before developing a framework to understand different facets of urban resilience social stresses that amplify crises and erode coping abilities and solutions that strengthen systems in section 41 we review some of the existing frameworks below the issue of resilience is emphasized on the strength of the system being built in the five dimensions natural economic social physical and institutional the physical represents resilience in infrastructure natural denotes ecological and environmental resilience economic includes the development of economies and societies institutional encompasses governance and mitigation policies and social represents resilience of people and communities some of the previous evaluations can be framed in more than one dimension or even all the five dimensions the analysis of the literature by ribeiro and pena jardim gonçalves suggests a strong link between the institutional and social this shows the importance of strategic and leadership structure due to the role of local authorities as the main stakeholders and essential leadership to guide government capacities for resilience in cities developing resilience requires understanding and assessing urban resiliencebuilding measures the essential elements of such a framework should include building awareness coping adaptation and transformation • building awareness by the public and private institutions as to the importance of resilience and what it takes to be resilient • copingunderstand the need to simply manage the difficulties when there are stresses • adaptationunderstand the measures to adapt to the new threats and the chronic stresses • transformationtransformative impact when the city is so evolved and robust in its response to shocks and stresses that it can continue without any harm in the future as a system urban resilience is not only about addressing the need for cities or of cities to withstand shocks and stress but also about the ability of people households communities and institutions to prepare for such shocks and stresses this ability is gained through the sources of resilience that enable secure and improved wellbeing outcomes the resilience capacities can be categorized into three groupings that reflect different dimensions of resilience • absorptive resilience capacitiesthe ability to minimize exposure and sensitivity to shocks and stresses through preventative measures and appropriate coping strategies to avoid permanent negative impacts for example disaster risk reduction financial services and health insurance • adaptive resilience capacitiesthe ability to make informed choices and changes in livelihood and other strategies in response to longerterm social economic and environmental change for example income diversification market information and trade networks • transformative resilience capacitiesthe governance mechanisms policies and regulations cultural and gender norms community networks and formal and informal social protection mechanisms that constitute the enabling environment for systemic change for example infrastructure good governance and formal safety nets these capacities need to be approached in line with different characteristics of resilience the rockefeller foundation identifies seven characteristics that various city systems need in order to implement resilience that is be reflective resourceful inclusive integrated robust redundant and flexible these characteristics condition the four dimensions of a citys framework toward resilience that is the dimensions of leadership and governance strategies health and wellbeing economy and society and infrastructure and environment must strive to be reflective resourceful inclusive and so on the rockefeller foundations framework has been widely referred to as a functional approach to encourage authorities to rethink their cities planning and design strategies toward resilience it also gave origin to the more recent resilient cities network when the foundations program closed in 2019 the rcn continues to adopt the original framework to approach urban resilience section 41 will elaborate on urban disadvantage and housing unaffordability which undermine the above four dimensions of a resilient city and call for action to strengthen social conditions in the path to resilience urban climate crisis and social stresses state of play the united nations environment program indicates that cities are both highly affected as well as a significant contributors to climate change the effect and damage that climate change causes on cities have major economic and social effects given that they comprise a high concentration of population and resource use at the same time urban activities are responsible for 75 of global co 2 emissions this was stated over a decade earlier by the organization for economic cooperation and development however to date there have not been enough improvements to the conditions of cities as both a source of environmental impact and a recipient of economic and social costs associated with the climate crisis thus cities continue to be the focus of attention to finding urgent solutions to the climate crisis urban heat as a climate event one of the critical effects of climate change in cities is the urban heat or urban heat island effect leal filho et al explain that the urban heat island effect can be defined as higher temperatures within urban areas compared to their surroundings studies show that uhi is the result of urban growth resulting in an increase in hard surface coverage with heatabsorbing materials as well as heat production from human activities there are many effects of uhi impacting comfort health energy consumption and air and water quality although particularly affecting human health and wellbeing paolini and santamouris highlight the reality that the increase in urban heat intensity can exceed an alarming five degrees celsius especially in summer months and severely impact energy demand the concentration of harmful pollutants and rising levels of heatrelated mortality and morbidity the c40 cities climate leadership group indicates that urban heat has a greater impact on certain sectors of the population including those at socioeconomic disadvantage due to poor conditions of housing in urban areas and lesser capacity to adapt and respond to critical climatic events leal filho et al explain that a system is vulnerable if it is susceptible to the negative effects of climatic changes and unable to cope with them they assert that there is an everincreasing vulnerability of cities to the uhi effect requiring urgent action to improve the resilience of urban areas approaching the resilience of vulnerable urban areas to the uhi effect involves first understanding where these areas are by measuring uhi and mapping its relation to areas of greater vulnerability of relevance here housing unaffordability and socioeconomic disadvantage and how this should inform an urban resilience framework urban disadvantage as a social stressor critical social stresses in specific urban areas may depend on the local context in the state of nsw and the city of sydney in addition to climate change other chronic stresses include lack of affordable housing transport congestion high unemployment and economic downturn the latter two could be collectively labeled as disadvantage therefore we focus on urban disadvantage and housing unaffordability as the critical social stresses impacting resilience in sydney as a social stressor urban disadvantage refers to the situation of people in possession of relatively low material prosperity in urban areas a lack of material resources may impact social participation opportunities and life outcomes when a person lives in disadvantage there is a chance that the person will be socially excluded as well a disadvantaged area can be conceptualized in at least three different ways a place with a spatial concentration of disadvantaged personsie people experiencing poverty or deprivation a place that inherently disadvantages its residentseg due to limited access to employment amenities and government services or a locality affected by high rates of social dysfunctioneg because of domestic violence vandalism and substance abuse the causations from susceptibility argue that if multiple demographic groups were exposed to the same climate cataclysm the disadvantaged would suffer worse disadvantaged groups are less likely to have the means to change behaviors to decrease exposure climate events also tend to ripple into economic markets where the price of resources such as food or petrol increases and disadvantaged groups cannot afford inflation by nature of their status disadvantaged groups often have less access to the resources required to recover from climatecaused tragedies this slower rate of recovery exacerbates their exposure and susceptibility leaving them trapped within the vulnerability cycle there is considerable research showing that these groups are slower to recover from climate impacts than advantaged ones these studies point to a lack of resources as the leading aggravator to their adaptive recovery housing una ordability as a social stressor housing affordability is the relationship between housing expenditure and household income housing unaffordability and housing stress are used interchangeably within the housing discourse to represent lowerincome households that spend more than 30 of their gross income on housing costs based on a more technical definition housing stress occurs when households with the lowest 40 of income spend more than 30 of gross household income on housing costs housing affordability can be looked at from a few different angles housing purchase affordability housing ownership affordability and rental affordability there are other lessknown indicators such as housing deposit affordability as well housing affordability has become a critical issue in australia affecting urban productivity and social wellbeing and the urban reform institue ranked sydney as the worlds second most unaffordable housing market once the climate crisis deepens the failure to provide secure and affordable housing will put the most vulnerable in our community at risk for instance exorbitant housing costs have resulted in families living in marginal forms of housing such as improvised dwellings boarding houses other temporary lodgings supported accommodation for homeless people crowded dwellings or staying temporarily with other households these populations will lack the capacity and resources to respond to potential climate events the housing and climate crises converge especially in communities that have been denied equitable access to housing and economic opportunity methodology the setting and data a framework for building urban climate resilience as discussed in section 3 building awareness is needed for coping adaptation and transformation toward more resilient cities understanding housing affordability and socioeconomic conditions helps assess the ability to minimize exposure and sensitivity to shocks and stresses and avoid permanent negative impacts we investigate urban heat from this perspective identifying the important facets of urban resilience and considering the most significant social stresses in sydney namely urban disadvantage and housing unaffordability this enables policymakers to reflect on the interconnectedness of these different aspects from a resilience perspective strengthening urban systems enables improving the wellbeing and coping capabilities of residents as conditions change and new climate threats emerge this framework has practical relevance due to the increasing awareness that cities could play an essential part in guiding global urban adaptation thinking going forward as cities have a longstanding tradition of adaptation cities are also known for their contextbased approaches embracing their geographical context and accordingly dealing with their unique climate change effects and challenges the nature of cities depends on aspects such as climate zones and their landscape system socioeconomic cultural and regulatory characteristics then determine their vulnerability the geographical and socioeconomic context of each city thus relates to unique climate change effects and therefore their approach to climate adaptation should be mostly contextspecific climate resilience on the urban scale thus also implies a multidisciplinary preparedness of the city where social economic and physical infrastructure culminates into a unified framework previous studies evaluate the dimension of vulnerability to uhi based on parameters of exposure sensitivity and adaptive capacity however there are many variables to this equation and studies often take a narrower approach dismissing some of these three dimensions or interconnected elements and often focusing on shortterm initiatives that are not intrinsic to urban planning and design policies leal filho et al suggest the need for shortterm incentives and longterm strategies to tackle uhi vulnerability and that its mapping and assessment can contribute to the more effective application of different intervention options and their normalization in the development of resilient cities the present study maps and assesses the two most significant social stresses in sydney to contribute toward a more effective placebased application of different interventions the setting the case study area is greater sydney the largest and most populous australian city with more than five million residents located on australias east coast sydney is considered australias commercial capital with a vibrant financial and economic center in the cbd a renowned world city sydney contributes more than a third of australias total gdp sydney draws on the benefits of density proximity and connectivity and has become a productive economic agglomeration alongside these positive connotations sydney is also experiencing high population growth exorbitant house prices and polarizing urban disadvantage the state of new south wales and sydney city council participate in some initiatives to build a resilient city for instance sydney is part of the resilience cities network and has adopted a citywide resilience strategy for the whole of greater sydney since 2018 there were three phases to the development of the strategy including an assessment of resilience through the application of the framework the development of the strategy and its implementation the strategy is structured around five directions peoplecentered living with our climate connecting for strength getting ready and one city urban heat is a flagship action of living with our climate direction focusing on adaptive technology green infrastructure and a collaborative approach to improve health safety and comfort the provision of affordable housing is an integral element of peoplecentered direction together with transport education and employment opportunities while extreme heat was recognized as sydneys biggest risk affordable housing was then recognized as a factor needing urgent attention in an expanding sydney nonetheless we emphasize that both are intrinsically related and seldom approached together the chosen unit of analysis is statistical area level 2 which has a population between 3000 and 25000 with an average of about 10000 people sa2s enable the mapping of locallevel geographies of urban heat housing affordability and urban disadvantage sa2 is designed as a generalpurpose mediumsized area to represent a community that interacts together socially and economically and it is closely synonymous with the australian suburb with an intrinsic familiarity and meaning to residents and policymakers the spatial analysis of sa2level finegrained information allows us to generate contextspecific knowledge about the climate events and social stresses in sydney data measuring urban heat housing a ordability and urban disadvantage we rely on a pragmatic yet meaningful indicator to measure urban heat australian gridded climate data is the bureau of meteorologys official dataset for climate analyses covering the variable of air temperature among others the dataset provides consistent temporal and spatial analyses across australia for this observed data variable at the monthly scale the mean monthly maximum temperature map is calculated as monthly means from the daily station maximum observations for the month which are subsequently analyzed to a grid the annual grids are calculated from the average of the corresponding monthly grids in a year the mean annual maximum temperature of the closest grid point in 2016 was assigned to each sa2 in australia a readymade metric is not available to measure housing affordability at the smallarea level therefore we developed a censusbased indicator of housing affordability for localities in australia specifically housing purchase affordability was considered and the price to income ratio the ratio of median household income to average median house pricewas computed for 2016 the median household income data for sydney were sourced from the abs 2016 census at the sa2 level average median house prices at the sa2 level were obtained from the australian urban research infrastructure network as provided by australian property monitors note the specific pir used is not a median multiple as the annual average of monthly median prices was used to represent median house prices only detached house prices were used for the analysis as prices of different dwelling types could vary considerably urban disadvantage was incorporated into the analysis using a peoplebased approach a widely used metric measuring peoplebased social disadvantage is the abs censusbased index of deprivation known as the socioeconomic indicator for areas seifa contains a suit of indicators measuring different aspects of disadvantage including the index of relative socioeconomic disadvantage which is the appropriate indicator for identifying the most disadvantaged sa2s irsd is calculated using 16 census variables including income unemployment education we opted to use detached houses as unitsapartments are only prevalent in city centers and near transitoriented developments level etc this index ranks areas in australia according to relative socioeconomic disadvantage and is commonly used to determine areas that require funding and services identify new business opportunities and to research into the relationship between socioeconomic disadvantage and various health and educational outcomes given our interest in exploring intracity patterns of disadvantage the lowest quintiles of seifa values were computed for the greater sydney area findings the spatial patterns of urban heat disadvantage and housing una ordability the quintile classification organizes the sydney sa2s into five equal groups considering the value for each indicator in each sa2 the lowest quintile represents the lowest fifth of the data the second quintile represents the next fifth etc in the context of this analysis it provides data classes at the extremeslowest and highest quintilesallowing us to identify the most affected local areas each group can also be equally represented on the maps overall quintiles are useful to understand and visualize how the climate event in focus and the social stresses are distributed across sydney the quintiles of interest here are the two highest quintiles of mean maximum temperature the two lowest quintiles of seifa irsd and the two highest quintiles of pir there are 324 sa2s in sydney although only 306 of them are included in the analysis this is because some sa2s do not receive a seifa irsd score due to their low populations and some sa2s have not recorded a monthly median price in the aurin dataset due to 10 transactions over a month the most heat affected sa2s stretch from northwest to southwest of sydney and include several middle and outer western sydney areas some key town centers of sydney such as penrith liverpool and campbelltown lie within or adjacent to this hightemperature zone this is consistent with the media reporting on the issuefor instance it was reported that some areas such as penrith reached temperatures above 50 • c in january 2020 the highest quintile of mean maximum temperature represents a higher population proportion compared to the lowest temperature quintile see table 1 the fact that higher temperatures affect more people is particularly problematic the desired low temperature areas spread along the coastline from north of the entrance to the royal national park and include the blue mountains previous evidence supports these spatial patterns the contiguity of natural resources and climate events can be explained by similarities of natural habitat types topographies and landscapes in nearby areas for instance speer et al reported that particularly western sydney has been significantly impacted by an increase in the intensity and frequency of urban heat effect in the last 30 years western sydney has experienced significant population and urban growth and generated greater human activity and increasing areas of impermeable concrete surfaces the oftencited reasons for higher temperatures in western sydney are the high concentration of buildings and other brown structures and long distance to coastal sea breezes speer et al point out that while western sydney is not the only area feeling the prejudices of urban heat associated with climate change its population copes with a greater effect due to a combination of natural factors and air currents while it is also home to a large proportion of sydneys socioeconomically disadvantaged population living in poorer housing conditions lesser green infrastructure elements and lower resources to cope with critical climatic events thus being a population more vulnerable to uhi effects social disadvantage has also increased over the past few decades in australian cities the economic concerns that followed the covid19 pandemic including financial woes due to loss of jobs and income high cost of living and energy crisis etc mean many urban residents experience poverty the most disadvantaged areas represented by the lowest quintile of seifa irsd are located mainly in the western and southwestern parts of sydney other notable areas are the entrance and gosford the northern and eastern parts of sydney represent the highest quintile meaning lowest disadvantage these spatial patterns were expected based on the general character of these areas some of the reasons for the incidence of higher disadvantage in the middle and outer suburbs in sydney include inner city gentrification public housing locations and affordable housing options in middle and outer areas and the changing economic structure in sydney where manufacturing jobs have moved to outer areas and highpaying service jobs remained in central areas the distribution of housing unaffordability shows many inner city sa2s have considerable affordability problems there are also a few middle city areas with high unaffordability interestingly austral and horsley park are the only outer areas with high unaffordability which would have been caused by their proximity to the new western sydney airport this site was announced in 2014 and construction began in 2015 this suggests house prices have increased considerably relative to income in these areas outer areas such as penrith and campbelltown are relatively affordable the most plausible explanations for the contiguity of highly unaffordable housing areas are associated with the drivers of higher price premiums in inner and some middle city locationseg scarcity of land better access to employment and highquality amenities and services spatial overlaps and priority areas the observation that some areas affected by high temperatures disadvantage and housing unaffordability tend to cluster together is noteworthy based on the framework for building urban climate resilience we now look at areas subject to both urban heat and the most significant social stresses in sydney namely urban disadvantage and housing unaffordability this analysis is based on the premise that if residents in areas exposed to higher temperatures also experience social disadvantage and housing unaffordability this impacts such residents ability to cope or adapt to climate events and makes them extremely vulnerable to climate risks when residents in the highest quintile sa2s of urban heat also experience the highest levels of urban disadvantage andor housing unaffordability such areas are identified as critical areas needing an urgent policy and planning response there were 11 sa2s in the highest quintile of temperature and the lowest quintile of irsd in other words the residents of these hottest sa2s also experience the highest levels of social disadvantage the spatial patterns show these are sa2s in the west and southwest of sydney such as mount druittwhalan st marys bidwillhebershamemerton lethbridge parktregear blacktown and kingswood social disadvantage limits their ability to adapt to changing climatic conditions and cope if and when climate events occur for instance in the 2021 heatwave of sydney many residents of the lower socioeconomic communities who live in the west where it is 810 • c hotter couldnt afford to use air conditioning the link between climate events and social disadvantage can be looked at from a property value perspective which raises the question whether disadvantaged areas are more vulnerable to floods one explanation is that land in floodrisk areas is underpriced and residents with low incomes who live in lower socioeconomic conditions are attracted to such areas it also could be because disadvantaged areas lack more resilient infrastructure also there were further two sa2s in the highest quintile of temperature and the highest quintile of housing unaffordability the residents of these two hottest sa2s in western sydney austral and horsley park are faced with the highest levels of housing unaffordability higher housing costs mean city residents are left with insufficient funds for other necessities and less savings a critical shortage of affordable housing also indicates such residents are unable to keep a roof over their heads they resort to makeshift arrangements such as living with parents or other relatives living in crowded houses boarding houses or in extreme cases being homeless these inferior housing arrangements affect an individuals or familys ability to manage normal household functioning reduce dwelling cleanliness and even cause injury and property damage this is more likely to result in greater anxiety or stress poorer health and child development outcomes household conflict and forced mobility or homelessness an individual or family in these circumstances wont be able there were no sa s intersecting all three indicators simultaneouslyie the highest quintile of temperature the lowest quintile of irsd and the highest quintile of housing una ordability frontiers in sustainable cities frontiersinorg all priority areas temperature and disadvantage and housing unaffordability 13 only temperature and disadvantage 53 only temperature and housing unaffordability 4 total 70 source authors analysis the totals for each area category are in bold figure critical areas based on spatial overlap source authors own work to cope with the prospect of climate change and extreme climate events since these 13 sa2s are in the extreme end of urban heat social disadvantage andor housing unaffordability they are in critical need of policy and planning interventions to address the climate risks and social vulnerabilities once the criteria are relaxed to include the two highest quintiles of urban heat social disadvantage and housing unaffordability a considerably large number of sa2s emerge as priority areas there are 13 sa2s that overlap the two highest temperature quintiles the two lowest irsd quintiles and the two highest quintiles of housing unaffordability the spatial distribution of these areas is shown in figure 6 these areas are in the west and southwest of sydney there are further 53 sa2s that fall within the two highest temperature quintiles and the two lowest irsd quintiles only this indicates a substantial number of sa2s reporting high temperatures were also ranked as disadvantaged locations these sa2s are spread across the west northwest and southwest of sydney moreover four additional sa2s fall within the two highest temperature quintiles as well as the two highest housing unaffordability quintiles only these represent some middle city and western sa2s of sydney a notable feature of these areas is the proximity to sydney cbd and hence higher land values current siloed approach to planning and the way forward building resilience is crucial especially in urban communities impacted by natural disasters and social stresses in fact planning for resilient cities has become synonymous with planning for a better and sustainable future improving housing affordability and reducing disadvantage will improve resilience in neighborhoods those who are vulnerable to social stresses often live in areas that are typically hazardprone unsafe and overcrowded with insecure tenure and limited infrastructure these issues heighten the sensitivity of the urban poor to climate change and disaster risks housing with the security of tenure and with access to basic services can help reduce vulnerability and can provide a basis for homebased resilient livelihoods building resilience before climate disasters occur can help keep millions out of poverty and save the worlds cities billions each year via downscaling the support programs evidence of the growing importance of resilience in urban planning is the globally adopted program of the 100 resilient cities funded and initiated by the rockefeller foundation the current siloed approach to urban resilience addresses the urban heat island effect as a standalone issue the key strategies identified to tackle urban heat include green growth initiatives such as providing green infrastructure increasing tree shading reducing hard surface areas in new developments reducing greenhouse gas emissions from buildings and improving energy efficiency for instance blacktown council is addressing urban heat by developing and implementing a plan to transition that city to zero emissions by 2040 sourcing funding opportunities for energy homebased livelihoods refer to the increasing number of enterprises set up at homes predominantly by lowincome women in developing countries frontiers in sustainable cities frontiersinorg efficiency programs and increasing tree canopy and biodiversity corridors similarly there are targeted policies in many cities to reduce poverty improve employability and address urban disadvantage including social welfare programs for instance the australian federal government has touted coinvestment with philanthropists and the private sector to address disadvantage emphasizing the role of placebased partnerships and community organizations these policies should consider different social stresses simultaneously for instance policymakers have argued low incomes and unemployment in western sydney will potentially be addressed through the western sydney aerotropolis now underconstruction however there is a risk of increasing house prices due to the arrival of new economic opportunities and better amenities and services to the area there are targeted solutions to improve the overall provision suitability and socioeconomic resilience of the housing system to address housing unaffordability the longstanding yet politically unpopular policy of providing statefunded public housing increasing social housing provision rental assistance lowincome housing tax credit and private sector solutions including innovative dwelling types homesharing models and planningbased solutions such as improvements to zoning laws are examples of available instruments to this end as a best practice example los angeles has put in place initiatives that will double the pace of affordable housing production and preservation and triple the production of new permanent supportive housing by changing regulations adopting new financing mechanisms and exploring adaptive reuse of publicly owned sites however policymakers must ensure addressing a specific problem does not lead to new problems for instance greater sydney plan highlights that by creating multiple subcenters residents will have better access to employment opportunities and affordable housing these strategies must however ensure the urban heat island effect from these new constructions is minimal another persistent challenge is though governments have implemented a number of these policies they have been overtaken by the growing scale of need for instance as of june 2021 there were 67700 greatest need households on the waiting list for public housing in australia the above siloed approach is known to be ineffective serageldin identifies the silo effect in management in the separation of responsibilities among resourcemanagement agencies and their incapability to consider mandates relative to mandates of other organizations in government the silo effect adopts vertical fragmentation where responsibilities are fragmented from one tier of government to the other or horizontal fragmentation where fragmentation occurs within one level of government among different agencies oseland specifically focusing on climate planning emphasizes that breaking silos creates new opportunities to bridge the gap between targets and results through knowledge sharing identification of cobenefits and anchoring of the plans beyond the departments in charge it is crucial that state and local governments overcome silo management and embrace integrated planning on their path to urban resilience rather than implementing standalone measures to mitigate climate risks address urban disadvantage and improve housing affordability an integrated solution that strengthens resilience through social protection programs has been proposed this emphasizes the need to comprehend the integration between human and ecological processes particularly within humandominated environments is crucial for reaching future resilience goals asian development bank highlights that social protection mechanisms must better target the urban poor and respond to increasing climate shocks and stresses investments should support underlying vulnerability through resilient livelihoods regular income promotion of savings and skills enhancement the urban disadvantaged should be supported to access affordable and resilient housing mainstreaming of climate adaptation in sectoral plans and policieswith major implications for urban policyrequires major efforts from local authorities conclusion residents in many areas of sydney particularly western sydney are living in hot conditions because of the high concentration of buildings and other brown structures and the long distance to coastal sea breezes meanwhile due to inner city gentrification public housing locations and affordable housing options in middle and outer areas and the changing economic structure in sydney where manufacturing jobs have moved to outer areas low income and other socioeconomically disadvantaged residents are moving to the same western areas one would expect housing to be affordable in these locations due to high temperatures and neighborhood effects however housing is increasingly unaffordable relative to income in these areas particularly in those sa2s located toward the sydney cbd due to scarcity of land better access to employment highquality amenities and services the spatial contiguity of the areas impacted by urban heat social disadvantage and housing unaffordability is more problematic due to the need for more resources large scale programs and a longer time periods to design and implement programs and policies we need better metrics to understand the climate events social stresses and resilience capacities some of the resilience measures that have been developed in the previous urban resilience literature are not quantitatively measurable for instance certain indicators listed in the city resilience index are qualitative in nature and hard to measure and compareeg cohesive communities flexible infrastructure services in contrast the measures developed in this paper are pragmatic measurable and accessible data for these indicators are also available in many other cities for benchmarking for instance pir is available for many world cities and socioeconomic disadvantage is available for numerous cities as well multiple deprivation in the uk to address the drawback of using only a handful of measures in the current paper future research will develop multiple other measures of social stresses in the introduction the question was raised whether the locations subjected to disruptive climate events also experience social vulnerabilities if residents in areas exposed to higher temperatures also experience social disadvantage and housing unaffordability this impacts such residents ability to cope or adapt to climate events and makes them extremely vulnerable to climate risks we considered the spatial overlapping of urban heat social disadvantage and housing unaffordability and identified two sets of priority areas for building resiliencecritical areas and all priority areas areas with the most extreme values of urban heat social disadvantage and housing unaffordability were included as critical areas and those with high values of urban heat social disadvantage and housing unaffordability were included as all priority areas in sydney 13 sa2s are critical areas with extreme levels of temperature and either the highest level of disadvantage or the highest level of housing unaffordability the extended list with relaxed criteria shows 70 sa2s are priority areas this is an alarming statistic as almost a quarter of sa2s show substantial social vulnerabilities if climate events to intensify the remaining 77 of sa2s have relatively improved social structures making them better able to bounce back from potential climate events based on the resilience framework presented by ostadtaghizadeh et al and elaborated by ribeiro and pena jardim gonçalves the issue of resilience should be emphasized more on the strength of the system being built in the five dimensions natural economic social physical and institutionalsee section 22 this framework highlights the importance of strategic and leadership structure due to the role of local authorities as a main stakeholder in the resilience process this is consistent with the pivotal role suggested in the present paper for local city and state governments in identifying the spatial dynamics of climate events and social stresses and addressing them through integrated solutions and policies for instance understanding the link between the five dimensions is key to overcoming climate change and social problems such as disadvantage and housing unaffordability such a system can reduce the impact of climate events by focusing on inherent resilience of people and communities implementing effective governance mechanisms and creating sustainable economic opportunities in local neighborhoods therefore an effective leadership to guide government capacities for resilience in cities becomes essential a limitation of using seifa for classifying socioeconomic disadvantage is that it is essentially compositional and as such is vulnerable to the ecological fallacy in other words socioeconomic disadvantage classified at the sa2 level doesnt mean all the individuals in such areas are disadvantaged despite this criticism seifa is still considered to be the most meaningful metric of disadvantage currently available in australia there was once an understanding that cities are places of consumption and production resulting in the replacement of the natural landscape there is now an increasing awareness that cities could and should be part of the solution to mitigate climate impacts and enhance overall sustainability our framework for building urban climate resilience incorporates facets of urban resilience social stresses that amplify crises and solutions that strengthen individuals and communities with coping abilities to withstand climate events the multifaceted nature of urban resilience suggests a siloed approach is ineffective and an integrated approach is needed for instance policies addressing urban disadvantage and housing unaffordability should also consider resilienceeg affordable housing should also be resilient housing furthermore the findings diverge from aggregate citylevel analyses by highlighting the smallarea differences of climate impacts and vulnerability the spatiality of the natural and social impacts indicates the need for contextbased approaches and placebased policies to address climate risks and social vulnerabilities this is especially important as climate change will only amplify the frequency and intensity of extreme weather events 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 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

a triple whammy how urban heat housing una ordability and disadvantage a ect urban spatial resilience

introduction understanding and supporting hivinfected womens awareness of their own status and their options regarding pregnancy requires an understanding of their backgrounds and the potential barriers to care and safe pregnancy studies have shown that both social pressures and concerns for vertical transmission play a large role in hivinfected womens choices about pregnancy 1 2 3 information from around the world supports the fact that since the introduction of reliable methods for the prevention of mothertochild transmission fewer hivinfected women are choosing terminations and many are choosing to become pregnant even to have multiple pregnancies after their hiv diagnosis 2 4 5 6 options for safe conception especially in serodiscordant couples now include artificial insemination and sperm washing 7 these methods even where they are available however remain relatively unknown and infrequently recommended by many healthcare providers even in developed countries 8 and may be prohibitively expensive or inaccessible for some couples in addition to these planned pregnancies a large number of pregnancies remain unplanned 910 women who live in developing countries where safer methods of conception are relatively unknown or unavailable are nevertheless choosing to become pregnant after their hiv diagnosis a survey of 459 hivinfected men and women in cape town south africa found that twothirds of women who became pregnant after commencing highly active antiretroviral therapy had intended to become pregnant 11 furthermore 50 of hivinfected men and women were open to the possibility of conceiving children after their hiv diagnosis being on haart had no significant impact on whether or not men intended to pursue pregnancy but did make women more likely to consider pregnancy 11 it is unclear what impact moving from a developing to a developed country may have on childbearing intentions but it is possible that this change in their socioeconomic environment and perceived options for care and support may play a role in womens childbearing intentions women in the usa who are hivinfected and foreignborn may have additional issues to consider during pregnancy they are more likely to have language educational and economic barriers to care and to exercising their options but may be even more likely to choose to keep a pregnancy because of cultural emphasis on childbearing and negative views of termination women who are born in areas of the world where fertility rates are between 5 and 7 children per woman especially africa and parts of south and southeast asia 12 may experience particular spousal and familial pressure to become pregnant even if they have disclosed their hiv status 1314 a crosssectional study done in canada revealed that 69 of 490 hivinfected women desired future pregnancy and african ethnicity was significantly correlated with intention to become pregnant 15 although foreignborn persons with hiv living in the us appear to be a growing proportion of the hivinfected population 16 current national sociodemographic data do not accurately reflect this demographic as they are generally listed under their ethnicity without distinction about place of birth 1718 thus persons who are originally from subsaharan africa where the highest number of hivinfected individuals exists are listed as blackafricanamerican in data used for determining funding and resource allocation africanborn persons often live within their own communities and may not be reached by programs that target africanamericans 1920 in washington state for example the hiv diagnosis rate among blacks in the state is five times higher than the rate among whites and 40 of all hiv diagnoses among blacks in washington state have been among foreignborn persons 21 similar data collected from five different states and highprevalence areas show that across all areas up to 41 of diagnoses in women and up to 50 of diagnoses in blacks occurred among africanborn individuals 16 additionally we should not presume all foreignborn persons were necessarily infected with hiv prior to arrival in the usa data suggest that in some parts of the country especially those parts with high numbers of hispanic immigrants patients are more likely to have been infected after arrival 22 which may indicate increased vulnerability among foreignborn persons unfortunately the complex social issues that contribute to women becoming hivinfected often present barriers to adherence with prescribed medication regimens and prenatal followup as well as with ensuring adequate testing and followup of the hivexposed infant studies have shown that 45 of mothers of hivinfected infants had missed opportunities for perinatal hiv prevention 23 indicating that although appropriate protocols are in place additional factors contribute to transmission rhode island the smallest state in the united states had an hiv prevalence of 209 per 100000 population by the end of 2009 24 among the general population 81 of persons identified themselves as white 12 identified themselves as hispanic and 6 identified themselves as black or africanamerican 25 amongst the 3080 hivinfected persons who have been diagnosed in rhode island since 1982 54 identified themselves as white 26 identified themselves as africanamerican and 19 identified themselves as hispanic 25 thus 45 of hiv cases in the state have occurred in the 18 of the population identified as hispanic or africanamerican no data is available on the percentage of hivinfected persons in the state who are immigrants or foreignborn following the lead of several other states rhode island adopted a law mandating testing of pregnant women during pregnancy or their children immediately after birth this was done in order to ensure that children receive medication to prevent mothertochild transmission in a timely manner and that women are appropriately identified if they need hivrelated services 26 this law has already led to increased rates of hiv testing during pregnancy from 528 in 20052006 to greater than 95 after the law changed in 2007 27 but it is unclear if it has led to an increased number of hiv diagnoses we seek to describe the experiences of hivinfected pregnant women and their children followed at a large hiv clinic in rhode island materials and methods the immunology center at the miriam hospital in providence rhode island is an urban hiv clinic with 1400 active patients in 2009 25 of hiv patients followed at the miriam immunology center were uninsured or covered only by the hospitals free care program and 32 were foreignborn all hivinfected patients in rhode island have access to antiretrovirals either through health insurance or through the ryan white program provided they have been registered as rhode island residents the immunology center has been caring for hivinfected women before during and after their pregnancies since its establishment in 1986 the hasbro childrens hospital pediatric infectious diseases ii clinic in providence generally sees all the hivexposed infants delivered to these women these clinics follow dhhs guidelines for perinatal prevention of mothertochild transmission and followup testing for hivexposed infants the two clinics are the largest providers for hivinfected women and their children in rhode island this study aims to characterize and understand the recent trends in the hivinfected pregnant population and hivexposed children in rhode island social and clinical data from hivinfected pregnant women collected regularly by the immunology center staff for care and research purposes were analyzed to identify and characterize trends in demographics viral control terminations miscarriages timing of diagnosis and adherence to followup data on the adherence with followup appointments and testing for the hivexposed infants were obtained from paper and online charts from both hasbro childrens hospitals primary care clinics and pediatric infectious diseases ii clinic data were analyzed for means of continuous variables percentages of descriptive variables and significant correlations between variables using statistical package for the social sciences version 170 statistical significance was assessed using a chisquare test this project was reviewed and approved by the miriam and rhode island hospital institutional review boards results between january 2004 and december 2009 321 hivinfected women between 18 and 45 years old were seen at the immunology center seventysix hivinfected women became pregnant with a total of 95 pregnancies seventeen women had more than one pregnancy and two women had three pregnancies fiftyfive percent of these women were foreignborn sixteen of the women were diagnosed with hiv during their pregnancy while 79 knew their hiv status prior to becoming pregnant sixteen of the women chose to terminate their pregnancies two of these women were diagnosed during this pregnancy and both were usborn seven women suffered miscarriages the trends by year and breakdown of specifics between foreignborn and usborn women are presented in tables 1 and2 the breakdown by continentregion of origin of the women is shown in figure 1 among the thirty women from africa sixteen were from liberia three from burundi two from guinea kenya and senegal and one each from angola ghana ivory coast mali and sierra leone among the seven women from latin america there were three women from the dominican republic two from guatemala and one each from venezuela and argentina while the number of hivinfected women becoming pregnant increased only slightly over the years of the study the proportion of women that were foreignborn rose from 41 between 2004 and 2005 to 575 between 2006 and 2009 there was no significant difference between usborn and foreignborn women in terms of their likelihood of being diagnosed with hiv during pregnancy choosing termination or choosing to have a second or third pregnancy usborn women were more likely to have fewer than two visits during the pregnancy or department of children youth families involvement with their children of the 72 women who had pregnancies that did not end in miscarriage or termination mode of delivery was known for 49 seventeen delivered vaginally twentyfive underwent elective caesarian section and seven required emergency caesarian sections sixtythree women had cd4 counts and plasma viral loads measured during pregnancy fifteen women had detectable plasma viral loads on their last test prior to delivery and all but one of them underwent caesarian section thirty women had both information on viral load prior to delivery and mode of delivery available of these sixteen had undetectable viral loads and six had viral loads less than 1000 only eight of the women who underwent caesarian section had viral loads above 1000 and five of these women had either repeat caesarian section or underwent the procedure due to emergency indications unrelated to viral load nine women were considered to have aids at the time of delivery based on a last cd4 count prior to delivery less than 200 cellsµl seven of these women were foreignborn the mean cd4 count prior to delivery was 480 cellsµl three children in this cohort were confirmed to be perinatallyinfected all of them were born to mothers with psychological andor social issues that had a significant impact on their ability to adhere to appropriate followup and preventive measures one mother was a young perinatallyinfected teenager at the time of her first pregnancy she received care in both rhode island and massachusetts but was unable to adhere adequately to care and treatment at either site the second child was born to a woman from west africa who had been diagnosed with hiv three years before the pregnancy upon immigration to the usa she did not adhere to her medication regimen during pregnancy and dcyf was involved soon after the child was born the third child was born to a usborn woman who had been diagnosed with hiv during a prior pregnancy she had delivered an hivnegative child at that time who was subsequently removed from her custody she had been out of care and off hiv medications for many months when she presented to the emergency department with complaint of abdominal pain she was quickly determined to be in active labor she denied knowing that she had been pregnant and had received no prenatal care discussion as has been seen around the world our data suggest that hivinfected women are increasingly choosing to become pregnant and to keep pregnancies that may have been unplanned the number of terminations has remained low this is consistent with other studies that have shown that fewer hivinfected women are choosing termination now that the efficacy of methods for prevention of mothertochild transmission are wellknown and wellvalidated 2 4 5 6 additionally a growing number of women are having second and even third pregnancies after their hiv diagnosis this trend likely reflects both the strength of the desire to have children and the perception of hiv as a controllable illness that does not preclude the creation of a family our data indicate that rhode islands relatively new optout law for hiv testing among pregnant women and the resultant increased rate of testing has not resulted in a higher number of hiv diagnoses however its effects may not yet be reflected in our data as this law was only passed in july 2007 in addition rhode island is known to have a low prevalence of hiv and the increased testing may not result in a significantly higher number of diagnoses furthermore laws to encourage testing during physician encounters outside of pregnancy may negate any potential increase in diagnoses during pregnancy while the number of hivinfected women becoming pregnant in our clinic has increased only slightly the proportion that are foreignborn has been steadily rising from an average of 41 between 2004 and 2005 to 575 between 2006 and 2009 now that the obama administration has lifted the travel ban on hivinfected persons entering the usa this trend may increase as the number of foreignborn hivinfected women entering the usa continues to grow however the numbers seen in rhode island may also decline as the freedom to enter any state may lead to some choosing to settle elsewhere previously rhode island was one of the few states that was allowed to accept hivinfected individuals emigrating to the usa under the travel ban available virologic control data for our clinic indicate that most women have favorable cd4 counts and undetectable viral loads prior to delivery all the women who had detectable viral loads underwent caesarian section which is associated with a lower risk of viral transmission for women with hiv plasma viral loads 1000 copiesml near the time of delivery the three cases of perinatal transmission are not necessarily representative of the overall outcomes of pregnancy among hivinfected women however they are indicative of the fact that while pmtct protocols are now able to reduce the risk of hiv transmission to less than 2 they cannot do so if patients are unable to adhere to them in our small state during the time period of this study there was essentially one clinic and one hivtrained obstetriciangynecologist who saw the women during pregnancy one hospital where they delivered and one pediatric infectious disease clinic where the children were followed each of these settings has robust medical social work and support staff that fully supported each hivinfected pregnant woman in order to optimize her care and adherence to therapy these data highlight the fact that despite this level of coordination and support nonadherence does occur and perinatal hiv transmission may ensue further study to identify atrisk women may be warranted in order to target further medical and psychosocial interventions in order to improve outcomes and decrease maternaltochild transmission these study results support prior trends noted from us and international studies that hivinfected women are increasingly choosing to become pregnant or to continue a pregnancy studies are needed to determine the knowledge and attitudes of foreignborn and usborn hivinfected women regarding childbearing and prevention of maternaltochild transmission additionally comparative studies among women in high hivprevalence regions and women who have moved from those regions to resourcerich settings would help healthcare providers and systems to anticipate and meet the needs of a growing population of hivinfected women who may have different understandings of and barriers to exercising options for safe pregnancy conclusion the face of hiv in pregnancy is changing hivinfected women in rhode island are more likely to be foreignborn to know their hiv status prior to pregnancy and to actively choose to become pregnant or to continue pregnancies whether planned or unplanned despite increasing rates of hiv testing in pregnancy an increased number of hiv diagnoses has not been seen when hivinfected pregnant women engage with appropriate prenatal care virologic control is generally excellent and outcomes are good for mother and child however risks for hiv transmission beyond lack of awareness of hiv status are emerging especially among women with psychological or social issues which may preclude adherence to pmtct protocols and lead to unnecessary infection of infants foreignborn women are a growing percentage of the population of hivinfected women becoming pregnant in the usa and may benefit from further study and targeted interventions identifying atrisk women during their pregnancy and providing extra social psychological and other support to them may be an important additional focus for pmtct programs in order to continue to prevent perinatal hiv transmission

meeting the needs of hivinfected pregnant women requires understanding their backgrounds and potential barriers to care and safe pregnancy foreignborn women are more likely to have language educational and economic barriers to care but may be even more likely to choose to keep a pregnancy data from hivinfected pregnant women and their children in rhode island were analyzed to identify trends in demographics viral control terminations miscarriages timing of diagnosis and adherence to followup between january 2004 and december 2009 76 hivinfected women became pregnant with a total of 95 pregnancies seventynine percent of the women knew their hiv status prior to becoming pregnant fiftyfour percent of the women were foreignborn and 38 percent of the 16 women who chose to terminate their pregnancies were foreignborn while the number of hivinfected women becoming pregnant has increased only slightly the proportion that are foreignborn has been rising from 41 percent between 2004 and 2005 to 575 percent between 2006 and 2009 a growing number of women are having multiple pregnancies after their hiv diagnosis due to the strength of their desire for childbearing and the perception that hiv is a controllable illness that does not preclude the creation of a family

introduction to say the covid19 pandemic has upended the delivery of healthcare in the united states and the rest of the world would be a gross understatement while the neonatal intensive care unit has escaped for the most part the ramifications of having patients critically ill with covid19 the impact of this pandemic snaked its way through row upon row of incubators 12 in addition to the potential for allocation or reallocation of resources away from babies in the nicu this pandemic forced healthcare providers and parents to face severe limitations to hospital visitation policies that modern healthcare has evolved in the face of a pandemic is not surprising as given the multitude of resources present for dealing with pandemic influenza many in the public health sector and biomedical ethics have been preparing for such an occurrence 34 importantly while many resources developed in response to pandemic influenza or other natural disasters discuss care delivery to neonates in times of crisis few if any discuss repercussions of limitations to visitation rights 5 the notions of quarantine and social distancing are not new concepts they represent a means to a necessary end lessening the impact of a pandemic accepting that parents are a vital part of the healthcare team providing care for the newborn it follows that parents rights to visit their baby should only be limited in extreme circumstances importantly while often used interchangeably quarantine and isolation are very different quarantine involves limited mobility of a person who is not to their best knowledge currently infected with the pathogen causing the pandemic there is less ethical defense for quarantine when compared to the isolation of a person with confirmed infection or symptoms of infection of course covid19 appears to be contagious in the asymptomatic carrier state thus the appeal to widespread quarantining at home ethical and legal considerations at the heart of debate regarding quarantining are the limitations of two essential liberties we hold dear mobility and the freedom of assembly such limitations are justified in particular circumstances one of which is a pandemic of an infectious agent hospital policies that limit visitation of patients and by extension limit mobility are rooted in consequentialist ideals 6 this means such limitations must have a positive impact on the greater constituency lower rates of infection for example public health policies are entrenched with utilitarianism the maximization of good for the highest number different from utilitarianism is libertarianism based on john stuart mills on liberty mill expounded upon the harm principle a principle that states the only purpose for which power can be rightfully exercised over any member of a civilized community against his will is to prevent harm to another 7 the current pandemic would constitute justification of limited liberties even under the basis of libertarianism the prevention of further communicable diseases may meet both libertarian and utilitarian criteria for limited visitation or complete closing of the nicu to visitors this draconian limitation of parents at the bedside can be justified if there are no other less intrusive means of preventing transmission of a pathogen the siracusa principles outlined in 1984 by the united nations coalesced the conditions necessary to legitimize restrictive public health measures in the setting of a pandemic 8 importantly these principles stipulate that the stateuse the least restrictive measures of interference and disruption to achieve the public health goal this freedom from undue interference refers to even in the setting of a pandemic a persons right to the least amount of interference 9 limitations on a persons mobility are extreme but sometimes necessary if wearing personal protective equipment cannot stem the spread of a pathogen complete exclusion from the nicu is warranted given quarantine and limitation of visitation are the only means of containment however with the proper application of ppe covid19 can be contained and transmission reduced 10 however the prospect of allowing asymptomatic carriers who could be contagious into the nicu is daunting 11 a precedent for disallowing some visitors already exists throughout the respiratory viral season importantly such measures aimed at limiting visitors at the bedside in nicus have been shown to decrease the acquisition and transmission of respiratory viruses 12 for visitation policies and limitations to mobility consider the following exercise two mothers present to two different hospitals in the same zip code both women are pregnant at 24 weeks gestation and are from the same community with the same degree of community transmission their community is under a mandated stay at home order and both followed this order as have their contacts neither woman shows signs of systemic illness associated with the current pandemic one woman presents to a hospital that allows no visitors the other woman presents to a hospital with limitations to visitation though one visitor is allowed in the nicu with proper ppe both babies are born and do well in the delivery room with similar survival statistics as based on the neonatal networks extremely preterm birth outcomes tool 13 to disallow one babys parents to visit while the other babys parents may visit is disingenuous because the decision is not based on facts particular to the case or the community but instead on hospital protocol while many americans approve of quarantine measures to stem the transmission of pandemic disease it is unclear what percentage of those polled had babies in the nicu 1415 what to do about parents then should they be allowed to visit with proper ppe if one unit allows parents to visit with proper ppe but another unit across town does not allow any visitors under any circumstances is this justified if parents cannot visit given limitations to mobility should they be subject to reciprocity classically reciprocity refers to the right of a person impacted by the state to receive basic necessities in the event of quarantine 9 the states provision of basic necessities lessens the impact of the limitation to mobility while reciprocity assumes meeting the basic needs of the states quarantined constituent many reasonable people can think of no more basic need than that of a parent to be with their newborn in the absence of the states provision of means to achieve reciprocity nicus across the united states have had to be creative with how to allow parents feel a part of their babys life to prevent theoretical consequences of limited visitation theoretical consequences of limited visitation whatever the rubric used to justify limited visitation to the nicu the reader must understand that such limitations do not come without repercussions for example a parent absent from the bedside of a neonate may have consequences we cannot anticipate especially for their developmental potential as neonatology moved toward more robust inclusion of the family at the bedside their exclusion is held to a higher burden of proof of benefit from that exclusion regardless of the method of inclusion the familys role at the bedside even in a virtual sense is of paramount importance parental stress has been linked to poorer developmental outcomes in preterm infants 16 cessation of visitation all together while not empirically studied in a pandemic would undoubtedly add to the parental stress of nicu admission this could further impact the eventual development of the neonate though time will tell how the current cohort of neonates some of whom had visitation restricted will develop what follows will be an explanation of attempts thus far to allow parents to feel a part of their neonates care this will not be exhaustive and given the lack of previous pandemics to compare to much of the presented information will be anecdotal or based on expert opinion solutions for supporting families supporting families at home as more and more hospitals limit and restrict visitation to hospitals including nicus opportunities to support parents caregivers and other family members while they are home certainly increase in the 21st century much of this support could potentially be done through technology familycentered care in the nicu requires communication and collaboration between families and health care providers 17 however when visitation is limited or restricted building that trust may be difficult alternative methods of communication which include a video component have been studied 18 webbased videoconferencing using facetime and skype and commercially available camera systems such as angel eye and nicview have demonstrated benefits 19 20 21 22 23 24 25 26 27 28 29 in their integrative review epstein and colleagues found that all studies of video technologybased interventions demonstrated parental appreciation of being able to see their infant when they could not be in the nicu parents believed that being able to visualize their infant reduced stress and anxiety and relief that their child was doing well 26 27 28 a minority of parents felt guilt at not being able to be with their infant when they viewed them on a camera 28 overall epstein and colleagues found videoconferencing …to be helpful and meaningful to parents across studies 18 realtime videoconferencing should be considered by nicus who have limited visitation as a means for families to see their child as well as communicate with the healthcare team videoconferencing will also allow extended family members such as siblings and grandparents to interact with their new family member for those nicus with limited resources health system information technology departments may have the ability to provide other options than those which require significant monetary investment smartphone applications may also be considered 30 families that are not able to visit or those that have visitation restrictions also miss out on interacting with peers peertopeer support for families in the nicu is important support groups have been found to help parents normalize their experiences work through issues of guilt and coping mechanisms and adapt to life in the nicu 31 hall et al recommend offering peer support to nicu families as one of the primary components of familycentered care 32 most studies evaluating peer support in the nicu have looked at inperson programs moderated by former nicu parents however with visitation restrictions and recommendations for social distancing in the era of covid19 it is unlikely that these support programs can meet in or outside of the hospital with that families may look to internet support groups even more benefits to online support groups include the ability to access groups specific to their needs and on their own time 32 in addition parents can post anonymously there may be decreased biases based on gender or socioeconomic status and support can continue beyond hospitalization 32 33 34 35 of course internet support groups can have drawbacks nonsupportive posts misinformation or unreliable data may be shared especially if the group is not followed by experienced or knowledgeable moderators 3236 some online support groups can be found in table 1 and additional support groups sorted by country can be found at the european foundation for the care of newborn infants website additional strategies for families while away from their infant include journaling and tracking nicu milestones and developments 37 in general parents do feel supported in the nicu from both nursing and medical providers 38 however there is consistent desire for more information on their child as well as emotional support 38 39 40 in times of reduced visitation how do we enhance psychosocial support of nicu parents hall et al provide several recommendations that can be quickly implemented andor augmented 41 ensuring that mental health professionals such as psychologists and social workers continue to work with families is imperative pastoral or religious care personnel can also supplement support while families are in the nicu palliative care teams and ethics committees may also benefit certain populations within the nicu and ensuring that these services are still provided is important for institutions that severely limited visitation of parents to the nicu a central tenet of modern neonatology was unable to be performed by the parents kangaroo care has been a part of neonatology since 1978 42 countless neonates have benefitted from kangaroo care with benefits including improved temperature regulation improved sleepwake cycles and augmented growth 43 to deny parents the experience to provide kangaroo care and neonates the demonstrated ability to reap its benefits seems imprudent especially when if available ppe could mitigate unwanted effects of a viral agent other ways that families can impact the care when they are visiting include reading to their infants several studies have demonstrated improved parental bonding and decreased severity of postpartum depression after reading to their baby 44 45 46 parent talk has also been demonstrated to be the strongest predictor of preterm infant vocalizations at 32 and 36 weeks gestation 47 it was noted that infants were exposed to more conversational language when parents were present than when parents were absent 47 supporting infants in the nicu the impact on reduced visitation does not simply affect the visitor but also has profound impact on the patient as well the neurobehavioral impact of parental visitation on infants is undeniable 4849 so in time of reduced visitation the nicu team needs to ensure that care typically provided by parents does not stop talking in conversations to the infant holding and interacting all can have significant impact over time music therapy has been shown to reduce infant respiratory rates and may have other physiological benefits 50 ensuring that therapy services such as occupational speech and physical therapists continue to help provide developmental support is imperative during this time in conclusion although there is substantial evidence that would suggest parental visitation should not change in the nicu environment we understand that hospital and infectious disease policies may supersede unit guidelines in the attempt to mitigate viral spread if parental visitation is restricted there are mechanisms that nicus can utilize to ensure that families and infants continue to be supported both in the hospital and when they are away from the hospital compliance with ethical standards supporting families in the nicu when parents are allowed to visit in the nicu supporting them in the moment is imperative studies have shown that

although the covid19 pandemic has largely not clinically affected infants in neonatal intensive care units around the globe it has affected how care is provided most hospitals including their nicus have significantly reduced parental and family visitation privileges from an ethical perspective this restriction of parental visitation in settings where infectious risk is difficult to understand no matter what the right thing to do is nicus are currently having to support families of their patients via different mechanisms in this perspective we discuss ways nicus can support parents and families when they are home and when they are in the nicu as well as provide infants the support needed when family members are not able to visit

introduction latinos constitute a large and growing minority group in the us reaching 469 million in 2008 comprising 154 of the total us population this demographic trend is more pronounced in california where in 2008 366 of californias population was latino with latinos comprising 419 of youth aged 1524 the latina teen birth rate is the highest of any major racialethnic group in the united states more than double the national average in 2008 the latino teen birth rate in california was 569 per 1000 females compared to 399 among african americans and 131 among whites latino youth also are disproportionately affected by sexually transmitted infections in 2008 national rates of chlamydial infection among latinos aged 1519 were 18736 as compared to 8493 among nonlatino whites partner risk behaviors including substance use incarceration gang affiliation and sexual partner concurrency influence the disproportionately high rates of pregnancy and stis experienced by latino adolescents and have been shown to be as or more important than individual behaviors in influencing reproductive risk in youth generally among 1525 year old clinic attendees in florida a composite partner risk measure that included incarceration sti diagnosis concurrency and alcohol and marijuana use was independently associated with sti diagnosis in a communitybased predominantly latino sample of female teens partner gang affiliation was associated with increased risk of pregnancy similarly in an ethnically diverse sample of detained male youth ganginvolved youth were more likely than nongang involved detainees to have gotten someone pregnant to have had sex while using alcohol or drugs and to have had concurrent sex partners in 2009 latino youth comprised 57 of youth offenders in the california juvenile justice system and constituted the majority of the estimated 10000 gang members in the san francisco bay area immigration may assume a prominent role in influencing latino adolescents reproductive health with much epidemiologic research suggesting increased sexual risk with increased time in the us in analysis of waves 1 and 2 of the national longitudinal study of adolescent health mexicanborn adolescents reported lower rates of early sexual intercourse compared to usborn mexicans but they were also less likely to use contraception at first intercourse likewise among latino participants in the national longitudinal survey of youth first generation youth were less likely than second and third generation youth to have become sexually active before age 18 however compared to third generation peers first generation males and second generation females had a lower odds of consistent condom and contraceptive use several other studies suggest changes in condom use with migration to the us with higher condom use documented among mexican migrants to the us relative to their nonmigrant mexican peers while research to date provides evidence that partner risk behaviors increase an individuals risk of stis and pregnancy we are aware of no studies that have examined whether such factors vary between immigrant and usborn latino youth and in addition between recent immigrants and generation 15 conceptual framework this investigation is shaped conceptually as an examination of whether the hispanic paradox holds for sexual partner choice among latino adolescents this paradox emerged in research among adult latina populations suggesting that despite lower socioeconomic status and poorer access to health care immigrant latinos tend to have better health outcomes than their usborn counterparts among latino adolescents however the findings are more inconsistent and there has been little focus on partnership characteristics and partner risk behaviors known to be important in determining sti and pregnancy outcomes in some studies of adolescents lower acculturation has been associated with older age at sexual debut and fewer nonmarital births other studies however have documented the inverse relationship or have found no differences in reproductive health behavior based on acculturation measures most studies of adolescents have examined this paradox among females only given evidence for gender differences in partnership patterns and risktaking we examine whether relationships between immigrant generation and partner risk vary between male and female adolescents family influence articulated through parental monitoring and familism a multidimensional cultural measure may contribute to this paradoxical relationship found between immigration and reproductive health adherence to traditional cultural and familial values may change with more time in the us which in turn may illuminate a trajectory of increased risk associated with separation from traditional cultural norms in a study of middleschool aged latino youth in new york city guilamoramos et al found that low familism beliefs was predictive of sexual risktaking for females in addition studies of adolescent sexual risktaking and reproductive health have underscored the protective benefits of parental monitoring and communication thus we consider both a cultural and a structural measure of family influence adherence to traditional family norms and parental monitoring as potential mediators of the relationship between immigration and partner risk characteristics in this manuscript we examine whether immigrant generation is associated with sexual partner risk behaviors among a population of latino adolescents in san francisco california we compare three measures of partner risk assessed prospectively furthermore we evaluate the mediating effects of two measures of family influence on the relationship between immigrant generation and partner risk methods data collection participants completed inperson study visits every six months over two years each visit consisted of an intervieweror computeradministered questionnaire urine and blood specimen collection for sti and pregnancy testing and a brief reproductive health education session including referrals condom provision and pregnancy options counseling participants with positive sti results were followed to confirm treatment including treatment for current sexual partners study visits were conducted at our communitybased study office adjacent to a teen health clinic because gang affiliation limited the mobility of some youth we also developed satellite interview sites at youth service agencies measures exposurewe considered immigrant generation as our immigration measure we created a fourlevel generation measure recent immigrant 15 generation 2 nd generation and 3 rd generation the cutpoint of age 10 was chosen to differentiate youth who immigrated to the us prior to versus during adolescence a relevant distinction when examining sexual risk outcomesthree prospective measures of sexual network risk constituted the primary outcomes examined and included a participants report of whether one or more of their partners 1 had concurrent partners 2 used alcohol andor marijuana at least weekly and 3 belonged to a gang or was incarcerated at any time during their sexual relationship participants reports of their partners behaviors were assessed for the four most recent sexual partners reported at each study visit covariateswe measured baseline sociodemographic factors including gender age maternal educational attainment and crowded housing conditions as potential confounders we assessed baseline sexual history including number of lifetime partners age of coital debut and condom use frequency in the previous six months as descriptive characteristics of the study population two measures of family influence assessed at baseline were included as potential mediators an attitudinal 14item familism scale that assessed three dimensions of culturallybased familism guardian generally know what you are doing when youre away from home descriptive characteristics of partners included latino ethnicity immigrant vs usborn where the respondent met hisher partner whether the respondent met their partner in their neighborhood and whether they considered the partners main or casual we report on partnership characteristics at the first followup visit during which a participant reported being sexually active analysis we examined descriptive characteristics of respondents and their partnerships and compared these factors by immigrant generation using chisquare ttests and wilcoxon rank sum tests to examine the relationship between immigrant generation and each of the partner risk outcomes we used generalized estimating equations to accommodate the repeated measurements of partner risk within individuals over time in multivariable analyses we examined potentially confounding effects of baseline sociodemographic factors and effect modification by gender we examined the potential mediating role of the two family influence measures on the relationship between immigrant generation and each partner risk measure added individually and jointly into the multivariable models human subjects protection all study procedures and interviews were approved by the committee for human research at the university of california san francisco participants or parentsguardians of minors gave informed consent prior to study enrollment the institutional review board at rti international approved this analysis results a total of 411 latino adolescents enrolled in the study with 84 percent of expected followup study visits completed this analysis includes the 343 adolescents who were sexually active at baseline or during followup with sexual partnership data excluded were 58 youth who were not sexually active during the study and 10 sexuallyactive youth missing partnership data study population characteristics the mean age for participants was 166 years and over half were female nearly 40 reported that their mothers had less than high school education and nearly half resided in crowded conditions one in three were born outside the us mexico and central american countries constituted the predominant places of origin among immigrants 58 immigrated to the us after age 10 at baseline 20 reported speaking and reading spanish primarily or exclusively threequarters of participants were sexually active at baseline and onethird began having sex by 14 years of age partnership characteristics at the first followup visit at which participants reported being sexually active nearly twothirds reported having only latino partners and onequarter reported having only immigrant partners during the previous six months nearly 40 of participants reported having casual partners though over half of participants reported meeting all of their sexual partners outside their neighborhood 1 most met partners through friends and school and almost onequarter met partners on the street compared to all other generations a greater proportion of recent immigrants reported having only latino partners and only immigrant partners having both latino and nonlatino partners was reported by a greater proportion of generation 15 youth we found no differences by immigrant generation in partnership type nor in whether participants met partners in their neighborhood partner risk behaviors over time overall participants reported high levels of partner risk at 40 of visits participants reported that they had a partner during the previous six months who had concurrent sexual partners with little difference by gender at 52 of visits participants reported that they had a sexual partner who used alcohol andor marijuana regularly a higher proportion of females than males reported having a partner with regular substance use at 38 of visits participants reported having a partner who was in a gang or incarcerated at the time they were having a sexual relationship with this being much more common for females than males effects of immigrant generation on partner risk profile despite gender differences in the overall levels of partner risk no differences by gender in the direction or magnitude of these associations were found for any outcomes so we present only combined estimates adjusted for gender and age immigrant generation had no significant relationship with partner concurrency however generation was significantly associated with having a partner who used alcohol andor marijuana frequently with evidence of a trend toward an increased odds of having a partner with frequent alcoholmarijuana use with increasing us generation even between recent immigrants and generation 15 immigrant generation also was significantly associated with increased odds of having a partner who was in a gang andor incarcerated 1 though partners may be from other neighborhoods in many cases they attended the same school affiliated with the same friends and lived in great proximity to one another since neighborhood was selfdefined based on social features rather than geographic boundaries during their relationship with increasing us generation mediating role of family influence neither familism nor parental monitoring mediated the relationship between immigrant generation and either of the two partner risks for which significant differences by generation were found nonetheless parental monitoring maintained an independent relationship with partner risk stronger parental monitoring was associated with a decreased odds of choosing higherrisk partners discussion the high proportion of sexual partnerships reported to be highrisk for sti transmission and pregnancy among this population of latino adolescents in san francisco underscores the need for a prevention focus on partner risk and the pattern of increased risk with increasing us generation the magnitude of partner risk was greatest among 2 nd and 3 rd generation youth however differences in partner risk profile were found even comparing recent immigrants and generation 15 though a greater proportion of females than males reporting having highrisk partners the magnitude and pattern of the associations between immigrant generation and partner risk were similar for females and males other examinations of immigrationrelated measures and reproductive health have compared immigrants to usborn populations without attention to differences within immigrant groups a more nuanced understanding of how these changes in partner risk occur between 1 st and 15 generations as well as between generations 15 and 2 could offer insight into the origins of increased risk that builds among later generations sharing characteristics of first and secondgeneration immigrants generation 15 youth may face distinct challenges including linguistic incompatibility with family members conflicts over intergenerational values and peer discrimination both from peers of the same ethnicity but of different immigrant generation and from usborn peers of different ethnic backgrounds our finding that 15 generation youth were significantly more likely to have both latino and nonlatino partners compared to all other immigrant groups may reflect a distinct identity formation and immigrant adaptation as they negotiate peer relationships and social norms aligning themselves with higherrisk secondgeneration youth could also contribute to their choice of higherrisk partners consequently in addition to the clear need for interventions designed to reach 2 nd and 3rd generation youth who due to discrimination and persistent poverty may experience limited future opportunities that minimize the perceived negative consequences of engaging in risk behavior 15 generation youth represent an important group for targeted prevention likewise intervening with 15 generation youth could improve outcomes for their 2 nd generation children that two measures of family influence familism and parental monitoring did not explain associations between immigrant generation and choice of higherrisk partners suggests that an examination of other contextual factors related to migration and adaptation could offer greater understanding of the mechanisms by which immigrant generation is associated with partner choices however stronger parental monitoring was found to be independently protective against selecting a highrisk partner when controlling for familism this relationship suggests that not only does parental monitoring constitute a unique component of family influence intervention strategies designed to improve positive monitoring techniques within families in this population may reduce adolescents sexual risks a substantial body of literature has highlighted the important role that concurrent partnerships play in the spread of stis despite high rates of partner concurrency in this population of youth that no differences were found by immigrant generation suggests concurrency is an key feature of sexual partnership norms for latino youth in this community consequently this finding points to the potential for amplified sti spread should sufficient levels of sti pathogens be introduced into the community partner concurrency substance use and gang affiliation also reflect social network norms as indicated by the majority of youth reporting meeting their partners through friends or at school a closer examination of social networks could offer insight into tailoring interventions that address partnerrisk behavior and the adoption of community norms following immigration another analysis of these data showed that having a gangaffiliated partner increased the risk of pregnancy thus living in or migrating to a neighborhood with high levels of gang activity may affect the social network influence on partner selection not only for usborn youth but also for recent immigrant and 15 generation youth seeking peer relationships and negotiating identity formation during adolescence in another examination of the relationship between the recency of immigration and risk behavior blake et al found among 2635 8 th and 10 th grade students in massachusetts that youth living in the us six or fewer years reported lower alcohol and marijuana use compared with lifetime residents however recent immigrants also reported greater peer pressure to engage in and less parental support to avoid risk behaviors these findings highlight the importance of attention to the social network including peer family and community influences in the initiation of risk behavior among 2 nd and 3 rd generation youth as well as the vulnerability to negative peer pressure and the consequent adaptation of risk behavior among recent immigrants our findings are limited by several study design issues first partner risk was reported by the index participant not his or her partner and may be biased by participants lack of knowledge of their partners behavior however we would expect this measurement error to be nondifferential and to bias estimates toward no effect of immigrant generation on partner risk second though we defined a fourlevel immigrant generation measure that permitted estimation of effects we had relatively small samples reflected in the imprecise confidence intervals furthermore addressing other migration characteristics could be informative to the formation of sexual partnerships in the us finally due to low prevalence of stis within the community we were not able to examine biological outcomes as measures of partner risk nonetheless our previous research indicated a relationship between partner gang affiliation and pregnancy new contribution to the literature this study examined the relationship between immigrant generation and sexual partner risk using prospective data from a communitybased sample of underserved latino urban youth it improves upon much past epidemiologic research through examination of a fourlevel generation measure with differentiation between recent immigrants and youth who moved to the us prior to adolescence and focus on established sexual partner risks rather than on individuallevel behaviors alone the significant increases in choice of higherrisk partners with increasing usgeneration even within immigrant youth were found similarly for males and females finally though parental monitoring reduced choice of highrisk partners neither this measure nor the multidimensional familism mediated the relationship between immigrant generation and highrisk partner choice thus further attention to how social networks and other neighborhood factors such as poverty and ethnic enclaves contribute to this pattern of increasing risk with increased time in the us appears warranted 2 50 of immigrants born in mexico 21 el salvador 12 guatemala 17 other latin american country 3 14item scale measures three dimensions of familism familial obligations perceived support from the family and family as referents 1 partnership data from first followup visit at which participants reported sexual activity summarized within individuals 2 total sums to more than 100 because participants could chose more than one response option supplementary material refer to web version on pubmed central for supplementary material

backgroundsexual partner characteristics increase risk for adverse reproductive health outcomes evidence is limited regarding whether choice of sexual partners among latino adolescents changes with us acculturationadaptation methodswe used generalized estimating equations to assess the associations between immigrant generation recent immigrant 15 immigrated prior to adolescence 2 nd and 3 rd and sexual partner risk in a prospective cohort study of 411 latino adolescents aged 1419 we examined three measures of partner risk and mediating effects of family influence familism and parental monitoring resultsthe odds of reporting a partner with frequent substance use increased with increasing immigrant generation odds ratios or referencerecent immigrants 23 34 and 56 as did having a partner who was in a gangincarcerated or referencerecent immigrants 24 36 and 57 though the odds of having highrisk partners decreased with higher parental monitoring neither family influence measure mediated these relationships discussionfindings underscore the need for a prevention focus on partner choice with attention to increased risk with increasing us generation

introduction the seduction community has been an object of media curiosity in and beyond the uk for almost a decade with men who participate in this communityindustry routinely positioned as pathetic pathological or perverse in their attempts to meet and seduce women this cultural narrative recently played out in spectacular manner when in november 2014 a series of campaigns were launched to ban a pickup artist named julien blanc from countries including brazil canada germany japan and singapore where he was scheduled to teach seduction seminars with the american company real social dynamics in the uk an online petition calling on home secretary theresa may to deny a visa to blanc quickly attracted widespread public support and extraordinary levels of media attention with a series of articles and opinion pieces appearing in the daily mail the telegraph the guardian and new statesman both the online petition and associated media coverage framed blanc as an aberrant individual whose teachings about how to pick up women are an affront to british values on 19 november it was announced that blanc had been denied entry to the uk by the home office through recourse to special immigration measures typically reserved for political and religious extremists as multiple news outlets reported at the time it was the first recorded instance of a person being denied entry to the uk on the grounds of sexism within a matter of weeks blanc had become a figure of international opprobrium encapsulated in the time headline is this the most hated man in the world the media event surrounding blanc adhered to a familiar narrative in which the deviance of the pickup artist was affirmed and reified in doing so this cultural figure i temporarily embodied by blanc became knowable as an individuated problem that could be safely contained through recourse to state intervention this paper attempts to complicate this narrative drawing on extensive ethnographic fieldwork undertaken within the london seduction community my intent is to provide a more nuanced perspective of this communityindustry and its operations in contemporary britain not to exculpate it from criticism but to demonstrate that what it represents is in fact less a deviation or departure from current social conventions surrounding sex and relationships than an extension and acceleration of existing cultural norms that is to say the underpinning logics of the seduction community are consistent with broader reconfigurations of intimacy and subjectivity taking place within late capitalism while calling into question the framework of understanding that has informed the campaign against blanc as well as related media representations of pickup artists and puas i should make clear that my intention here is not to undermine feminist critiques of the teachings and practices advanced by men such as blanc indeed i share many of the concerns raised by campaigners as well as those raised by feminist scholars elsewhere rather my argument is guided by the feminist ethnographic principle that in order to successfully challenge gendered economies of power it is necessary to know as much as possible about the foundations on which they are built the paper proceeds in three parts in the first section i present a series of extracts from my fieldwork diary the intention of which is to provide some sense of the discourses that animate the lived spaces of the london seduction community to contextualise these extracts i provide some further details about the operations of this communityindustry in london and discuss the research i have undertaken in this context in the second section i advance an understanding of the seduction community as a site of mediated intimacy that must be understood in terms of the broader cultural rationalities fostered by neoliberal capitalism the third and main section elaborates this argument more fully by examining how logics of enterprise and management structure the intimate and sexual subjectivities of men who participate in this sphere i explore the ways in which pickup or game here defined as a set of techniques and knowledgepractices for the governance of self and intimate relations draws on more widely available cultural logics to promote a marketised and consumerist orientation to sexual relationships among heterosexual men i further consider how the commercial structure of the london seduction community figures intimate life as a site of commercial endeavour such that the ability to gain sexual access to womens bodies functions not only as a marker of status among men but acquires material exchange value in conclusion i offer some comments as to how feminist activism and scholarship might think differently about this and related concerns regarding contemporary permutations of gender intimacy and equality researching the london seduction community its 12pm on saturday afternoon in the windowless conference room of a hotel in central london i sit amongst a group of about fifteen men mostly in their twenties and thirties though one or two look older waiting for the session to start striding from the back of the room where he has been speaking with the other trainers aaron calls for our attention introducing himself aaron recounts how he and the other trainers all started out on the same programme weve been where you are now weve sat where youre sitting weve looked up with our note pad and pens wondering are we going to get good at this are we going to get results so we know what its like after going through the structure of the course aaron asks each student to explain why they are attending this training programme and what it is they want to achieve in turns men introduce themselves some index the number of women theyve dated or slept with in the past others detail their current skill level and talk about their sticking points all profess a desire for greater choice and control in their relationships with women as hes introducing himself a student named anwar explains that he thinks of himself as a decent guy when aaron interrupts him the problem is youre not the guy thats going to take them home and bend them over we need to get you to be that guy these notes recount scenes from within the london seduction community a central locus within the transnational communityindustry variously referred to as the pickup community or pua industry and the express purpose of which is to enable heterosexual men to achieve greater choice and control in their relationships with women through various forms of skills training and personal development an import from the united states the seduction community has had a presence in london for at least ten years with the first ukbased seduction training company established in 2007 today a panoply of private companies as well as freelance trainers offer feebased seduction training services which include onetoone coaching weekend courses and livein residential programmes while free and ostensibly noncommercial events regularly take place in the city online forums provide spaces for men involved in this communityindustry to document their activities discuss concepts and techniques seek advice and offer feedback to one another those with established profiles as trainers within the london industry host channels on social media sites such as youtube where the instructional videos they produce routinely receive tens or even hundreds of thousands of views while spatially and temporally discontinuous the activities of the london seduction community are concentrated in londons west end with commercial trainers meeting clients running seminars and hosting promotional events in and around oxford street leicester square covent garden piccadilly circus and soho upmarket areas of london such as kensington and chelsea as well as newly fashionable areas such as shoreditch are also popular sites for trainers to work and socialise although those involved in the london seduction community are often referred to and refer to themselves as pickup artists or puas there is a good deal of ambivalence around these terms such that it has become common for those who have made careers in this industry to at least nominally distance themselves from such labels as the preceding notes clearly indicate the term community is also something of a misnomer and rather conveniently promotes a sense of authentic collectively while concealing the machinations of what is in fact a lucrative industry nevertheless because it remains the most common appellation used to describe this sociocultural formation i use it here alongside and in conjunction with the hybridised term communityindustry i conducted ethnographic research within the london seduction community between 2012 and 2013 during this time i attended training and promotional events observed private coaching sessions and also attended free community events and social occasions as i have discussed elsewhere negotiating these spaces as a woman presented particular challenges but also allowed for the development of important conceptual insights in the course of my fieldwork i conducted interviews with 32 participants representing a broad crosssection of those involved in the london community these included freelance trainers as well as those employed by established companies event managers and business directors students at commercial events and community organisers interviews were semistructured and averaged two hours in duration with the longest of these lasting four and a half hours at their own request a number of participants were interviewed on a second occasion while others kept in touch via email periodically sending updates about their activities as well as links to content they felt was relevant to the research the demographics of participants in this study reflect the general composition of the london seduction community more broadly which is largely made up of middle class men in their twenties and thirties of various racial and ethnic identities ii as part of the research i also examined a range of media associated with this communityindustry including books blogs forums and promotional materials seduction as mediated intimacy in this paper i advance an understanding of the seduction community as site of mediated intimacy arguing that the orientating logics and underpinning premises of this communityindustry are in many ways consonant with broader reconfigurations of intimacy and sexuality taking place in and beyond the contemporary british context in doing so this paper represents a contribution to an emergent body of literature concerned to examine the mediation of intimacy this thematic imogen tyler and rosalind gill note was identified by sociologist ken plummer in his work on sexual stories almost twenty years ago but has received little attention to date especially as compared to sociological debates over the transformation of intimacy for tyler and gill a number of shifts in the social and cultural landscape mean that the need to attend to this thematic is even more acute now than it was then in the first instance representations of intimate relations proliferate across the mass media from stories about politicians affairs celebrity pregnancies and experiences of heartbreak to reality shows preoccupied with making over intimate life second a new kind of intimate gaze closely related to the personalising tendencies of contemporary media has come to constitute a kind of grammar of mediation such that all mediated life becomes refracted through a lens of intimacy in a way that is distinct from earlier moments finally new media technologies have become increasingly central to the ways in which intimate relationships are established and maintained in affluent societies of the global north such that intimate relationships in these contexts are increasingly lived out in relation to and through relations with media technologies on this basis tyler and gill contend the need to develop an understanding of mediated intimacy has never seemed more urgent of central concern for scholars interested in the mediation of contemporary intimate life are the ways in which intimate and sexual subjectivities are configured through broader social and cultural rationalities most especially those of postfeminism and neoliberalism in her work on womens magazines gill examines how sexual subjectivity and intimate relations are increasingly represented as sites of labour and investment focusing specifically on the forms of sex and relationship advice administered by womens magazines gill identifies a series of representational patterns or discursive repertoires intimate entrepreneurship whereby sex and relationships are to be meticulously planned for organised and managed menology where women are given instruction in how to appeal to and please men and transforming the self which calls on women to remodel how they think and feel about their bodies and desires the kinds of sexual practices they engage and the intimate relationships they have with men gill argues that these kinds of repertoires exemplify the operation of neoliberal rationalities within the domain of intimate life as women are repeatedly exhorted to work on their sexual selves and invest in an intimate skill set particularly notable here is the psychological work women are expected to perform women are enjoined to selfmonitor and monitor others to work on and transform the intimate self to regulate every aspect of their conduct and to present every action however constrained or normatively demanded as the outcome of individual choice and a deliberative personal biography these discourse are in addition distinctly postfeminist insofar as they emphasise womens choice and empowerment while nevertheless directing women to please and appease men as gill describes activities which might in a different moment be understood precisely as enacted to please your man must be reapprehended in postfeminist terms as something you are doing for yourself taken together these discourses offer a distinctively postfeminist articulation of intimate relationships which helps to sustain unequal gender relations and is profoundly connected to neoliberalism similar discursive patterns whereby intimate and sexual subjectivity are represented in terms of enterprise and management have been identified across a broad range of media including selfhelp texts makeover television and lifestyle magazines while both men and women are enjoined to become enterprising sexual subjects these discourses are deeply gendered with masculine repertoires frequently organised around themes of scientific rationality and efficiency as well as planning and strategy these discourses are also highly contradictory as gendered performances are presented simultaneously as moments of freedom choice empowerment and pleasure yet also as hard work that is normatively demanded and essential to the success of heterosexual relationships surveying this cultural landscape melissa tyler argues that through the incorporation of managerial imperatives discourses and techniques into those cultural resources that in part guide us through everyday life sexuality has also become yet another aspect of the lifeworld in which the work ethic seemingly reigns supreme tylers research which encompasses not only textual analysis but also interviews suggests that the exhortation to manage intimate and sexual relationships inculcates a performance imperative that has the potential to fundamentally change the character of intimate experiences and sexual relations she contends with this incitement to sexual and managerial discourse has come a corresponding performance imperative that does not simply repress sex but suppresses the intersubjectivity of eroticism my argument in this paper is that the emergence of the seduction community as a contemporary sociocultural formation must be understood in relation to these developments in doing so i should highlight first that the london seduction community is a highly porous entity that lacks fixed boundaries as such knowledgepractices germane to this context frequently manifest elsewhere enabling this is the common practice whereby established figures from within the london pickup industry rebrand themselves as dating coaches or lifestyle experts when contributing sex and relationship advice to mainstream magazine titles such as cosmopolitan fhm and mens health as well as online sites such as askmen over the past few years many of the most successful pickup training companies in london have been moving towards a more marketable model of selfdevelopment and lifestyle management offering advice on subjects that have long been the purview of mens lifestyle magazines such as fashion health and fitness personal finances entrepreneurship and travel indeed the american company real social dynamics widely regarded as an industry leader has been at the forefront of this marketing shift the seduction urtext the game is recognised as one of the bestselling and most widely read pieces of sex advice literature ever produced its sales far exceeding even the most popular texts currently directed at women thus my framing of the london seduction community as a site of mediated intimacy is based in part on a recognition of the continuities between this and more conventional forms of sex and relationship advice media however in approaching the seduction community in this way i also want to argue for a conception of mediated intimacy which goes beyond a concern with textual representations to address questions of how mediated intimacies are lived and experienced while analyses of media representations have much to tell us about ideal constructions of intimate and sexual relations it is crucial for feminist scholars to further consider how these constructions are negotiated this is particularly important in the case of the seduction community because while feminist scholars have directed critical attention to the textual productions of this communityindustry less has been done to examine how men engage with the knowledgepractices these texts elaborate or indeed those elaborated in the seduction seminars and training events which regularly take place in cities from london to berlin new york to tel aviv sydney to montreal stockholm to mumbai in arguing for a conception of the seduction community as a site of mediated intimacy i also want to draw attention to the ways in which the cultural logics of neoliberalism and postfeminism are immanent with contemporary formations of masculinity while scholars elsewhere have begun to take up these issues through analyses of lad culture there remains far too little scholarship examining how neoliberal rationalities shape mens sexual practices and how men negotiate a social and cultural context in which feminism is simultaneously taken into account and undone the work of seduction i cultivating a sexual work ethic for many men the knowledgepractices elaborated in the london seduction community commonly referred to as pickup or game are appealing precisely because they recast success with women as a matter of labour and investment in this way heterosexual men are enjoined to cultivate a sexual work ethic and engage a model a self as enterprise adam a trainer in his thirties who has worked in the industry for a number of years explained i think what game does it kind of gives power back to those who are not the biggest strongest most athletic its a set of skills that can actually be learned by different people which kind of makes it quite accessible to all through the language of meritocracy the contention that these skills are accessible to all pickup or game promises that any man can achieve greater choice and control over their intimate and sexual lives evincing a similar logic a financial consultant in his midtwenties named moe explained if you think yeah well sometimes i get lucky and sometimes i dont you just stand there and wait and hope somebody will fall in your lap or anything but in pickup you you take action you do something there is however a kind of compulsion attendant on this promise as the opportunity pickup provides men to exercise greater choice and control in their intimate lives is weighted by an imperative for men to take responsibility trainers i interviewed frequently impressed this point and complained about students who fail to take responsibility for themselves one recounted we had one student the other day who expected everything to be done for him and i was just thinking how can you expect someone to become good with women for you you know where does it get done for you … nowhere does it say that you get to do that this is effortless this is an intense seven day twelve hours a day course we cant do it for you this view was also commonly held among students or at least among those who had attained a certain level of competency in pickup to this end moe complained about some of the other students on a course we had both recently attended saying i understand youre there to get help but you have a responsibility to take action as well … the instructor can lead you but they cant take you all the way you have to push that little extra as well by recourse to neoliberal vocabularies which exhort men to take responsibility and take action the teachings and practices of the london seduction community borrow from and redeploy the meritocratic feeling that structures neoliberalism in the uk context framing success with women as a matter of individual graft and a capacity for hard work inevitably some proportion of men who seek out seduction training materials or otherwise become involved in the london seduction community do not achieve anything like the kind of choice and control promised by seduction training companies indeed many of the men i spoke to admitted that investment in pickup training and materials had not significantly improved their relationships with women yet consistently framed this as their own personal failing indeed this was the case even when their engagement with pickup had resolutely negative implications for their relationships with women exemplifying this a business professional in his late thirties named anwar described losing a muchvalued relationship after undertaking pickup training she just said id changed and ahm and she said that she didnt know me anymore and i think the fact that ii mean i have really deep feelings on this in the sense that i mean she was the reason i took the course because i wanted her she was the only thing i really cared about when i asked anwar how this made him feel about pickup he related im mad and angry but not at pickup im angry at me because its my fault … i mean its not games fault okay … its not games fault its my fault if id done because i as i said its a bit like you give me a set of tools and … if i didnt know how to use those tools properly im going to make a mistake and so its not games fault its my fault for not having the skills and using them properly and so ahm im not ahm im not bitter for game im its my fault unable or unwilling to criticise the efficacy of the knowledgepractices elaborated within the london seduction community anwar blames himself for being unable to master the tools pickup provides in doing so he accedes to the prevailing culture mandate wherein the neoliberal subject is required to bear full responsibility for their life biography anwars attachment to pickup is perhaps best understood a form of cruel optimism which lauren berlant defines as a relation in which something you desire is actually an obstacle to your flourishing such that the object that draws your attachment actively impedes the aim that brought you to it initially berlant 2011 2396 p1 having undertaken a pickup training course with the sole intention of using the skills he would learn there to secure a relationship with this particular woman anwars engagement with the knowledgepractices of this communityindustry quickly brought the relationship to an end as he himself stated its because of pua shes gone however by locating blame on himself anwar is able to sustain the fantasy that pickup will eventually and with sufficient effort on his part enable him to realise the kinds of sexual and intimate relationships he desires in an interesting inversion of the logic whereby pickup transforms sex and relationships into a form of work many of the men i interviewed described engagement with pickup materials and training as having been of professional benefit to them indeed this was one of the most frequently recurring narratives across all interviews seemingly irrespective of the kind of employment participants held for example when i asked ravi a researcher in his thirties whether or not he had seen any changes in himself since becoming involved in the london seduction community he responded in my professional life i have drastically and visibly seen the difference because now im more confident presenting something in front of an audience before i was not i can talk more confidently more decisively with my manager with my boss before i was not like that so these are some of the visible changes i got i explicitly owe it to game this side of things noting that his response neglected to mention anything about how pickup training had impacted his relationships with women i asked ravi if he had experienced any changes in his intimate and sexual relations he explained the other side the other side i have still to work on many things but im seeing the results so i know if i put more hard work into it if im more determined then down the line ill definitely get results on the sexual part the actual pickup part of it impressing that what is required is more hard work here ravi demonstrates how by reimagining success with women along entrepreneurial and meritocratic lines seduction training companies gainfully exploit the neoliberal fantasy that anything can be achieved if the correct disposition has been adopted unlike ravi a recent university graduate i interviewed named derek felt that his relationships with women had changed dramatically since he had become involved in the london seduction community and undertaken a succession of training courses however like ravi and many other men i spoke to derek also felt that pickup training had given him an advantage in his professional career illustrating this he described how his social skillswhich he accredited to pickup training had enabled him to compete successfully against candidates with more prestigious educational qualifications when interviewing for a highprofile job and all of these other peoples backgrounds were oxford and cambridge … you know and im just like ive got nothing on these guys but i do ive got everything on them because they may be very smart but can they string a few words together not really when he later mentioned that it was a woman who conducted the interview the relational dynamics that underpinned his success more clearly came into focus i was in that interview with a woman and im thinking to myself you know what like youre nothing onyoure nothing on the shit ive been through this week youre literally nothing you know ive had people getting ive had hardcore situations what could possibly what could possibly be more intense than that like other kinds of immaterial labourers for whom the distinction between life and work and work and leisure has collapsed those who work in the london seduction industry particularly those who are wellknown and have established profiles often have little separation between their public and private lives it is here that the pursuit of pleasure is most clearly seen to replicate and facilitate work patterns as trainers intimate and sexual lives literally become their work when i asked danny a trainer in his late twenties what it takes to work in the industry he explained i think everyevery coach and trainer theyre only good if theyve actually gone out and have been successful themselves and by success i definitively mean getting out and getting laid not gone out and had dates a good trainer needs to have gone out dated and have gotten laid … i genuinely wouldnt take any trainer seriously unless hes i dont know had sex with i dont know forty or fifty women and its not just the numbers its also about the quality so they would have needed tohe would have needed have slept with quality women also so not just unattractive women and low self esteem women then i could say he might be qualified as a trainer where in other homosocial contexts success with women frequently functions as a kind of currency and marker of status among men within the london seduction community being good with women acquires material exchange value the process by which trainers prove themselves in this industry by attaining sexual access to womens bodies plainly exemplifies the general commodification of sex which is one of the most striking characteristics of neoliberal culture today but for trainers in the london seduction community intimate life is not only governed by commodity logics but commodified for market exchange in order to build their brand trainers commodify their intimate lives by producing a whole range of reality media seemingly private moments are recorded or written about shared online or published in books many trainers write diarystyle blogs in which they provide detailed accounts of their sexual encounters with women explaining precisely their techniques and providing guidance to other men some additionally film these encounters which they then screen at live training events or post online via social media or paytoview online training programmes where they are consumed by entrepreneurial voyeurs in producing these videos trainers subject themselves to the regimes of surveillance and monitoring commonly seen in reality television the crucial difference however is that these videos are actually real rather than scripted reality and typically filmed without womens knowledge or consent in this way women are not only objectified but made into object lessons the practice of producing and sharing infield footage whether freely or for financial gain is virtually innocuous within the london seduction community explaining why he himself films and publicly posts videos of himself interacting with women in the street on dates and in private settings one participant stated simply i wanted to give an honest insight into pickup some guys might be sceptical and i think some guys will always be sceptical so i wanted to demonstrate that this is a skill just like anything else if you put the time into it youre going to reap the rewards from it the lack of regard shown for the women who are unknowingly made to appear in these videos both reflects and reproduces the violability which commonly structures womens representation in the media and further demonstrates that in the contemporary cultural conjuncture sexuality has increasingly becomes autonomized an independent field of action containing its own rules and moral values ii consuming sex in talking about how and why they became involved in the london seduction community men i interviewed frequently made reference to the kinds of intimate and sexual relationships they wanted to have while trainers frequently impressed that many of their students are seeking committed relationships likely out of a perceived need to contravene negative perceptions about the seduction community for most of the men i spoke to learning how to more skilfully negotiate casual sexual encounters was their immediate priority discussing his decision to undertake a weekend training programme at a cost of several hundred pounds a banker in his midtwenties named doug said simply i just wanted more casual sex at the same time most participants also assumed that they would eventually become involved in some kind of committed relationship in some cases this was not so much because they wanted to be in a committed relationship per se but rather that there was a point at which seeking casual sexual encounters would become untenable as exemplified by trainer marks rhetorical supposition because what are you going to when youre forty or even when youre fifty still walk around trafalgar square opening sets in this regard most of the men i interviewed ascribed to a kind of twophase masculinity where mens pursuit of casual sexual encounters is supposed to eventually give way to monogamous relationships as a signal of heterosexual maturity in keeping with the exigencies of the male sex drive discourse the desirability of casual sex for men was very often assumed to be selfevident and as such did not require further explanation doug for example did not immediately elaborate why he just wanted more casual sex yet when i asked him and other participants to detail more precisely what it was that appealed to them about casual sexual encounters their explanations were notably lacking in any explicit sense of carnality or embodied desire indeed the rationales they put forth more often betrayed a highly rationalised form of eroticism consistent with the neoliberal construction of self as enterprise as doug went on to elucidate it seemed like the investment would be worth it you know i spend time in the gym and i was trying to figure out whats the pay put from that i buy nice clothes whats the pay out from that whats the expected payout from this almost certainly higher than either of those two here doug contends that pickup training is likely to offer him a better pay out or return on his investment than other practices geared towards casual sex namely fashion and body work in doing so he reproduces a commonlyheld understanding of sex as a commodity controlled by women and which men seek to gain access to through various forms of labour and investment crucially however this investment is directed inwards as men who undertake pickup training seek to acquire a skill set which will enable them to have greater choice and control in their relationships with women as doug further detailed part of his motivation for taking the course was that i would want to know that if i wanted to have casual sex i could walk into a bar and it wouldnt be a problem for me dougs investment in pickup training then is a means to realise a certain sexual lifestyle in which casual sex is pursued and engaged primarily as a recreational activity in this sense seduction training is yet another form of serial recreational sexuality organized under the aegis of the market for many participants the point at which they envision themselves becoming involved in a committed relationship was in some way related to or dependent on the kinds of casual sexual encounters they wanted to have moe explained of course i want to have great experiences with girls and eventually someday i will get married as well but ah yeah iive promised myself that i wont get into a relationship a serious one until i feel that ive arrived at a level that wherewhere i am very pleased with while relating a desire for great experiences moe here fixates on reaching a certain level he went on to explain that attaining a certain degree of proficiency in pickup was also important for securing his future relationship i dont want to meet my dream girl and then make her disappointed or lose her to some cooler guy evincing a similar logic a trainer in his thirties named rahul claimed youve got to work on yourself and your life get it to a competent level then go out and meet women especially if youre going to go for really hot ones youre going to compete with their boyfriends or youre going to compete with other guys that are going to go after them in an intensely competitive romantic field in which the entrepreneur of himself has only competitors pickup is perceived as a means for some men to gain an advantage over others indeed this was a common sentiment among the men i interviewed describing how he felt after completing a pickup training course university student antonio explained like just from this bootcamp i feel like ive gone from disadvantaged to totally advantaged notably the advantage pickup is held to offer men pertains not only to their relationships with other men here cast as competitors in the sexual marketplace but also their future relationships with women derek for example described i need to go out there and do a lot of stuff before i can commit to anybody because i want her to know that i chose her out of thousands you know i want her to know that actually there was something about her she wasnt the first thing that i ever got my hands on you know she wasnt the first person i ever was with that i thought wow you know i want her to know definitely that i had options i could have had anybody but i chose her for derek doing a lot of stuff is a means to gain leverage in an imagined future relationship this same sensibility was elsewhere in evidence when trainer danny explained the advantages of meeting women in the street or other public venues rather than through online or mobile dating applications describing how a brief stint of online dating left him feeling like such a pussy he explained when you start the girl on the street as long as youve done it well it creates a much better and stronger impression and it can actually resonate for the rest of the relationship also because the girl knows okay this guy he met me by approaching me so hes got game generally girls respect you more so it resonates for the rest of the relationship and girls are actually less likely then to take the piss by treating you badly because they know that youre a man with options for both derek and danny being a man with options is conceived as a means to retain an advantage in sexual and intimate relationships with women which are inscribed by an almost adversarial dynamic far from the democratic bargaining and mutual exchange of the pure relationship envisioned by scholars elsewhere here heterosexual relations are given over to a much more competitive ethos of selfinterested individualism such that every aspect of the relationship including how you meet becomes a matter of tactic strategy and ultimately power as already stated participants talk about the kinds of sexual encounters and intimate relationships they want to have was often marked by a lack of attention to or concern with the affective or embodied aspects of heterosexual experience instead men tended to place emphasis on attaining a certain level of sexual proficiency or amassing a certain number of sexual partners seduction training moreover enjoins men to understand intimacy not as a mutual and somewhat unpredictable dynamic but rather as an affective relation that can be wilfully produced where participants did talk about the experiential dynamics of intimate and sexual relationships this was most often as something to be looked back upon from the perspective of a distant future exemplifying this derek explained i want to do a lot of things i want to sleep with a lot of people i want to have a lot of interactions and stuff like that and i dont feel like ive done enough maybe its just because im young you know but i want to do that shit because i want to look back at this time when im old and think fucking hell you absolutely killed it in a similar manner doug related id like to pick up more women i just think it would a fun thing to do and i will regret it if im old and married which i probably will be and thinking i should have chased more women when i was younger i dont want to look back and regret not doing that when i was in my twenties both derek and doug express a desire for casual sexual encounters that are valuable not as experiences in and of themselves but as experiences that they can later reflect upon the prospective and anticipatory relation these formulations express is unambiguous as even before they have had these encounters derek and doug imagine themselves looking back on them in ways which bolster their own sense of masculinity these narratives exemplify the operations of the extended present in which the future is alwaysalready within the present measured planned for determined chosen in the present in this sense derek and dougs desire for casual sex reflects a logic characteristic to capitalist labour organisation insofar as they are concerned not so much with the embodied experience or relational dynamic of these encounters as with the creation of potential their narratives also exemplify the imprint of a culture in which sex has become a consumptive rather than relational act this same logic aligns with the consumer orientation that structures the intimate practices and sexual desires of many of the men i interviewed who frequently intimated that their past intimate and sexual partners had not been attractive or not been attractive enough talking about the kinds of sexual relationships he had in the past predominantly casual encounters with women he met in bars and clubs an engineer in his late twenties named gavin described i just went for the girls that i thought i could get really that was basically what my past was i just went for what i thought i could get so i was picking off easy targets pretty much these same marketised notions of getting and having women also figured in some mens descriptions of the women they had previously had longterm relationships with talking about an exgirlfriend whom he had dated for one or two years and described as not very attractive moe stated at the time i that was in my mind it was the best i could get if i could get any at all elsewhere university student jay described his exgirlfriend whom he had dated for over four yearsas quite attractive but not like my ideal later he explained that this had became a problem in their relationship i mean when she woke up in the morning without makeup it wasnt ah it wasnt i didnt i liked her better with makeup on so so yeah more than more than other people like you know i think she needed a little bit of makeup on at least but yeah i think that should be a problem for you if youre gonna be ah like waking up next to if im going to be waking up next to her like everyday that would be a problem in the long term against these descriptions of their past sexual partners physical inadequacies many participants offered detailed specifications about the physical characteristics their desired partners should embody including age weight height and body type skin hair and eye colour race ethnicity and nationality though participants often framed their preferences as idiosyncratic the overall uniformity of these descriptions was striking as men almost invariably described a feminine ideal that closely resembles that depicted in contemporary advertising young slim and ablebodied normatively white or an exoticised other and conventionally attractive injunctions that women be fit were frequent with many men describing preferences for women who work out go to the gym and take care of themselves physically the overwhelming emphasis placed on womens appearance and lack of consideration given to the affective and relational dynamics that might pertain in their future relationships gives lie to the consumer orientation which has increasingly come to structure heterosexual encounters and relationships in late capitalist contexts where a range of social cultural and technological developments conspire to transform the pursuit of sex and intimacy into something akin to a shopping experience the competitive and comparative ethos which structures mens engagement in the london seduction community is also crucial here as was demonstrated by men who spoke enviously about the kinds of women trainers date and have relationships with talking about a seduction trainer whose blog he follows ravi stated the quality of women hes getting its really good my target is also like that getting the highest in high value the relentlessly aspirational quality of these narratives can be read as a symptom of the ways in which intimate and sexual relations are being remade in a culture enamoured with the upgrade and further demonstrates that it is often not women per se that men desire but womens bodies conclusion in this paper i have argued that the london seduction community is not so much a deviation or departure from current social conventions as an extension and acceleration of existing cultural norms that is to say the underpinning logics of this communityindustry are consonant with broader reconfigurations of intimacy and sexual subjectivity taking place within the contemporary british context in developing this analysis i have attempted to show how the forms of intimate and sexual subjectivity negotiated by men who participate in this communityindustry ordered by logics of enterprise and management competition and consumerism have resonance with broader patterns of subjectivity and sociality elaborated in neoliberal capitalism approaching the seduction community as a site of mediated intimacy my argument complicates a dominant cultural narrative which figures men involved in the seduction community as pathetic pathological or perverse an army of sleazebags saddos and weirdos or as individuated problems who can be safely contained through recourse to state intervention again i must reiterate that my intention is not to exculpate the seduction community from criticism far from it but rather to nuance our understanding of this deeply problematic phenomenon this research adds to growing concerns about the ways in which the proliferation of neoliberal rationalities are reconfiguring intimate and sexual subjectivities and producing distinctly antisocial forms of sociability these concerns are further exacerbated by the recognition that the lack of mutuality fostered by neoliberal rationalities within intimate and sexual relations may well be conducive to sexual coercion and violence particularly in a context where gender equality is assumed to have been achieved and women are imbued with compulsory sexual agency with and alongside feminist scholars elsewhere i find myself asking what can be done to unsettle the entrepreneurial and consumerist modes of sexuality that are taking hold in the contemporary cultural conjuncture and instead find ways to forge more mutual and ethical forms of intimacy and sexuality i do not presume to have the answers to these questions moreover like breanne fahs i am sceptical of the idea that there can be any definitive solution to the problems of gender inequality and sexual oppression what i do want to impress here however is the importance of undertaking more rigorous analysis in an attempt to get the story right it is only too easy to dismiss the seduction community as a cultural anomaly and pathologise the men who participate in this communityindustry examining how the seduction community as a site of mediated intimacy reflects and reproduces broader cultural rationalities is a much more difficult and much more urgent endeavour notes 1 my thinking about the pickup artist as a cultural figure here owes much to the work of imogen tyler for tyler the term figure denotes the ways in which at different historical and cultural moments specific social types become over determined and are publicly imagined in excessive distorted and caricatured ways she further argues that the emergence of these figures is always expressive of an underlying social crisis or anxiety 2 men involved in the london seduction community are largely young and middle class the majority are in their 20s and 30s though men older than this regularly attend commercial and noncommercial events they are typically highly educated having attended or currently attending university and many have postgraduate qualifications most work in professional occupations in fields such as business science and education in part the class dynamics of the seduction community can be attributed to the significant costs involved with a weekend training course with an established company costing several hundred pounds noncommercial events also presume a certain financial status as attendees must have both the time and income required to travel and socialise within central london in terms of race and ethnicity the london seduction community reflects the general population of london in that it is predominantly but by no means exclusively white at events i attended white men typically accounted for between half and three quarters of attendees british asian and south asian men are somewhat overrepresented within the london pickup scene a trend that was often commented on and discussed by men i interviewed despite this overrepresentation it is notable that the most wellknown and commercially successful trainers within the london seduction community are white set against the general population relatively few black men participate in the london scene an absence which leads some men involved in this setting to conclude that black men are naturally good with women reflecting these general characteristics in this study just over half of interview participants identified as white british or white european 8 described themselves as south asian british asian or british indian 3 as east asian 2 as black and 1 as middle eastern all names given here have been changed and identifying personal details have been omitted

this paper explores negotiations of intimate and sexual subjectivity among men involved in the london seduction community a central locus within what is more properly regarded as a transnational communityindustry herein heterosexual men undertake various forms of skills training and personal development in order to gain greater choice and control in their relationships with women as an entry point to this discussion i consider the international media event that enveloped american pickup artist julien blanc in november 2014 shifting focus away from the cultural figure of the pickup artist and onto socially located men i attempt to complicate a dominant narrative that characterises men who participate in this communityindustry as pathetic pathological or perverse this analysis makes use of extensive ethnographic research undertaken within the london seduction community between 20122013 and examines how men who participate in this setting engage a mode of intimate and sexual subjectivity ordered by themes of management and enterprise ultimately i argue that the central logics of the seduction community are not dissonant from but are in fact consistent with broader reconfigurations of intimacy sex and capital taking place in the contemporary uk context

introduction this article aims to better understand the real and potential role of civil society in assisting asylum seekers and facilitating their integration into the host country taking sweden as a critical and extreme case existing research on migration and integration in europe is centered on major population centers while we focus more on the role of civil society in supporting the reception and facilitating the integration of asylum seekers in small and mediumsized rural municipalities further we note the tension in opinions between antimigration sentiments expressed in the electorate in response to public opinion and political party rhetoric versus the positive attitudes expressed in the eu 27 barometer for sweden and in our survey hence we ask how can this discrepancy be explained and to what extent can civil society counteract antimigration attitudes the selection of sweden is of strategic importance for two main reasons it is a critical case for understanding a sudden policy shift after the 2015 inmigration and it is an extreme case as regards the discrepancy in opinion between populist antimigration sentiments in the electorate and the positive attitude towards migrants in civil society a critical case is either the most or the least likely to fulfill a certain proposition given swedens long history of inand outmigration in an ever more established and wellfunctioning welfare state along with its generous and at times very active migration policy it was most likely that sweden would welcome asylum seekers in 2015 but it was least likely that sweden would suddenly shift to a very restrictive migration policy in the wake of the soc sci 2023 12 403 2 of 20 european asylum crises sweden is also an extreme case given the positive attitudes in sweden towards migration both in the eu 27 barometer and in civil society playing a very active and central role in the 2015 reception and in the further integration of asylum seekers after that it is a surprising contrast that a populist party with an explicit antimigration agenda receives an increasing share of political votes taken together these conditions make sweden an extreme case that may reveal compelling findings about complex dynamics we have settled for an open definition of integration as the process of becoming an accepted part of society that process raises further questions on how to conceptualize and implement rights obligations and reciprocity how to explain the dynamics between economic and social integration and how to include new actors and perspectives our focus is explicitly on civil society and the integration of asylum seekersgrantees and not on the migration of cheap labor often driven by the need for rather than the needs of lowwage migrant workers migration and demography in 2015 the unhcr recorded the highest number of displaced people since its establishment in 1949 of those onethird were refugees although questioned by scholars the rapid influx to europe of over one million asylum seekers in 2015 is often labeled the european crisis of migration within a few months in late 2015 sweden received more asylum seekers per capita than any other country in the eu and well beyond what sweden received either before or after that in response the number of civil society organizations and networks quadrupled and were praised for their capacity to quickly engage collaborate coordinate activities and start solving problems at least every other municipality depended on the readiness of civil society organizations to assist asylum seekers on arrival and help them access accommodation and facilities such as home schooling language cafés legal assistance translation work trauma treatment internships and leisure activities soc sci 2023 12 x for peer review 2 of 22 but it was least likely that sweden would suddenly shift to a very restrictive migration policy in the wake of the european asylum crises sweden is also an extreme case given the positive attitudes in sweden towards migration both in the eu 27 barometer and in civil society playing a very active and central role in the 2015 reception and in the further integration of asylum seekers after that it is a surprising contrast that a populist party with an explicit antimigration agenda receives an increasing share of political votes taken together these conditions make sweden an extreme case that may reveal compelling findings about complex dynamics we have settled for an open definition of integration as the process of becoming an accepted part of society that process raises further questions on how to conceptualize and implement rights obligations and reciprocity how to explain the dynamics between economic and social integration and how to include new actors and perspectives our focus is explicitly on civil society and the integration of asylum seekersgrantees and not on the migration of cheap labor often driven by the need for rather than the needs of lowwage migrant workers migration and demography in 2015 the unhcr recorded the highest number of displaced people since its establishment in 1949 of those onethird were refugees although questioned by scholars the rapid influx to europe of over one million asylum seekers in 2015 is often labeled the european crisis of migration within a few months in late 2015 sweden received more asylum seekers per capita than any other country in the eu and well beyond what sweden received either before or after that in response the number of civil society organizations and networks quadrupled and were praised for their capacity to quickly engage collaborate coordinate activities and start solving problems at least every other municipality depended on the readiness of civil society organizations to assist asylum seekers on arrival and help them access accommodation and facilities such as home schooling language cafés legal assistance translation work trauma treatment internships and leisure activities historically sweden has experienced substantial migration flows when the massive outmigration of farming smallholders in 18501930 turned into an inmigration of industrial labor in 19501970 the share of foreignborn people tripled to 7 percent in two decades again from 2000 to 2021 the share of people born outside of the eu increased now mainly through asylum immigration from 6 to 15 percent the highest percentage share in the eu geographically the population in sweden is unevenly distributed with only 10 percent in the whole of the north covering 60 percent of the country versus 25 percent in the three largest citiesall located in the south rapid rural outmigration from the north implies that small municipalities struggle to maintain basic welfare social services and job opportunities while small dynamic municipalities in the south struggle to attract skilled labor this has resulted in a complicated situation where political parties compete in promising services and favorable labor policies for rural development while at the same time advocating increasing restrictions on asylum migration to sweden in 20132023 migration politics and the number of asylum seekers in sweden varied like a rollercoaster to peak in 2015 after that sweden introduced firmer border control timelimited residence permits and reduced options for family reunification and thus settled at the minimum level required by the court of justice and international conventions more recently the government that came into power in the autumn of 2022 has further restricted the possibility for people to seek asylum in sweden intending to have the eus most restrictive migration policy this includes a reduction of quota refugees from 5000 per year to 900 per year migration and attitudesin sweden and in the eu according to the special eurobarometer on the integration of noneu immigrants in the eu the attitude towards noneu migrants is much more positive in sweden than in the rest of the eu27 people in sweden also state that they interact more often with noneu migrants than the average in the eu27 the survey defines immigrants as people born outside the eu who have moved away from their country of birth and are currently staying legally in an eu country historically sweden has experienced substantial migration flows when the massive outmigration of farming smallholders in 18501930 turned into an inmigration of industrial labor in 19501970 the share of foreignborn people tripled to 7 percent in two decades again from 2000 to 2021 the share of people born outside of the eu increased now mainly through asylum immigration from 6 to 15 percent the highest percentage share in the eu geographically the population in sweden is unevenly distributed with only 10 percent in the whole of the north covering 60 percent of the country versus 25 percent in the three largest citiesall located in the south rapid rural outmigration from the north implies that small municipalities struggle to maintain basic welfare social services and job opportunities while small dynamic municipalities in the south struggle to attract skilled labor this has resulted in a complicated situation where political parties compete in promising services and favorable labor policies for rural development while at the same time advocating increasing restrictions on asylum migration to sweden in 20132023 migration politics and the number of asylum seekers in sweden varied like a rollercoaster to peak in 2015 after that sweden introduced firmer border control timelimited residence permits and reduced options for family reunification and thus settled at the minimum level required by the court of justice and international conventions more recently the government that came into power in the autumn of 2022 has further restricted the possibility for people to seek asylum in sweden intending to have the eus most restrictive migration policy this includes a reduction of quota refugees from 5000 per year to 900 per year migration and attitudesin sweden and in the eu according to the special eurobarometer on the integration of noneu immigrants in the eu the attitude towards noneu migrants is much more positive in sweden than in the rest of the eu27 people in sweden also state that they interact more often with noneu migrants than the average in the eu27 the survey defines immigrants as people born outside the eu who have moved away from their country of birth and are currently staying legally in an eu country sweden responses to the question would you personally feel comfortable or uncomfortable having an immigrant as your friendwork colleagueneighbordoctorfamily membermanager the interviews were carried out in the period 229 november 2021 the eu27 data contain 26510 interviews and the swedish data contain 1070 interviews despite the positive attitude towards migrants integration in terms of employment is lagging in sweden in fact among all oecd countries sweden stands out with the highest unemployment gap between migrants and people borne in sweden policy shifts on migration and integration in sweden the political debate about migrant integration is associated with strong opinions about real and potential challenges while some opinions are rooted in the 1930s 1940s or 1960s further ideas emerged in the wake of the inmigration of asylum seekers in 2015 political sentiments about migration as expressed in political narratives and campaigns often build on the perception rather than on the actual number of migrants and are often associated with problems supposedly related to migration but often without robust evidence when conservative and nationalist circles tend to overestimate the number of migrants this is often driven by misinformation or a particular political agenda the sheer threat of immigration may therefore not be reflected in real numbers nevertheless the inmigration of asylum seekers to sweden in 2015 did put further pressure on society as regards national reception and integration facilities and not least on housing health care schools and other welfare services especially in bigger cities at the graph shows responses to the question on average how often do you interact socially with immigrants interaction means anything from a few minutes of conversation to doing an activity together the interviews were carried out in the period 229 november 2021 the eu27 data contain 26510 interviews and the swedish data contain 1070 interviews despite the positive attitude towards migrants integration in terms of employment is lagging in sweden in fact among all oecd countries sweden stands out with the highest unemployment gap between migrants and people borne in sweden policy shifts on migration and integration in sweden the political debate about migrant integration is associated with strong opinions about real and potential challenges while some opinions are rooted in the 1930s 1940s or 1960s further ideas emerged in the wake of the inmigration of asylum seekers in 2015 political sentiments about migration as expressed in political narratives and campaigns often build on the perception rather than on the actual number of migrants and are often associated with problems supposedly related to migration but often without robust evidence when conservative and nationalist circles tend to overestimate the number of migrants this is often driven by misinformation or a particular political agenda the sheer threat of immigration may therefore not be reflected in real numbers nevertheless the inmigration of asylum seekers to sweden in 2015 did put further pressure on society as regards national reception and integration facilities and not least on housing health care schools and other welfare services especially in bigger cities at the time many eu governments shifted the responsibility for migration politics upwards to interand supranational levels and downwards to local municipalities while outsourcing to civil society many of the welfare services related to the reception and integration of asylum seekers this policy shift was evident in sweden as were further changes in reception management and inmigration politics in short municipalities and civil society organizations played a central role in filling the voids between authorities in the public sector and facilitating both the reception and early integration of asylum seekers integration in sweden is meant to benefit the whole society policies and regulations are designed to cover education and employment via general measures if social integration was previously seen as the prerequisite for entering the labor market it is now the reverseeconomic integration via the labor market is the suggested entrypoint for social integration in sweden this is paralleled by a shift in the political responsibility for migrants from social authorities to employment agencies thus representing a shift away from welfare institutions to the swedish public employment service however due to political pressure from liberal parties to privatize the spes more than every other of its agencies shut down in 2019 especially in small municipalities and the staff was reduced by 35 percent this policy shift is unhelpful when the number of employment seekers including migrants is growing as is also the concern for their integration given the persistent unemployment gap between people born outside versus inside sweden the new policy to prioritize employment as a precondition for social integration may delay or reduce asylum seekers opportunities to integrate into society integration must therefore be understood and addressed within the wider context of economic cycles human capital public opinion and civil society this calls for an analysis taking a broad political economy approach to sum up the political economy in sweden is characterized by institutional continuity but also decisive change first in terms of core features of the economy the current labor market suffers more from unemployment than from the labor shortage typical of the 1950s1960s second and regarding status and region of origin migrants are more often asylum seekers mainly from the middle east and africa rather than migrant labor from scandinavia and europe third sweden is a postindustrial society with a growing care and service sector rather than a booming industrial society in need of workers except for a growing demand for industrial labor in branches associated with a decarbonized economy mainly located in the north of sweden fourth politics are less influenced by historical social democratic solidarity than by contemporary neoliberal thinking and antimigration populism fifth since its eu membership inclusion in 1995 sweden has been expected to collaborate regionally and adhere to eu recommendations and regulations theory about society theoretically we apply a sociological perspective to discuss the integration of asylum seekersgrantees with a particular focus on civil society organizations as facilitators we proceed from granovetter stating that weak ties to acquaintances are more important for social change than strong ties to family and close friends accordingly we propose that civil society can potentially provide weak ties that promote integration further we draw on fligstein and mcadams theory on strategic action fields to discuss the wider social order and political context within which civil society is operating and to understand the interplay between the political regime determining the national migration policy municipalities receiving migrants and civil society facilitating integration finally we engage briefly with framing theory to underline the importance of political communication and the powerful role of media in shaping attitudes about migration besides we apply a few concepts on demographic dynamics and structures presented below three concepts demographic opportunity cosmopolitanism inclusive practices although international migration especially of workingage groups and children may help alleviate rural population decline asylum seekers ability to stimulate the economy in municipalities strained by outmigration is understudied a soc sci 2023 12 403 6 of 20 particular question therefore divides demographers ie to what extent can the inflow counterbalance outmigration from rural areas in recipient countries some argue that international migration does revitalize rural communities while others disagree for rural municipalities in dalarna in midsweden scholars have shown that despite mounting pressure on education and housing the influx of asylum seekers in 2015 was an energy boost to schools and an opportunity to vitalize both rural and civil society even if asylum seekers may later leave rural areas we propose that they may serve as a demographic opportunity for dwindling rural communities whether that opportunity will materialize into longterm benefits will depend on political willingness in the municipality the strength of the local economy and successful integration to better conceptualize if and how asylum seekersgrantees succeed or do not to establish a livelihood in a rural community with little or no previous experience of migrants from the global south woods refers to rural versus precarious cosmopolitanism from the 1970s the small irish community of ballyhaunis had a high influx of inhabitants from asia and the middle east in the economic crisis of 2008 their comparatively successful establishment in this small remote community turned from rural to precarious cosmopolitanism due to economic contraction and lost job opportunities not least for migrants a similar pattern was seen in the small irish community of gore with a high share of migrants from brazil and on the norwegian island of herøy drawing on interviews about the reception of asylum seekers in sweden exemplified by the city of malmö fry and islar argue that successful integration of asylum seekers should build on extended collaboration between civil society and municipalities and be based on inclusive practices rather than on the outsourcing of welfare services from the municipality to civil society in our study we confirm that inclusive practices are important for integration also in rural society three strategic action fields political regime municipality and civil society to understand social change and continuity it is helpful to speak of social order and strategic action fields referring to how individuals groups and organizations interact in relation to structures and institutions social order can foster community consensus and belonging but also produce and reproduce oppression and resistance resulting in tension or conflict interaction occurs within and between collaborating and competing strategic action fields inhabited by incumbents protecting the dominant social order and challengers resisting it incumbents repeat and institutionalize their practices to stabilize their field while challengers seek to disrupt it transform it or pave the way for competing strategic action fields apart from defining the fields and their actors features stakes and discursive and material skills and tools it is important to identify how strategic action fields react to external incidents and shocks like the 2015 inmigration taking governments by surprise inspired by this theory we identify three strategic fields the national political regime the recipient municipalities represented by politicians and officials and civil society the national political field is primarily driven by regular elections the outcome of which determines the mandates for governing the economy and society at large including how to regulate migration asylumseeking labor market institutions and various integration support systems similarly the political mandate in municipalities is determined by local elections following campaigns while officials act and perform based on rules and regulations set by politicians at multiple scales the composition and power of the national political regime and the political representation of municipalities are determined by rhetoric narratives and discursive tools that political parties use in national regional and municipal election campaigns followed by elections and the political mandate resulting from that in contrast civil society organizations are driven by benevolence and trust and they design their activities in line with their respective ideology and mission while still being flexible primarily this field is driven by members everyday practices initiatives participation and experiences the emergence of populism as a fourth strategic action field in response to the huge inmigration in 2015 the national political regime in sweden decentralized and delegated the responsibility for asylum seekers housing and schooling to municipalities in turn it outsourced an increasing share of its responsibility for various welfare services to civil society actors who also actively engaged in the immediate reception of asylum seekers this quick and resolute response is documented in both urban and rural settings in 2015 when the pressure on housing health services and schools increased civil society organizations admitted the stress while asserting that the situation was manageable they maintained and even intensified their capacity to keep a consistent humane attitude towards and practices for successful integration in parallel populist views and voices increasingly challenged the incumbent national political regime on the generous migration policy this triggered a drastic change not only in the rhetoric around migration but also towards stricter migration policies with regulations and border control resulting in a dramatic decline in asylum seekers from november 2015 in national politics the 2015 inmigration was soon framed as a problem and a crisis in response to the massive media coverage reporting on the shortcomings of authorities and the pressure on the welfare system but many authorities and municipalities who worked under increasing pressure did not report any collapse of routines or regulations the crisis rhetoric did not change attitudes in society more profoundly however given the spread and strength of populist antimigration sentiments we consider this to be a serious challenge and thus an emergent strategic action field it is well organized with strong transnational ties notably in france germany hungary italy and the nordic countries and driven by antiestablishmentarianism in contrast we see civil society as part of the generous incumbent regime rejecting the antimigration sentiments promoted by populism here we propose that populism as an emerging fourth field will succeed only if it also has the capacity to transform civil society civil society civil society can be defined as a space at the nexus of society the economy and the private sphere where citizens work together towards what they perceive as the common good importantly civil society is an arena separate from the state the market and the individual household where people groups and organizations act together for the common good and interest based on ideology or a particular mission they seek to contribute to social development and problemsolving in relation to both people and municipalities this echoes an old and widely held assumption spanning from tocqueville tönnies and durkheim to putnam that civil society participation is conducive to social trust even if empirical evidence is weak this assumption seems valid at the aggregate level of nations while putnam famously described a drastic decline in social capital in the usa since the 1950s assessed through participation in civil society rothstein found no evidence for such a decline in sweden neither in trust nor in participation recent research shows that sweden and norway stand out with high steady or even increasing participation in civil society organizations around 50 percent of the population participate in at least one civil society association further in the year before the asylum crisis the total value of voluntary work in sweden was estimated at 131 billion sek representing 332 of gdp an exceptionally high share in a european context swedish civil society is wellanchored it is characterized by a corporatist model wherein negotiations and joint decisionmaking occur in an institutionalized alliance with the state historically civil society organizations were already crucial in building expanding and strengthening the welfare state from the late nineteenth century onwards in the postwar era 19501970 they facilitated the integration of migrant workers from nordic countries mainly finland and from southern and eastern europe again in the 2015 asylum crisis in europe civil society played a crucial role in the reception and integration of asylum seekers in sweden as documented by authorities and scholars however social relations are changing toward becoming more pluralistic and less institutionalized in addition economic support has shifted from unconditional grants to shortterm contracts the role of civil society has also been characterized by increasing uncertainty regarding the division of responsibilities between different levels and spheres especially since a major reform in 2010 in line with neoliberal politics certain subcontracted civil society organizations now act as alternative providers of welfare services such outsourced publicly financed services are increasing in every welfare sector voluntary immigrant organizations are found in most countries and represent a special type of civil society organization worth mentioning each of them draw their members from a particular country or region and specialize in assisting migrants in language training administrative support facilitating communication with their country of origin religious services and employment seeking in sweden some 52 such organizations are active in various ways in supporting integration theoretically we would refer to them as providers of strong rather than weak ties but empirically they are part of the civil society support system for migrants importantly policymakers pay more attention to civil society organizations as arenas for dealing with social challenges and promoting integration in many municipalities the local government is increasingly engaging in partnerships to support hobby clubs as a medium to foster communal values social integration and welfare provision moreover state funding has been directed specifically to actors providing sports activities and language education in line with that state funding to civil society organizations increased by euro 20 million to compensate for all voluntary work in 2015 although hobby and sports clubs are praised as integration tools in the policy field scholars caution against idealization by pointing to issues of exclusion and racism studies have shown that norms in hobby clubs may cause a sense of alienation among minorities especially if integration translates into assimilation focusing on eliminating differences and making minorities integrate into the majority similarly research on the role of hobby clubs in denmark shows that there are situations where these can be criticized for reproducing established political goals rather than opening for multiple voices this shift in civil society activities from voice to service is mentioned widely in the literature and scholars have expressed concerns regarding the weakened democratic role of civil society when civil society increasingly provides public services its role in advocacy and resistance runs the risk of becoming weakened or depleted yet research also shows that advocacy activities among civil society organizations continue to be strong not the least concerning migration the church of sweden is engaged in issues associated with asylum rights and can use its institutional role and resources to engage in swedish politics in a survey of 2791 swedish civil society organizations researchers found a deepseated advocacy culture exemplified by hobby clubs establishing relations with municipal decisionmakers as an advocacy strategy further scholars conclude that recent changes in funding arrangements and expectations of civil society organizations as increasing service providers do not put the culture of advocacy at risk instead advocacy remains a cornerstone of the swedish model to sum up civil society organizations unite on the national level through federations and umbrella organizations the municipal level constitutes the main arena for their activities and mobilization of resources whereas the european level adds a complementary layer of opportunities in multilevel governance nevertheless the development towards a pluralistic political system is influenced by eu membership and reflects a europeanization of swedish civil society methodology this study is explorative striving to be explanatory in a mixed methods approach we combine a qualitative content analysis on migration in localregional media with a quantitative survey on reception integration and attitudes towards migrants sent to civil society organizations based on our preunderstanding of national and regional migration politics and swedish demography we identified three types of rural municipalities with potentially different interests resources and capacities to integrate asylum seekers in these geographically dispersed and purposively selected municipalities we study how attitudes towards initiatives on and inclusive practices to support integration correlate with the demographic profile political majority and socioeconomic structures to deepen our understanding of public opinion and sentiments towards migration and migrants in various settings we conducted a content analysis of local media reports in doing so we are particularly interested in demographic structure employment opportunities and if and how the profile of the local political regime influences the interest and ability of civil society to engage with migrants for the media analysis we selected one unit of analysis for each type one dwindling in the north of sweden one dynamic in the central south and one dissenting in the very south below we describe the types and their corresponding units dwindling dynamic and dissenting municipalities type 1 small dwindling municipalities in need of a growing population to keep up private and public services we assume that these municipalities seek demographic opportunities and are willing to receive any migrants they are mainly located in the sparsely populated north of sweden dominated by an economy of smallscale agriculture and forestry here exemplified by åsele in jämtland county they have undergone a steady demographic decline since the 1980s and generally have a low percentage of foreignborn inhabitants since the 1950s jämtland county has been best described by outmigration until a recent trend reversal thanks to international migration type 2 small dynamic municipalities in need of labor we assume these municipalities adhere to rural cosmopolitanism and are willing to receive migrants especially skilled workers they are characterized by an entrepreneurial spirit and smallscale industries in need of labor they are mainly located in sparsely populated areas in southern sweden here exemplified by gnosjö in småland county the population has increased steadily since the 1980s and has a rather high percentage of inhabitants born outside sweden mainly in the middle east type 3 small and welltodo municipalities dominated by antiimmigration politics we assume that they are unwilling to receive migrants and therefore call them dissenting municipalities yet to balance such antimigration sentiments we assume that there may be counteracting forces that promote inclusive practices they are mainly located in comparatively densely populated southern sweden here exemplified by sjöbo in skåne county receiving migrants from many parts of the world such municipalities have a in line with this typology we started with a content analysis of news media articles from localregional newspapers covering the three selected municipalities in 20092019 the objective was to screen attitudes and how local politicians and populations frame immigration integration and civil society for that we systematically analyzed how these issues are discussed in debate articles by local politicians editorials letters from the local population and news reporting articles in the media analysis we asked the following question • how do local politicians and populations frame immigration integration and civil society activities relating to these issues guided by the insights from our media analysis we sent out a survey to civil society organizations in the three municipalities later followed by a wider distribution to include civil society organizations in all 290 municipalities in sweden the objective here was to learn more specifically if and how civil society organizations engage in various activities to promote integration in the survey we asked • how is civil society active and important in integrating asylum seekers and what kind of civil society actors are most or least engaged • how does civil society engagement vary with the demographic political and socioeconomic conditions of the municipality as a starting point for analyzing the survey results we categorized all 290 municipalities into our three types and analyzed the responses from civil society organizations accordingly our categorization is specified by the following quantitative and qualitative criteria • dwindling small municipalities with a declining population from 2010 to 2020 and with comparatively high unemployment • dynamic small to mediumsized municipalities with comparatively low unemployment • dissenting small to mediumsized municipalities with a strong antiimmigration political party after the survey and to identify more profoundly how civil society interacts with migrants we supplemented our database on demography we added data on the percentage of inhabitants born outside sweden including changes in these numbers since 2010 concerning politics we added percentage votes in the 2018 election for all political parties concerning the socioeconomic dimension we added data on the percentage of unemployed divided into three categories swedishborn foreignborn and total guided by insight from the media analysis and survey we asked two related questions • why is civil society in terms of attitudes and activities expressed in actual practice and in the responses to the eu 27 in 2021 much more positive towards migrants than swedens restrictive migration policy • why is there a discrepancy between national restrictive migration politics and municipally based civil society activities and attitudes towards migrants materials media analysis to identify how ideas and perceptions about immigration vary between actors in the period of 20092019 we analyzed a total of 386 articles on immigration from local newspapers in three municipalities åsele gnosjö and sjöbo the newspapers were accessed in pdfformat from the database bibsam through lund university we used the nvivo software for the extraction and analysis of the relevant texts eleven codes were used that we had either predetermined as sensitizing concepts for the search or classified as reoccurring themes in the analysis business civil society other than sports civil society sports criminality culture demography economy employment health housing and school for every code we categorized texts according to type such as debate article by local politicians editorial letter from the local population and news reporting article survey of civil society organizations we developed a webbased survey that asked 72 questions 21 of which were followup questions made visible when respondents chose certain answers migrants were people who have been granted residence permits in the last two years it started with questions aimed at identifying organizational characteristics followed by general questions on migrants engagement and involvement in the organization such as whether migrants are currently engaged in it and how whether parents to migrants are involved and general attitudes towards involving migrants in the organization it then turned to practices and strategies that organizations used to reach out to migrants after that the survey posed questions about useful skills and knowledge gained from both sides from migrants involvement as well as experienced or potential obstacles to including migrants here we asked whether members have increased their knowledge and understanding of different experiences and living conditions we then moved on to questions on the organizations relationship with the municipality ie the elected regime and its officials and whether involving migrants has affected the relationship lastly we asked about the effects on activities due to the covid19 pandemic in sweden civil society organizations can receive municipal funding and are subsequently listed in a municipal register with contact information we sent the survey via email to organizations in all 290 municipalities in sweden in each municipality we selected organizations that could be expected to engage with migrants in business culture education sports and outdoor recreation or who have an ethnic religious or humanitarian profile or any other relevant community orientation we reached out to 12774 organizations and received 1338 responses thus a response rate of just over 10 percent the survey was open for one month the actual response rate is probably higher than 10 percent because some contacted civil society organizations may no longer exist or had changed the contact person at the time of the survey respondents were anonymous but the survey offered the option of providing contact details for followup interviews the full breakdown in groups is shown in supplementary s2 but in short sports clubs clearly dominated the responses followed by cultural religious and outdoor organizations for the analysis we downloaded data from the survey into spss files we generated descriptive statistics using frequency tables and crosstabulations to depict general trends and themes in respondent data while considering highlights from the media analysis we corroborated the survey data with three selected dimensions of municipality data we then used the three dimensions to categorize municipalities into the three types of dwindling dynamic and dissenting finally we tested for differences in responses between three categories of municipalities based on size small mediumsized and major cities the survey questions are listed in supplementary s1 in supplementary s2 we give a full breakdown of the number of responses from different types of civil society organizations and a formal definition of the three types of municipalities the statistical details of our analyses are found in supplementary s3 tables s1s3 the newsmedia analysis there was a significantly higher number of newspaper articles on sjöbo indicating that migration is a contested issue there and high on the political agenda in all three cases the economic aspect is debated the most the code economy is most frequent in sjöbo followed by åsele and gnosjö among local politicians there are strong ambiguities about the economic effects of migration reception as regards negative sentiments both local politicians and the local population point to increasing tax expenditures resulting from the influx of migrants with a general understanding that the costs for receiving migrants are too high in contrast local politicians who oppose the highcost argument claim that the integration processes should be improved and supported since every new inhabitant is a potential new taxpayer adding revenue to the municipality we see a clear difference in how economic implications are discussed in the three municipalities economy articles in åsele are mainly positive debate articles and letters the arrival of migrants is described as a vitamin injection as something to embrace a possibility for growth rather than a burden and a muchneeded addition to the workforce articles from both åsele and gnosjö discuss forms of employment training programs and their positive effect on integrating migrants into the local industry and workforce regarding education sjöbo articles mention various school forms for adult migrants that may more easily enable integration into the labor market investing in this is important since the migrants will become an important future resource for the municipality at the same time there are negative sentiments around employment in news coverage interviews the local population expresses a sense of perceived unfairness that migrants steal the jobs from local inhabitants similarly negative sentiments relating to housing are reflected in an editorial about house owners who oppose the construction in their neighborhood of accommodation for unaccompanied migrant children in åsele and gnosjö limited access to housing is seen rather as hampering the reception of asylum seekers some articles about sjöbo mention initiatives to combat prejudices and racism in schools this suggests that while sjöbo in several ways is a hostile environment for migrants there are counteracting forces the media analysis suggests that civil society in the sjöbo region holds an antiracist position and that several initiatives are explicitly working against xenophobia and hate crimes similar articles are not found in the other municipalities which we interpret as a sign of an overall positive attitude towards migrants in those yet none of the articles coded as civil society are classified as debate articles suggesting that local decisionmakers may lack interest in using civil society as an arena to improve integration civil society is mentioned more often in gnosjö articles than in those on sjöbo or åsele the media analysis also suggests that gnosjö has a strong civil society both within sports and other areas in contrast to sjöbo newspaper articles from gnosjö frequently point out civil society as important for the integration process in interviews and debate articles local politicians attributed the successful integration of migrants to civil society actors who collaborated with the municipality here civil society initiatives range from sports activities to language cafés dance classes and friendship matchings articles from åsele do not mention civil society initiatives much none was coded as civil society other than sports and only one article was coded as civil society sports when it is mentioned the sentiment is positive and emphasized as a good way to integrate newly arrived children this might suggest that while there is a generally positive attitude towards the reception and inclusion of migrants through civil society the demographic decline means limited resources for civil society to mobilize and perform welcoming initiatives local newspapers in åsele state that the arrival of migrants is positive for the local demography according to local politicians and the local population and regularly expressed in debate articles the influx of migrants offers a solution to the municipalitys sharp demographic decline thus a demographic opportunity all six articles coded with demography articulate the positive effects of inmigration news coverage articles present statistics on the population trend and editorial letters along with letters from the local population express generally positive sentiments in gnosjö letters from the local population point in the same direction as in åsele stating that the arrival of migrants is positive and an opportunity for demographic and economic growth thus a sign of rural cosmopolitanism representatives of the local industry point out in interviews that the influx of migrants is necessary for the survival of the industry in sjöbo two news coverage articles mention the positive demographic effect attributing the growth of some rural municipalities in skåne county to the arrival of migrants three key media insights three key insights on migration and integration emerge from the media analysis one for each type of municipalitydwindling dynamic and dissenting we interpret the insights based on the theory and concepts we presented above åsele the small municipality with a dwindling population in the sparsely populated north is unanimously positive to inmigration and asylum seekers but seems to lack resources to mobilize impactful initiatives to seize the full demographic opportunity that international migration offers yet civil society is still an important actor that can potentially offer the weak ties that may foster integration gnosjö the small dynamic and entrepreneurial municipality in a sparsely populated area in the south is positive to inmigration the community celebrates civil society initiatives and attributes successful integration to civil society actors and their activities thus like above a sign of the strength of weak ties but dissent is brewing perhaps more in speaking than acting and can probably be attributed to a slowly increasing unemployment rate hence this situation may trigger a shift from rural to precarious cosmopolitanism sjöbo the small dissenting municipality situated in the rural and comparatively rich agricultural region in the south has a strongly negative attitude to asylum seekersbut civil society is trying hard to challenge the dominant view of the political establishment one key task for civil society is to oppose the hostile environment towards migrants by explicitly addressing racism and xenophobia and promoting counteractive initiatives and inclusive practices again a sign of how the weak ties between civil society organizations and social groups can be used to strengthen the support for migrants and by its extension their integration into the municipality the survey of civil society organizations overall and regardless of geographic location or type of municipality we found that civil society organizations in sweden have a very positive attitude towards migrants what is the attitude towards the participation of migrants in your organization 97 positive or very positive 1 neutral and 2 negative of the organizations with the active participation of migrants they are seen as an asset by almost 80 migrants from different cultures are an asset for your association agree 79 neutral 18 disagree 2 organizations also recognize the importance of participation in civil society for the integration process association life in general is important for the integration of migrants agree 81 neutral 16 disagree 3 regarding participation we found that on average 38 of all organizations reported that migrants are currently active in their association we found a significantly higher participation in the large cities compared to small and mediumsized ones among rural municipalities the participation was significantly higher in dwindling municipalities than in the dynamic and dissenting ones on interaction with the politicians and civil servants in the municipality we found that civil society organizations report that they have a good or very good relationship how would you describe the associations relationship to the municipality positive 67 neutral 23 negative 10 there was a significant difference in responses based on the size of municipalities where small and mediumsized municipalities more often reported a good or very good relationship compared to major cities the financial support to civil society organizations for integration activities did not vary significantly across small municipalities to major cities if we break down the responses based on faithbased and nonfaithbased organizations we find several significant differences regarding their attitudes and engagement with migrants the analysis shows that faithbased organizations have significantly more favorable attitudes toward migrants than nonfaithbased ones they also engage migrants and their parents much more often than nonfaithbased organizations in addition faithbased organizations are much more active in recruiting migrants and parents of migrants and receive financial support for this more often compared to nonfaithbased organizations the positive attitude held by christian organizations confirms arguments about the church of sweden in previous studies getting a job is important but often difficult for firstgeneration migrants employment can therefore be seen as an important indicator of integration however there is no significant relationship between levels of unemployment in the municipality and organizations attitudes towards migrants nor with their levels of participation in civil society we tested both for employment in general and for the difference in unemployment between people born in and people born outside of sweden there are some highly significant differences between the three types of rural municipalities in dwindling municipalities civil society organizations engage migrants and their parents much more frequently than in the other municipalities particularly compared with the dissenting ones attitudes towards migrants show some differences between the three types even though the significance is low civil society organizations in dwindling municipalities have more positive attitudes than those in either dynamic or dissenting municipalities in dwindling municipalities civil society organizations are also more actively working to recruit migrants than in dynamic or dissenting municipalities the financial support given to civil society organizations for integration activities does not vary significantly across the three types of rural municipalities civil society organizations in the three types of municipalities responded differently to the question do you feel that the municipalitys goals for integration and your goals for integration agree due to few responses we could not see if there was any significant difference but the response ranged from 58 in dwindling to 31 in dissenting municipalities three key survey insights three main insights emerge from the survey one referring to attitudes another to integration and the third to interaction first as regards attitudes it is clear that at large civil society organizations have an overwhelmingly positive or even very positive attitude towards asylum seekers and their participation in organized activities this is confirmed by and reflected in the eu27 barometer previous research has also shown that emerging social relations between civil society and asylum seekers facilitate integration second as regards the integration of asylum seekers into swedish society organizations trust that civil society itself has the capacity skills and discursive tools to contribute decisively to facilitate that process and that they also should do so this is particularly clear among faithbased christian organizations as seen in other studies moreover it echoes the governments effort to decentralize responsibility to civil society organizations by giving them the mandate to provide certain welfare services it is evident that civil society seeks to live up to this a profound study on rural municipalities in dalarna sweden shows that civil society was central in assisting the public sector and creating social relations with asylum seekers that study identified three types of civil society units engaged in the reception and integration of asylum seekers new ad hoc groups emerging as a spontaneous response established organizations with previous experience from working with asylum seekers and hobby clubs attracting and recruiting members while some of these organizations were involved in the reception and immediate needs of asylum seekers or in serving as a bridge to the municipality others such as sports clubs activated new members third as regards interaction between strategic action fields the dynamic between civil society organizations and the municipality is working well according to respondents and it is characterized by a division of labor and mutual trust rather than competition or conflict the level of financial support from municipalities does not vary between types of municipalities not even in the dissenting ones to conclude here with increasing financial means civil society organizations would have the potential to improve their material resources and tools even further in the results from the survey sent to civil society organizations there are no signs of or any support for the dramatic shift of asylum politics that emerged and was implemented in late 2015 in the aftermath of the wave of asylum seekers civil society organizations responding to the survey did not report any support for antiimmigration sentiments or policies despite increasing municipal representation of political parties with antiimmigration policies in the 2018 election nor did the profound study on dalarna identify any antimigration sentiments it would be interesting to initiate a followup study on this for the 2022 election where populist parties increased their mandate even further and at all scales discussion and conclusions civil society in europe is central to democracy and legitimacy in the eu this is evident in sweden the division of labor between the swedish state municipalities and independent public agencies requires a strong capacity and competence to network cooperate and coordinate activities in times of social change it has been confirmed that civil society organizations together with individual volunteers developed an impressive collective ability to assist asylum seekers and government agencies in the acute phase of inmigration in 2015 and the subsequent integration with that it became evident that civil society organizations are important even necessary in the reception of migrants after 2015 many municipalities continued their collaboration with civil society organizations and considered them to be equal and vital partners in community work in difficult times we may therefore expect that civil society organizations will again reinforce their agency to facilitate social integration as suggested by the oecd in 2016 and reiterated by the eu commission in 2020 as a foundation for that swedish authorities have declared that migration is part and parcel of global society and that a rapidly increasing migration flow is not a threat to society or the welfare system in and of itself even if the situation may become very strained this is also confirmed in research in line with that we have seen that civil society organizations express overwhelmingly positive attitudes toward migrants while we found that civil society organizations of varying profiles have a positive or even very positive attitude towards as well as active engagement with migrants it is a further observation that faithbased organizations stand out as even more engaged than nonfaithbased organizations in the aftermath of 2015 from that we now confirm that weak ties provided by acquaintances play a decisive role in social change in terms of paving the way for employment integration and mobility among asylum seekers admittingly strong ties also play a positive role despite such strong civil society engagement in the integration process and despite the positive attitude towards migration and migrants among people in sweden as reflected in the eu barometer 2021 it is notable that sweden shifted towards strict migration politics and restrictive asylum regulation starting at the end of 2015 the remaining question is therefore why did sweden make a drastic shift to restrictive migration politics and how come civil society organizations challenge this according to one visible observation the massive media attention to the asylum crisis served as a trigger for the shift another and politically more precarious reason was the immediate threat of a government crisis pushed forward by the populist party that wanted an end to the influx of asylum seekers to which the government responded forcefully by reintroducing border controls a further and more profound observation points to how established political parties in the eu had not responded in time to a growing discontent concerning the crumbling welfare system creating a political opportunity for rightwing populist parties to gain political influence based on the rhetoric of a faltering welfare state in some countries populists successfully created new parties in other countries they were able to coopt existing parties and gain electorate support by skillfully using the discursive tool of tying the welfare issue to migration thereby step by step making asylum seekers into scapegoats and a threat to the whole system since 2015 the electorates support for populist parties propagating antimigration policies has been growing general elections in sweden in 2018 and 2022 resulted in a substantial increase in the number of municipalities with a strong representation of the antiimmigration party sweden democrats from their low influence before 2018 and almost negligible position before 2014 the party became the second largest party in the national election in 2022 since then it has been represented in the governing majority of 34 out of 290 municipalities holding the chair in ten of those in seeking an answer to how this increasing political resistance to migration impacted civil society organizations we tested for a relationship between sd representation and variables related to attitude towards and involvement of migrants both in a local news media analysis and a survey of civil society organizations however none of the variables differed significantly between municipalities with high or low sd representation therefore we conclude that civil society organizations keep a positive attitude towards migrants irrespective of the political support for sd in their municipality hence we do not see many signs of how the emerging populist regime ie the challenger of the incumbent regime is capable of penetrating civil society organizations below we seek to explain the discrepancy in attitudes towards migrants between civil society and the antimigration policy reflected in the elective vote speaking of the core social science concepts of structure and agency it is evident that multiple interacting agents use a range of resources and skills to act with and against others in the context of structures and institutions in doing so agents are empowered by access to discursive and material resources and their agency builds on the capacity to interpret and mobilize these resources in a variety of ways the agency also varies with incentives and motives and depends on the capacity to draw on complex repertoires to engage creatively in interaction the increasing elective support in sweden for political parties with antiimmigration policies on their agenda can be seen as a discursive structure or an emerging strategic action field not yet fully consolidated it is not stable enough to withstand the challenges posed by civil society organizations that use their own agency to explicitly express willingness to engage with migrants in support of integration and who do so via inclusive practices there are several intertwined reasons for this first civil society organizations tend to be driven by benevolent principles to serve a particular ideology practice or social goal they also tend to advocate social interaction and belonging like that in faith communities and hobby clubs what the sociologist ferdinand tönnies would call gemeinschaft second it is obvious that civil society cannot compensate for all the municipal and regional services that are needed and expected to be provided by state authorities at multiple scales services may be missing or in short supply in many municipalities especially in dwindling ones be it in health care schools transport or communication hence rural municipalities have reasons to attract migrants and seem to engage more strongly than big or bigger cities to support civil society organizations this is probably grounded in the incentive and intention to grasp the demographic opportunity meaning that an increasing migrant population of working age or younger can help a municipality to keep or expand its welfare services through work and taxes by drawing on the theory of strategic action fields we can conceptualize and better illustrate the relationships between the three active fields in this debate the national political regime the municipality with its officials and civil society organizations by discussing their roles and interaction we will get closer to explaining the discrepancy between the antimigration politics seen as a discursive structure and the practiced agency of supporting the reception and integration of asylum seekers one way to do that is to conceptualize populist antimigration politics as a severe challenge to the incumbent regime of generous migration politics and thus an emerging strategic action field political parties create narratives based on three main components partyspecific ideology particular signifiers and symbolic reasoning appealing to voters thus offering a partial and ideologically biased description of reality narratives are presented by party representatives and diffused through a range of communication channels and political campaigns political constituencies respond to the narratives in their voting behavior once every four years it should be noted that political parties can change rules regulations and financial conditions but have a very limited mandate to change how civil society organizations operate apart from the time of elections most individuals are passive in relation to municipality politics while many are engaged in civil society while political parties rely on votes only once every four years civil society organizations consolidate their existence based on participation and by attracting individuals including migrants to engage actively regularly and continually in all sorts of activities and practices to conclude we argue that populism has limited persuasive power in effectively spreading antimigration sentiments and their antiestablishment program when civil society as a profoundly grounded yet flexible institution acts as a counterweight by doing good for society institutional review board statement ethical review and approval were waived for this study because no questions of personally sensitive issues were involved all questions of the survey refer to civil society organizations and not to respondents informed consent statement not applicable data availability statement data can be made available upon request supplementary materials the following supporting information can be downloaded at supplementary s1 survey questions to civil society representatives in all 290 municipalities supplementary s2 descriptive statistics of the survey and formal definition of the three types of municipalities supplementary s3 cross tabulations of the survey results supplementary s4 descriptive statistics of the media analysis

the dramatic increase of asylum seekers entering the eu in 2015 profoundly changed migration politics in many eu countries not least in sweden which accepted more migrants per capita than any other eu country but then swung abruptly to become among the strictest recipient countries we use sweden as a critical and extreme case to argue that the rapid shift in asylum politics and public opinion towards migration is not profoundly shared in society based on a local media analysis of three types of purposively selected rural municipalities followed by the analysis of a survey of civil society organizations sent to all 290 municipalities in sweden we find strong civil society support and willingness to both receive migrants and facilitate their integration into society despite increasing votes for political parties with antimigration policies we also find remarkably positive attitudes towards migrants in civil society organizations and among citizens in the eu27 barometer for sweden the upshot is optimism that civil society can balance the antiimmigration governance imposed by both left and right political regimes and that populism will succeed only if it has the capacity to thoroughly transform civil society attitudeswhich we doubt

introduction mental disorders are among the leading causes of disability and disease worldwide and estimates suggest a higher burden of mortality among individuals and populations with mental disorders 12 across the european union mental illnesses have been reported to affect more than one in six adults and the social and economic costs are substantial 3 the strong positive relationship between mental distress and mental disorder and the strong negative relationship between mental distress and mental wellbeing 4 underlines the importance of identifying modifiable factors that may prevent development of mental distress and mental illness in the general population healthy lifestyle behaviors such as higher levels of physical activity have been associated with reduced risk of mental distress 5 moreover evidence reported by research literature reviews suggest a doseresponse relationship and that any level of physical activity seem to decrease the risk of developing depressive symptoms 67 observations among a representative sample of canadian adults have confirmed a doseresponse relationship between objectively measured physical activity and improved mental health but also suggested that physical activity and mental health associations could be hampered by daily sedentary time 8 a positive association between sedentary time and mental distress independent of physical activity level was also confirmed by a crosssectional study among belgian adults 9 in addition studies have identified short sleep duration as a risk factor for depression 1011 and mental distress 12 and that sleep distrubances are independently and strongly associated with poor healthrelated quality of life in middleaged and older adults 13 involvement in organized activities such as cultural engagement and participation in sport has also been suggested to be an independent riskreducing factor for development of depressive symptoms 1415 further as involvement in social organized activities seemed to predict both higher quality of life and lower levels of depressive symptoms 16 development and maintenance of organized sport and recreational activities that are socially and culturally relevant has been supported 17 several studies especially among elderly have also confirmed that social support plays an independent and important role in enhancing and maintaining improved mental wellbeing 18 19 20 21 further results indicating a significant association between social support from friends spouse or relatives and reduced odds of panic disorder and mental distress especially when the severity of mental health problems are low highlights the importance of social networks and support 22 on the other hand a crosssectional register study among danish adults showed that individuals with less frequent social encounters than desired and those with less contact with family and friends than once a month had increased risk for poor mental health 23 most previous studies investigating associations between modifiable lifestyle behaviors participation in organized activities social support and mental distress are hampered by low participation rate low quality of the studies and focus on few explanatory factors of mental distress 52425 thus the present study contributes to the existing literature by examining possible associations between a range of modifiable factors including low level of leisuretime physical activity high sedentary time low participation in organized activities low social support sleep problems and mental distress among a large sample of norwegian adults methods participants and procedures the present crosssectional study was part of the norwegian counties public health surveys designed to collect information about healthrelated behaviors health wellbeing and quality of life among the adult population across norway 26 for inclusion in the present study a random sample of 75191 adults from all 30 municipalities in southern norway was drawn from the national register of these a total of 10862 had actively reserved against participation in surveys in the contact and reservation register and was removed from the sample after further removal of deceased individuals those registered with unverified contact information or address outside the included municipalities a total of 61611 residents were invited by sms and email to participate in the present study written and oral information about the study was provided to invited participants and through official webpages and social media six random participants each received a gift card worth 4000 nok a total of 28047 adults agreed to participate all participants gave their consent by filling out an online consent form and proceeded by filling out an online selfreport questionnaire between september and october 2019 approximately 15 min were used to complete the study participation in the present study was voluntary and all participants had the opportunity to withdraw from the study at any time the national institute of public health was responsible for collecting and anonymizing data independent researchers who did not participate in the data collection process or had access to personally identifiable information analyzed the data the norwegian institute of public health holds legal responsibility for the public health survey and the study was conducted in line with the declaration of helsinki ethical approval and research clearance were obtained from the ethical committee at the university of agder measures all questions response alternatives and variable definitions used in the study are presented in table 1 participants with mental distress were identified using the short version of the hopkins symptom checklist which has proven to be a valid and reliable instrument developed from the original 25item version to measure symptoms of anxiety and depression 2728 each of the five items used to measure mental distress were coded as follows not bothered a little bothered somewhat bothered or extremely bothered the total score of the hscl5 was calculated by adding the points from each item and divided by the number of questions participants who did not respond to all five hsclitems were excluded from analyses further the variable was dichotomized and a validated cutoff score of 20 was used for identifying participants with mental distress 27 leisuretime physical activity level was assessed by asking three questions reflecting frequency intensity and duration the data were processed as follows frequency of physical activity was assessed by the question how often do you usually exercise the response alternatives were coded never less than once a week once a week 1 23 times a week 45 times a week and approximately every day duration was assessed by the question for how long do you usually exercise each time the response alternatives were coded less than 15 minutes 1529 min 22 30 minutes1 hour 29 and more than 1 hour finally intensity was assessed by the question how hard do you usually exercise the response alternatives were easy without being short of breath or sweaty being short of breath and sweaty or almost completely exhausted further data reflecting frequency duration and intensity of leisuretime physical activity were combined to identify individuals who achieved the who recommendations of at least 150 min of moderateintensity aerobic physical activity or at least 75 min of vigorousintensity aerobic physical activity per week 30 information about sedentary time was assessed by a single question identifying hours of sedentary time per day a cutoff of ≥8 h were used based on results from another study showing that adults who spent less than 8 h per day sitting were less depressed and anxious and had higher levels of vitality compared to those who spent more than 8 h per day sitting 31 in the present study involvement in organized activities was measured using two questions reflecting frequency of participation in different activities and the response alternatives for both items were coded as follows never or rarely 13 times per month 1 weekly or daily 2 total score for involvement in organized activities was achieved by adding both items which resulted in a score from 0 to 4 points further the variable was dichotomized and 2 points was used to identify participants with low involvement in organized activities the oslo social support scale is a brief and economic instrument to assess the level of social support and consists of three items that 1 reflect the number of close confidants 2 the sense of concern from other people and the relationship with neighbors and 3 the accessibility of practical help response alternatives for the first item were coded as follows no one 12 2 35 3 and 6 or more 4 for the second item the response alternatives were coded no interest little interest 2 neither great nor little interest 3 some interest 4 great interest 5 finally response alternatives for the third item were coded very difficult difficult 2 neither easy nor difficult 3 easy 4 and very easy 5 the total score of the oss3 was calculated by adding the points from each item in line with previous research 32 a score 12 was used to identify participants without strong perceived social support in the present study referred as low perceived social support sleep problems were estimated by a single question focusing on subjective experience of having sleep problems the past week the four response alternatives ranged from not bothered to very much bothered participants reporting pretty much bothered and very much bothered were considered having sleep problems in the present study information about age and gender was obtained from the central population register age was used as a continuous variable information about perceived financial situation was used as a proxy for socioeconomic status the response alternatives very difficult and difficult were used to identify participants with perceived financial difficulties statistical analyses pearson chisquare tests were used to identify differences in financial situation mental distress leisure time physical activity sedentary time participation in organized activities social support and sleep problems and independent sample ttest was used to analyse differences in age between men and women pearson chisquare tests were also used to identify differences in mental distress between men and women with low leisuretime physical activity high sedentary time low participation in organized actives low social support and sleep problems further crude multivariable logistic regression models and models adjusted for age and perceived financial situation were used to investigate possible associations between low level of leisuretime physical activity high sedentary time low involvement in organized activities low social support sleep problems and mental distress separate models were presented for men and women pearson correlation tests revealed low pairwise correlations between independent variables in the models indicating that multicollinearity was not present dataanalyses were performed using ibm spss version 25 and the level of statistical significance was set to p 005 results the sample comprised 13122 men and 14925 women in which a total of 1538 men and 2256 women reported mental distress respectively compared to women a higher number of men reported high sedentary time low participation in organized activities and low social support whereas a higher number of women than men reported to have sleep problems no gender differences in leisuretime physical activity were identified among individuals with low leisuretime physical activity and high sedentary time a higher proportion of women than men reported mental distress likewise among individuals with low participation in organized activities and low social support a higher proportion of women than men reported mental distress our results revealed no gender difference in the association between sleep problems and mental distress for men binary logistic regression analyses adjusted for perceived financial situation and age showed that the odds of having mental distress was increased among individuals reporting low leisuretime physical activity high sedentary time or 132 1 16 discussion results from the present crosssectional study showed an association between lifestyle risk factors and mental distress in a large sample of adults living in southern norway our study revealed an association between low leisuretime physical activity and mental distress but not for woman after controlling for possible confounders a previous metaanalysis confirmed that physical activity seems to reduce depression by a medium effect and anxiety by a small effect in nonclinical populations 33 and results from a thirteenyear prospective cohort study indicated that both light and moderate to vigorous leisuretime physical activity may play a protective role against mental distress 34 in line with our results another metaanalysis has reported that gender may modify the effect of physical activity on incident depression 7 whereas another metaanalysis has suggested that the potential protective association of physical activity on depressive symptoms and depression is similar for men and woman 35 the association between depression and physical activity appears to be bidirectional physical activity may prevent and alleviate depressive symptoms in the general population and in turn having depressive symptoms in early adulthood may be perceived as a barrier to physical activity 36 results from previous studies suggest that regular physical activity recruits a process which results in enhanced emotional resilience to stress 3738 however possible mechanisms explaining observed effects of physical activity on mental distress are most likely complex and might be manifested at psychological and neurophysiological levels 3940 further our results confirmed an association between high sedentary time and mental distress in both men and women systematics reviews have suggested a small positive association between sedentary time and symptoms of both anxiety and depression but also highlighted that only a few studies with partly inconsistent results had examined this relationship 4142 in addition previous crosssectional studies have confirmed an association between high sedentary time and mental distress 2943 a possible explanation for the observed relationship between sedentary time and mental distress is that high sedentary time may displace physical activity which has been shown to reduce levels of mental health problems 44 high sedentary time may also be an independent risk factor of mental distress as uninterrupted sedentary time seems to moderate and deleterious insulin sensitivity changes glucose tolerance and plasma triglyceride levels which indirectly could affect mood and wellbeing 45 research has indicated that participation in organized activities provide a sense of belonging value and attachment 24 and may thereby have a positive influence on mental health whereas our study used a broad approach to identify participation in organized activities by including focus on both involvement in physical activity groups political teams volunteer work religious communities as well as clubs most previous studies have focused solely on whether participation in physical activity groups may be associated with improved mental health results from the present study indicated that low involvement in organized activities was associated with increased odds of mental distress both among men and women these findings are supported by results from prospective studies among european adults suggesting that involvement in social organized activities predicted higher quality of life and lower level of depressive symptoms over time and be a protective factor against the onset or development of chronic conditions especially among individuals with few close social ties 1646 finally a norwegian populationbased study has suggested a doseresponse effect of participation in organized activities on perceived health anxiety depression and satisfaction with life in both women and men and that men who engaged specifically in receptive rather than creative cultural activities reported better healthrelated outcomes 47 however few longitudinal and experimental studies have examined gender dependent effects of participation in different organized activities on mental health similar to our results several other studies have also reported that lower level of perceived social support are associated with mental distress in both men and women 4849 furthermore among older individuals who lacked social support women seemed to need more emotional support whereas men seemed to need more tangible support 48 a longitudinal study among british adults has also confirmed a bidirectional relationship between social support and mental health and that the relationship varied over the life course 50 furthermore low social integration among peers in adolescence has recently been shown to predict higher levels of depression among us adults 51 and systematic reviews have reported evidence linking low of social support social isolation and loneliness to mental health problems 2552 on the other hand having trust in people feeling safe in the community and having social reciprocity has been identified as factors associated with lower risk of mental distress 53 previous studies have argued that high perceived social support could play a key role in reducing risk factors of mental distress caused by negative life events such as job loss and marriage breakdown 5455 finally the current study showed that having sleep problems was strongly associated with increased odds of mental distress in both men and women results from previous studies indicated a ushaped association between sleep duration and mental distress 56 and that individuals who experienced both insomnia and short sleep duration had increased risk of chronic mental health symptoms 57 moreover a study among norwegian adults confirmed that different symptoms of insomnia seemed to play a key role in rising of anxiety levels 58 and a metaanalysis indicated that nondepressed subjects with insomnia had a twofold risk of developing depression compared to those with no sleep difficulties 59 studies have also suggested a bidirectional relationship between sleep problems and mental distress and that mental distress increase the risk of experiencing insomnia later in life 6061 underlying psychophysiological mechanisms through which insomnia or general sleep problems predicts mental distress are still not clear previous studies however have raised attention to the role of sleep in emotion regulation 62 and from a neurobiological perspective a dysfunction in sleepwake regulating neural circuits may lead to alterations in emotional reactivity 63 several methodological limitations of the present study should be considered this studys main limitation is the crosssectional design which precludes inferences about causality further the present study relied on selfreported measures which are prone to memory and recall bias as well as socialdesirability bias despite a limited participation rate and a higher proportion of high educated participants compared to the total adult population in norway 64 a major strength of the present study was the large sample drawn randomly from a general population another strength is that we used validated tools to measure mental distress and social support 65 66 67 and that data reflecting frequency duration and intensity and duration of leisuretime physical activity were combined to identify individuals who achieved the who recommendations 30 further perceived financial difficulties has previously been identified as a major contributor to mental distress 68 and was therefore used as a measure of socioeconomic status in the present study conclusion the present comprehensive study among norwegian adults from the general population confirmed increased odds of mental distress among those with high sedentary time low participation in organized activities low social support and sleep problems however future longitudinal studies are needed to confirm a possible causal relationship between different lifestyle behaviors participation in organized activities and social support and mental distress and thereby contribute further to developing targeted strategies for prevention of mental distress and illness in society funding the authors received no specific funding for this work competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and 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background identification of modifiable factors associated with poor mental health is crucial to develop targeted and effective intervention strategies for prevention of mental distress and illness in the general population thus the aim of the present study was to examine the association between low level of leisuretime physical activity high sedentary time low participation in organized activities low social support sleep problems and mental distress in a large sample of norwegian adultsa crosssectional study was completed by 28047 adults ≥18 years old in southern norway by filling out an online selfreport questionnaire multivariable binary logistic regression models stratified according to gender and adjusted for age and perceived financial situation were used to examine possible associations between unhealthy lifestyle behaviors participation in organized activities social support and mental distressour results showed an increased odds of having mental distress among men reporting low leisuretime physical activity or 118 95 ci 103137 high sedentary time 132 116151 low involvement in organized activities 143 125164 low social support 255 218299 and sleep problems 729 635837 compared to the rest of the male population for women the results showed increased odds of mental distress among those reporting high sedentary time 125 111139 low involvement in organized activities 160 142180 low social support 271 239306 and sleep problems 578 515650 compared to the rest of the female population for both men and women results also indicated that mental distress was increased among younger adults and among those reporting financial difficulties compared to the rest of the populationour results showed an association between unhealthy lifestyle behaviors low participation in organized activities low social support and mental distress and that the strength of the association varied substantially these findings provide increased knowledge about the relationship between modifiable lifestyle factors and mental health which should have implications for future public health efforts

introduction amenable mortality understood as untimely and unjustified deaths that should not occur in the presence of timely healthcare procedures to avoid them is a type of mortality used to assess the impact of the response and quality of a health system as well as the potential weaknesses of its healthcare thus it has also been used during the last decades to evaluate the positive impact on a populations health due to the improvements in access monitoring diagnosis and treatment particularly in industrial countries 12 for decades in most european countries the trend of allcause mortality has been decreasing 3 moreover a progressive decrease in amenable mortality can also be observed in several of these countries at different rates depending on the country and population group 4 5 6 however in some of the lowerincome european countries this trend has tended to change direction in recent years particularly in the case of women 7 in this context the impact of the economic downturn on health either due to worsening general socioeconomic conditions or due to cutbacks in health services and public investment in health or the privatization of health services is the subject of a growing scientific literature whose results are paradoxical on the one hand a series of studies indicate that mortality has a procyclical behaviour against macroeconomic difficulties that is the recession unemployment etc cause an improvement in certain healthy habits such as quitting smoking cooking at home playing sports or visiting family and friends that improve living conditions and reduce mortality while economic booms increase mortality 89 on the other hand economic crises can exacerbate poverty levels or stress and therefore increase morbidity and mortality in a countercyclical trend sometimes procyclical and countercyclical effects operate sequentially 10 or at different rhythms in the short and long term 7 some authors who provide procyclical results warn that while a recession can reduce death rates in the general population they can worsen in specific social sectors or geographical areas 11 this shows the need to study socioeconomic inequalities in health in general and in mortality in particular 1213 within this growing scientific interest various studies have investigated the impact of the economic slowdown on the populations health and healthcare both in spain 14 15 16 and in other european countries 7 17 18 19 as well as in other continents 2021 the 2008 economic crisis coincided with the implementation of austerity policies that reduced the capacity of the spanish public health system this reduction struck unevenly depending on the position of the people and social groups in the social structure and depending on geographical location therefore as amenable mortality depends directly on the response capacity of the health system its use is not only relevant as an indicator of the crisis impact but also as an indicator of the inequalities of that impact at different socioeconomic or educational levels sexgender age ethnic group or geographical area so reveal recent studies in spain 622 and europe 23 these inequalities in socioeconomic level or access to health services are in themselves a risk factor and therefore it is necessary to study them in order to identify the most vulnerable groups or geographical areas to carry out specific interventions 24 an adequate instrument to study health inequalities and the effects of economic downturns is the deprivation index designed to measure the disadvantages of an individual a family or a group with regard to their community or society they are usually built from various indicators 25 in spain a di has been devised within the framework of the medea projects 26 this index based on census data has allowed the census tracts to be classified according to their level of socioeconomic deprivation and its usefulness has been demonstrated in several studies on inequalities in mortality in urban areas 192728 in europe some studies on socioeconomic inequalities in amenable mortality at the country level or comparisons between countries have been carried out 42930 however few studies have researched these inequalities at the urban level and there is no evidence that the changes in these inequalities have been studied after the start of the 2008 economic slowdown therefore the objective of this article is to analyse the socioeconomic inequalities in amenable mortality in the three most important cities of the valencian community and their evolution after the start of the 2008 economic crisis taking the census tract as the basic geographic unit the main hypothesis is that the economic crisis did not affect all social groups in the same way this differentiation in impact might depend on multiple factors ranging from the duration of the crisis in the different economic areas to the position of the different census tracts in the socioeconomic structure and that of the families and individuals that inhabit them also the different actors responses visavis the crisis and the crisis victims needs materials and methods design study population and unit of analysis this is an ecological analysis of am comparing two periods 20002007 and 20082015 the units of analysis were the census tracts of the cities of alicante castellon and valencia a census tract in the different countries where it is used is the smallest territorial unit established for operational purposes for which statistical data is available in spain a ct average population is 1000 inhabitants these three cities are located in the autonomous community of valencia with an average annual total population of 1240744 inhabitants during the period 20002007 and 1310123 in the period 20082015 mortality data all deaths of residents in these cities in the study periods have been included in the research the death data were taken from the mortality registry of the valencian community obtaining the variables year of death age sex city and cause of death the causes of death used in the analysis were coded according to the international classification of diseases tenth revision the causes of amenable deaths analysed in the study were those proposed by nolte and mckee 1 and following the criteria defined by these authors it is important to notice that only 50 of the deaths due to ischaemic heart disease were included 231 all deceases were georeferenced and assigned to their ct of residence the data were obtained from an anonymized database maintained by the mortality registry of the autonomous community of valencia since the study was based on retrospective administrative data the approval of an ethics committee in spain was not required cts by socioeconomic deprivation level a deprivation index for each ct in all three cities and periods was established using the following indicators unemployment manual workers casual workers insufficient education in young people and insufficient education in general these indicators have already been proposed in the calculation of deprivation index on the basis of census data in major spanish cities as the first component of a principal component analysis 26 for our research indicator data were obtained from the 2001 population and housing census for the period 20002007 and from the 2011 population and housing census for the period 20082015 the deprivation index used was developed within the framework of the medea3 project from which the study data both on socioeconomic inequality and mortality stem for each period and city the 10 25 75 and 90 di percentiles were calculated thus classifying the census tracts into five deprivation levels according to their value that is dl1 di values lower than p10 dl2 di values between p10 and p25 dl3 di values between p25 and p75 dl4 di values between p75 and p90 and dl5 di values greater than p90 figure 1 shows the census tract distribution in the three cities in relation to their dl this classification was outlined according to the aim of this research in order to quantify the difference in risks between the most socioeconomically favoured areas and those of greatest deprivation table a2 of appendix a shows the average values of the five socioeconomic indicators used in the different dls of each city and period under study in addition the di calculated for the two periods has made visible the changes that have occurred over time in the three cities alicante population data the population data used in order to calculate mortality indicators for the periods studied were obtained with permission from the valencian institute of statistics which is responsible for compiling population statistics in this region table a3 of appendix a shows the average annual population for all the cities under study by sex age group dl and period data analysis to study the evolution of the risk of death over time the data were classified into two periods 20002007 and 20082015 deaths were also grouped by three age ranges 044 4564 and 65 and older the specific rates by sex age group dl and period have been calculated for the total number of deaths due to all causes and the total amenable mortality in order to estimate the relative risks between the categories of the variables under study the poisson regression models also have been adjusted taking into consideration the city age dl and period effects separated by sex and carrying out a robust estimation to control the possible overdispersion of the data in addition the proportional mortality of the large icd10 groups was calculated according to sex and deprivation level for all three cities so as to compare the pattern of mortality by groups of causes according to period finally the program ibm ® spss ® statistics and our own software were used for calculating the mortality indicators results between 2000 and 2015 there occurred 177583 deaths in all three cities under study nevertheless 2634 of these could not be georeferenced and assigned to the census section of residence as the deceased persons residence address was not stated or did not correspond to the cities under study regarding the remaining 174949 that could be georeferenced 86479 occurred in the period 20002007 and 88470 in 20082015 tables a4 anda5 of appendix a show the death frequencies and percentages for the specific causes of amenable mortality and the chapters of the icd10 according to period dl and sex in table 1 the average values and confidence interval of the di are displayed in it it can be seen that the average values per di varied scarcely from the period 20002007 to the period 20082015 the city of castellón for instance showed smaller differences in the averages observed between the more extreme dls but similar in the rest of dls the table also includes the number of sections for each of the dls in each city and all cities as a whole observing table a2 of appendix a it can be noticed that areas with dl5 are areas with an alarming situation where all the indicators used to build the index appear in high values areas hit by unemployment lack of training school dropout precarious work and so on in order to verify if the effects of dl period and age group on mortality risk were significantly different according to city the poisson models were adjusted including the effects of the following variables city dl period age group and the interactions between the city and the rest of the other variables verifying the absence of statistical significance of the terms of the interaction of the city effect with the other effects all interactions were not significant for both allcause mortality and mortality due to amenable causes due to the absence of a significant interaction the estimation of effects was carried out jointly for the three cities under study in the joint analysis of the three cities the poisson regression models were adjusted by sex these included the effects of the following variables dl period age group the firstlevel interactions between dl and the rest of the other variables and also the secondlevel interaction between dl period and age these models suggested the existence of a significant secondlevel interaction between the dl effect period and age group in both men and women figures 2 and3 show the specific rates by sex age group period and dl for all causes and amenable mortality mortality graphs for overall and amenable mortality suggest that the mortality rates are generally higher at the levels of greatest economic deprivation the detected interaction could be due to some exceptions to this general behaviour thus for general mortality in men in the age group of over 65 there are hardly any differences in rates according to the dl in the period 20002007 while on the contrary regarding amenable mortality in men aged 044 years there are in women the age group 65 and over has not experienced increases in rates according to the dl for general mortality in any period unlike for amenable mortality due to the existence of an interaction the relative risks between categories of dl specific by sex age and period were estimated using a simple poisson model with dl as the only effect to estimate the increase or decrease in the risks of death of one to another period a simple poisson model specific by sex age and dl was adjusted with period as the only effect mortality graphs for overall and amenable mortality suggest that the mortality rates are generally higher at the levels of greatest economic deprivation the detected interaction could be due to some exceptions to this general behaviour thus for general mortality in men in the age group of over 65 there are hardly any differences in rates according to the dl in the period 20002007 while on the contrary regarding amenable mortality in men aged 044 years there are in women the age group 65 and over has not experienced increases in rates according to the dl for general mortality in any period unlike for amenable mortality men women due to the existence of an interaction the relative risks between categories of dl specific by sex age and period were estimated using a simple poisson model with dl as the only effect to estimate the increase or decrease in the risks of death of one to another period a simple poisson model specific by sex age and dl was adjusted with period as the only effect regarding mortality from all causes as table 2 shows the risk of death increased as the dl worsened in the younger age groups both in men and women and both in the first and second period under study nevertheless in the 044 age group the rrs were higher for men in the first period and women in the second suggesting a tendency towards decreasing inequalities in men and increasing in women the behaviour of the mortality risks in the age group of 65 years of age and over was different since only the rrs significantly higher than 1 occurred in men in the second period whereas regarding women only the relative risk of the dl2 group was significantly higher in the first period regarding the evolution from the first to the second period overall the risk of death decreased with the rrs adjusted by age in the second period as compared to the first period of 0875 in men and 0961 in women regarding mortality from all causes as table 2 shows the risk of death increased as the dl worsened in the younger age groups both in men and women and both in the first and second period under study nevertheless in the 044 age group the rrs were higher for men in the first period and women in the second suggesting a tendency towards decreasing inequalities in men and increasing in women the behaviour of the mortality risks in the age group of 65 years of age and over was different since only the rrs significantly higher than 1 occurred in men in the second period whereas regarding women only the relative risk of the dl2 group was significantly higher in the first period regarding the evolution from the first to the second period overall the risk of death decreased with the rrs adjusted by age in the second period as compared to the first period of 0875 in men and 0961 in women table 3 shows the rr of the 20082015 period visavis the 20002007 period in men a significant overall decrease in the risk of death in all categories of dl can be seen however there was no significant drop in the risk of death at levels dl4 and dl5 and in dl1 in women and in dl5 and dl4 in men this means that men and women of these age groups and dl did not improve the risk of death from all causes men women regarding mortality due to amenable causes according to table 4 the risks of death increased in women for any age in both periods as the dl worsened however in men the behaviour of this variable was different depending on the age group in the group of 044 years of age the rrs went from being lower than 1 in the first period to rrs greater than 1 in the worst dl categories in the second period although this suggests a tendency to increase inequality these results were not significant in addition in the intermediate age group the rrs were significantly higher than 1 in the most deprived dl categories in both periods finally in the group of seniors the rrs increased slightly in the second period comparing period 20082015 with period 20002007 it can be seen that the risk of death decreased with rrs adjusted by age of 0725 in men and 0785 in women table 5 shows the rrs of the period 20082015 as compared to the period 20002007 a significant reduction in the risks of death in most of the dl categories can be observed although with some exceptions since no significant drop was observed in men of 044 years of age in dl1 dl4 and dl5 and of 4565 years in dl1 and dl4 nor in women of 044 years in dl1 dl2 and dl4 and of 4565 years in dl1 dl4 and dl5 in addition there was an upsurge in the risk of death at the dl4 level in men of 4564 years and in dl5 in women of 044 years discussion summary of findings inequalities and evolution of death risk this study has shown that the inequalities between areas of greater and lesser deprivation in both allcause mortality and amenable mortality persist along the two study periods in the three cities and that these inequalities appear with greater risk of death in the areas of greatest deprivation although they present nuances depending on whether it is allcause or amenable mortality level of deprivation age group sex or period it has been found that in general the risks of death from all causes and amenable mortality have decreased significantly from one period to the other although not in all the groups studied inequalities overall mortality inequalities in allcause mortality among levels of deprivation have not disappeared in some cases although inequalities remain the rrs have decreased for both men and women showing in most cases a clear gradient between the most impoverished and the most favoured levels however in some age groups such as men 65 and over and women 044 inequalities have increased in the case of younger men inequalities tend to decrease this result could indicate that men of working age are the recipients of procyclical impacts on health the reasons may be related to the reduction of work stress due to increased unemployment 3233 in the specific valencian case due to the bursting of the housing bubble or a decrease in tobacco consumption 34 as well as the general decrease in pollution from industrial activity 35 in other words with the economic contraction an overall reduction in mortality risks can be observed in men of working age this process might have developed to a greater extent among the most deprived sectors highly affected by unemployment the analysis on the effects of procyclical and countercyclical mechanisms proposed by catalano et al 33 is appropriate here in the case of men over 65 inequalities appear in the second period while in the first period they were nonexistent this could be due to the fact that the economic crisis deteriorated the socioeconomic conditions of the census sections that already had high levels in all the deprivation indicators in all three cities this could have directly affected the age cohorts who had not yet retired men in the later years of the working agea situation aggravated by the feeling of not being able to fulfil the traditional provider role this sector of men was most affected by the crisis with deficiencies in unemployment benefits and in which the effects of this appear in the short but also in the long term or even with permanent consequences of increased mortality as found by bender et al in greece 36 in the case of women inequalities persist although not in all age groups in women aged 65 and over there are no inequalities in general mortality in either of the two periods whereas in the youngest these inequalities increase in older women this could be due in part to the fact that in the life cycle of women they achieve economic stability and establish social and family capital as they age furthermore although they do not have social capital around them both the legislative body and the institutions offer them different forms of protection however in the case of younger women inequalities not only persist but tend to increase particularly in the most disadvantaged groups this may be due to the fact that women of this age are one of the most vulnerable sectors in times of crisis as they suffer more severely due to unemployment job insecurity and various aspects of the socalled feminization of poverty or the intersection between poverty and gender 37 during childbearing age childcare can distance them from full inclusion in the labour market or the training necessary for reincorporation when the children have grown up in the case of singleparent households they can also bear the double burden of work and the care of children alone this period which can last up to two decades depending on the number of children and the spacing between births constitutes in itself an element of exclusion for all women even those of the least deprived levels in this sense the risks of death may be related to the mechanisms of stress and frustrationaggression and although this is shared by women of all classes it could more sharply affect women from the most disadvantaged dls amenable mortality in general terms the existence of inequalities by age group sex and level of deprivation can be seen in young men inequality practically nonexistent in the first period appears in the second although it does not reach statistical significance regarding the men of intermediate age in the first period a clear gradient of inequality in mortality is perceived which decreases in the second period at these ages paradoxically unemployment can increase healthy habits and reduce deaths from some amenable causes such as cardiovascular disease in the case of the elderly an increase in the inequalities towards old age can be perceived from the first to the second period the combination of the factors mentioned above can influence this age in the case of women inequalities in amenable mortality persist over time furthermore some significant increases in rrs can be seen ie regarding younger women in dl5 and women aged 4564 years in dl4 and dl5 this is consistent with what has been said previously in relation to the allcause mortality over the life cycle of women in older women inequalities persist with similar gradients in the two periods this may be because women of these ages do not see their personal economic situation directly affected by the economic downturn as their pensions are not affected as described above on the other hand an increase in the malignant neoplasm of the colon and rectum as well as malignant neoplasm of cervix uteri is also perceived in this combination of simultaneous or successive procyclical and countercyclical trends short or long term many of the mechanisms of stress frustrationaggression or effect budgeting described by catalano et al 33 might be at work in summary the patterns of socioeconomic inequality in amenable mortality show some remarkable differences from those of general mortality in women the most notable difference occurs in the group over 65 years of age for which the inequalities in amenable mortality remain over the two periods whereas inequalities in general mortality are not observed in any of the periods in the rest of the age groups amenable mortality is similar to the overall mortality with inequalities in both periods in the case of men aged 044 years amenable mortality presents inequalities in the second period that did not exist in the first one while in overall mortality the inequalities remained over the two periods although with a slight decrease in the 4564yearold group inequalities were observed in both amenable and general mortality finally in those over 65 years of age while inequalities are observed in overall mortality in the second period the inequalities in amenable mortality were similar in both periods evolution of the risk of death although both allcause and amenable mortality have decreased amenable mortality shows a more pronounced decreasing trend this pattern had already been described in a similar way in other studies in europe 233839 in the spanish case this might suggest that the decrease could be due to preventive measures in risk factors and advances in treatments and health technology 6 as well as the entry into force of law 422010 on sanitary measures against smoking that regulates the sale supply consumption and advertising of tobacco 3440 this decline in allcause and amenable mortality in times of crisis also seems to corroborate procyclical theories of health although this may be so in macroeconomic terms the study of inequalities taking into account both social structure and territory allows us to identify as in the previous paragraphs the population groups in which the procyclical decrease in allcause or amenable mortality is not as pronounced furthermore this is even for the groups in which mortality would have risen although not significantly in a countercyclical manner ie men older than 65 years women older than 45 years in the most deprived levels or women older than 45 years in the level of least deprivation for all causes and middleaged men in low deprivation and high deprivation and young women in greater deprivation for amenable mortality in general terms as some authors argue infrahousing mental disorders drug addiction waiting lists energy poverty or evictions increase the risks of death 41 and must be analysed at their simultaneous intersection with health 42 all these processes present in the cities studied also validate the countercyclical theory for these reasons it is important to include inequality in the analysis and to take into account both procyclical and countercyclical trends 11 so that the macrofigure does not hide the reality of the sectors that suffer from the countercyclical trend impact of the crisis and hypotheses despite the general decrease in amenable mortality socioeconomic inequalities have remained along the two research periods this study has been carried out in urban areas of the same region with common health policy and management and where access to healthcare was universal during the first period the start of the crisis meant the widespread application of cuts in healthcare investment outsourcing of services exclusion of social sectors from public healthcare or increased difficulties in accessing it 43 in this context the endurance of inequality along the two periods could be due to complex reasons on the one hand the impact of health cuts could have affected to a greater extent the most disadvantaged population groups preventing a possible reduction of inequalities on the other the results obtained are consistent with other studies carried out in spain in them an effect of the socioeconomic level on mortality was observed independent from that of health care based on the differences in access to and quality of health care as previously suggested 6 or the lower participation by the most disadvantaged population in early detection programs of some diseases such as breast cancer or colon cancer 4445 in addition it should be borne in mind that the prevalence incidence and natural course of some diseases could have an effect on amenable mortality and differ between socioeconomic levels as their risk factors also differ on the other hand survival after treatment could be affected by characteristics of individuals related to their socioeconomic level although these variables have not been considered in this study in any case amenable mortality proves to be a useful indicator of the degree of efficiency of health systems also in times of crisis failure to reduce or increase amenable mortality is generally accepted as a deterioration of healthcare methodological strengths and limitations this research has the usual limitations of ecological studies thus it is not possible to infer a causal association the relationship obtained between the dl and the risks of death when using the cts may not be applicable at the individual level reflecting both the effect of the individual socioeconomic level and the contextual effect of the area of residence the data analysis has been carried out jointly for the three cities this was mainly due to reasons of statistical power however no important differences have been observed among the three cities regarding socioeconomic indicators in addition the interactions between the city and the rest of the effects on mortality such as dl period and age was not significant therefore a differential effect for each city cannot be stated georeferencing often entails difficulties in this kind of research in our study the percentage of nongeoreferenced deaths is 13 lower than usual and should have little effect on the results the list of amenable causes has been chosen for its potential for comparison with previous studies and also because other lists even more recent ones such as that of the amiehs project 46 disregards some causes and might not be appropriate for periods such as 20002015 the chosen list includes a wide number of amenable causes sensitive to the effects of austerity and cutbacks in healthcare since the start of the economic crisis in spain 22 the inclusion of 50 of deaths from ischemic heart disease could have modified the estimated rrs among the dls and between periods as it is a highfrequency cause to verify this possibility such rrs were estimated excluding deaths from this cause as can be seen in tables a8 and a9 of appendix a the rrs were hardly modified conclusions this study confirms that inequalities persisted during the two study periods although they have not increased in general terms except in some sectors such as young women for amenable mortality the patterns of inequality evolution showed some differences in amenable mortality and overall mortality in some groups according to sex and age thus while for women of 65 years of age and over inequalities in amenable mortality remained over the two periods inequalities in overall mortality were not observed in any period in men in the group aged 044 years inequalities in amenable mortality were observed in the second period while in the group aged 65 and over amenable mortality presented similar inequalities in both periods while general mortality only in the second period at the same time it has also been found that the evolution of death risks from before the onset of the crisis to the period after the onset presented overall a general procyclical trend however it has been possible to identify population subgroups by age sex and level of deprivation in which the trend on the contrary would be countercyclical the use of the deprivation index has made it possible to identify specific geographic areas with vulnerable populations in all three cities and at the same time to identify the change in the level of deprivation of the geographical areas throughout the two periods it is precisely in these areas with the greatest deprivation that more studies that deepen the knowledge of the causes of health inequalities and those that could indicate the interventions aimed at reducing these inequalities are needed appendix a

several studies have described a decreasing trend in amenable mortality as well as the existence of socioeconomic inequalities that affect it however their evolution particularly in small urban areas has largely been overlooked the aim of this study is to analyse the socioeconomic inequalities in amenable mortality in three cities of the valencian community namely alicante castellon and valencia as well as their evolution before and after the start of the economic crisis 20002007 and 20082015 the units of analysis have been the census tracts and a deprivation index has been calculated to classify them according to their level of socioeconomic deprivation deaths and population were also grouped by sex age group period and five levels of deprivation the specific rates by sex age group deprivation level and period were calculated for the total number of deaths due to all causes and amenable mortality and poisson regression models were adjusted in order to estimate the relative risk this study confirms that the inequalities between areas of greater and lesser deprivation in both allcause mortality and amenable mortality persisted along the two study periods in the three cities it also shows that these inequalities appear with greater risk of death in the areas of greatest deprivation although not uniformly in general the risks of death from all causes and amenable mortality have decreased significantly from one period to the other although not in all the groups studied the evolution of death risks from before the onset of the crisis to the period after presented overall a general procyclical trend however there are population subgroups for which the trend was countercyclical the use of the deprivation index has made it possible to identify specific geographical areas with vulnerable populations in all three cities and at the same time to identify the change in the level of deprivation ascending or descending of the geographical areas throughout the two periods it is precisely these areas where more attention is needed in order to reduce inequalities

introduction participating in physical activity including recreational and team sports has been shown to be beneficial to health 1 specifically adolescent sport participation improves physical health cognitive functioning and enhanced social interactions 23 with a current concern for decreased physical activity and increased screen time use in adolescents there have been increased efforts to enhance sport participation and increase physical activity 4 one commonly recommended activity for not only benefitting adolescents physical health but also their holistic wellbeing is participation in high school sports 56 there are roughly 8 million high school students who participate in sports annually 7 however while sport participation has benefits there is always a risk of injury from participation sport participation injuries can vary in severity type participation time lost and how the injury impacts the overall health of the athlete 8 one such injury that is associated with sport participation is sportrelated concussions it is estimated that each year between 11 and 19 million sportrelated concussions occur in the united states with a majority of those occurring in the pediatric and adolescent age groups 910 concussions present with a variety of symptoms deficits in cognition and balance impairments that may impact the daily functioning of the patient in addition to restricting participation in sport historically studies have focused on the acute effects of concussionrelated impairments including symptom presentation cognition deficits and balance dysfunction from the time of injury through returntoplay with only more recent publications focusing on how concussion may impact overall health status or healthrelated quality of life 11 12 13 the concept of hrqol is global and takes into account the physical psychological and social domains of health while considering the whole person and addressing disability and societal limitations 14 the social domain of health revolves around interactions with family peers and teammates sportrelated injuries pose potential strains to the social aspect of an athletes hrqol and the nature of sportrelated concussions present a unique set of challenges in this regard 1516 unlike other musculoskeletal injuries with which a patient may have a cast or brace concussions do not display observable signs furthermore the symptom presentation and prognosis for recovery are individualized and can vary greatly between patients 1718 as a result patients may be out of competition and unable to engage socially with teammates during recovery that may lead to negative influences on the social aspect of an athletes hrqol particularly in the sensitive developmental period of adolescence this is supported by studies that have identified that athletes experience griefrelated symptoms following concussion and throughout recovery social isolation that can affect school and social activities and changes in the social dynamics with teammates and coaches 19 20 21 there is a need to further explore this area with a specific focus on understanding the interactions between the social aspects of sport and the perceived social consequences of concussion which was the purpose of this investigation methods experimental design prospective data was collected from high schools as part of a larger mixedmethods study investigating the influence of sportrelated concussion measures on impairment and hrqol 1216 for this study a qualitative research design consisting of inperson interviews conducted within the first month postinjury was used this manuscript focuses solely on patient interviews addressing their experiences following a sportrelated concussion with a specific focus on the social aspects of the injury instrumentation the qualitative interview protocol was intended to assess all aspects of the disablement model and used the short form36 outcomes measure and the international classification of functioning disability and health model as a general framework 222324 the icf framework allows the study of health status outcomes and contributing determinants establishes a common language among various groups and provides a holistic view of the injury or illness 2425 the interview protocol aimed to address all aspects of hrqol including social emotional and mental health through a series of approximately 50 questions the general topic areas covered in the interview included personal and sport demographics injury history physical functioning mental health functioning accomplishment and support seeking social statusrole transitioning relationships spirituality and expectancies prior to data collection pilot testing was completed with healthy adolescents to assess for question clarity participant understanding and administration timing procedures participants were recruited from 15 high schools if the patient had remained out of sport participation for at least 10 days following the concussion the schools athletic trainer notified the research team the parent and studentathlete were contacted by the research team to participate in the qualitative study at which time parental consent and athlete assent were obtained two researchers who had postgraduate academic training and experience in qualitative interviews were involved in conducting the interviews with the participants the interviews were conducted to assess the meaning given to participants sportrelated concussion and how they perceived it affected their health status the interviews were conducted at a location of comfort to the participant and were audibly recorded on average the interviews lasted 45 minutes after the interview was completed the recordings were professionally transcribed data analysis data analysis was conducted by 3 researchers previously trained in the consensual qualitative research data analysis process 2627 the cqr approach focuses on using multiple researchers coming to a consensus while constantly and repetitively analyzing the cases until there is a conclusive and complete understanding of the findings 2627 data trustworthiness was ensured through the inherent nature of the consensus process and use of multiple analysts of cqr to minimize researcher bias we followed the 4 progressive stage cqr analysis process as detailed by hill et al 26 these stages include developing initial code domains separating key ideas from each domain crossanalyzing multiple interviews via development of categories and themes and identify the frequency of participants per category 2627 to begin the research team coded three initial transcripts individually to identify initial code domains they then met to discuss the code domains and develop a consensus codebook all transcripts were then coded into the proper domains based on the consensus codebook once the data were placed into the domains the research team separated the core ideas from each domain so that the statements made by the participants could be concisely summarized 27 finally multiple interviews were crossanalyzed to examine relationships similarities and differences after crossanalysis was completed the frequency occurrence for all categories was recorded to determine the occurrence of each category across the whole sample thus allowing for the entire sample to be represented 27 results four main themes emerged during the data analysis which included 1 perceptions of social aspects of sport 2 social perspectives of a sportrelated concussion 3 psychosocial experiences following a sportrelated concussion and 4 singleitem hrqol responses 16 however for this manuscript we solely focused on the perceptions of the social aspects of sport and the social perspectives of a sportrelated concussion themes and their associated categories frequency counts for each theme are provided in table 2 following the frequency categorization conventions of hill et al family and friendships participants discussed their desire to participate in sport due to a family history of participation in that sport or other sports or because it was an activity in which many of their close friends also participated greg highlighted his familys closeness to sports sports thats basically life because we dont do much besides sports like espn is almost always on our rooms are all decorated in sports we have a batting cage our back yard has a huge field to play sports in so whenever we have time its sports jane mentioned her mothers athleticism as a reason yeah my mom actually played soccer as well up until college and i think its just genetics too and it just rubbed off on me like you know how sometimes parents like whatever they do their kids start to do thats how it was with me my mom played soccer and then i played soccer benjamin described his parents push to include sports within his social network um well early on early in my childhood when i was younger i didnt really have that much interest in sports and stuff like that and they didnt take it like as a concern but they were kind of worried like oh we were all interested in sports is there anything wrong with him but when i started getting into football and i played baseball a little bit and basketball i kind of touched every sport here and there they started thinking okay this is going to be good like get friends and stuff like that so i would say yes they have seen it as a good success for like friends and school and stuff while jane described the role of friends usually on fridays and then saturdays i hang out with my soccer friends because usually every weekend we have either a game or a tournament so then we just hang out until our next game together so basically my soccer friends are like one of my closest friends i mainly hang out with them every weekend paul further described his teammates as friends i have a relationship with each player like we joke around and have fun but when it comes down to it were a team and were a family and were supposed to like each other but sometimes you get to that point where you dont like that person but yeah its a big role as captain © the internet journal of allied health sciences and practice 2022 furthermore many described participating in sports starting from a young age and how it has become an important aspect of their lives charlie mentioned um well i had four brothers growing up and the always played baseball so they would take me out and play catch or whatever when i was really young and then i think i started playing tball when i was 3 or 4 robert noted well i mean its just fun its nice ive been playing sports since before i can remember my dad has put me in sports since i could walk its just always been something ive done finally greg noted it was well my dad showed the sport to me and i just liked it ever since my first word was ball decisions to participate based on peers participants highlighted that their decision to participate in sport was often based on peers and to interact with friends benjamin noted i got started with one of my friends we played football once and i was just a tagalong and i guess i did really good and one of my friends recommended that i play football and i just kind of continued on andrew commented one of my friends in our neighborhood asked me to play for their team so i started there and i was pretty good and i had natural talent and the coaches at school started working with me and then i was starting towards the second half of the season charlie mentioned because all my friends were playing and talking about it and i just got excited and wanted to play again lastly susie suggested like i know in volleyball there was like 8 of us seniors on one team and there was some drama but overall it was like a lot of fun and like i think thats half the reason why i do sports is because i enjoy just the hang out because they think its honestly i probably dont know why but probably just like oh its a concussion but some of my friends think that i dont know why they think this but they think im faking it greg also noted concerning comments from coaches they like ask me how my symptoms have been and ive told them and theyre like youve got to be kidding me its still lasting this long jane also mentioned other times like okay like my family member says you use your concussion for an excuse for everything then i got pretty upset because of that because thats so not true and i got pretty upset at her for that but that was probably the only time when i got really upset at home in contrast other participants reflected on the support they received from family and teammates sarah described how much the people around me care and how much they worry about me benjamin noted some understanding from teammates i think since they do the concussion tests and stuff like that too i think they have a general understanding like i do on how serious these concussions can be so i think they see this more as like you know like athletes out like hes got some situation you know like nothing like teasing or anything like that theyre still just as great of friends as they were before i think they just kind of understand that its kind of serious and that im just sitting out and making sure that this is alright before i go on the field i think they do understand that parentguardian and peer roles participants were divided on the roles assumed by parents and peers and the understanding of and empathy towards the concussion some felt that their parents were very understanding and helpful while others noted conflicts with parents as a result of the concussion jane mentioned the helpfulness of her mother and teachers my mom like shes made a huge difference probably without her i still would have been how i was the week after my concussion well probably not that way but i mean like i wouldnt have been as well i probably wouldnt have made such big improvements as i have from a month ago to now without her just having like my teachers being understanding because that really helped because i thought my grades would really going to suffer because of this because ive been missing so much school lately and i was stressed out about like having my grades like having a c or something on my report grade and i was pretty stressed about that i think my mom and my teachers have made a difference in this because they put a lot of stuff off of me i wouldnt have as much i mean i would have more stress if they didnt help me out as much as they have benjamin noted frustration on the part of his parents well theyre frustrated at me with not being able to be on the field and that stuff but to be honest i dont think they really understand i dont think they realize that after all these concussions like i could be in trouble here but its like they dont really realize that they think i should be better and should be back on the field as did andrew who was recovering from his concussion at the same time as a teammate yeah well hes somebody i can talk to about it like almost every day hell text me and ill text him and say like hey how are you feeling or were going to be on the news tomorrow together so that was cool for us to be able to do that together and were both like the team managers of the baseball team so we both go to the games and sit there i just relate to him more its just we were on the same baseball team last year together so i knew him and had a class with him last year so we were buddies but he wasnt really somebody that i hung out with on a regular basis but now its turning into that um having somebody to vent to or relate to so i dont feel so bad because i felt when i was okay i felt really bad for him because i saw him standing on the sidelines not being able to do anything he wanted because he felt bad i can just talk to him or hang out with him because well just like hang out sarah mentioned similar support when describing her teammates they call you know theyre all worried about me and stuff and i dont like being worried about like all this stuff ive thought about it a lot i just dont like people worrying about me so they come kind of want me to be safe and also say i only have one brain and so you know theyd rather me be healthy than to keep playing soccer communication and expectation about the concussion lastly concerns were expressed regarding the type of communication received and the expectations provided by medical personnel in regards to recovery from the concussion sportrelated activities and activities of daily living specifically many participants noted it would have been helpful to have a better understanding of the recovery process and timeline jane noted well it probably wouldnt have made it any different but it probably would have made me a little bit more prepared because if somebody had told me that i wouldnt be able to do any physical activity like any playing of sports or anything for a long time because i think that would have helped me i probably would have been a little upset in the beginning but then i probably would have gotten used to it later on but now thats all i can think about not really all i can think about but mainly what i think about is like when am i going to get back to playing soccer © the internet journal of allied health sciences and practice 2022 similarly greg noted um that probably it would last this long all the headaches and stuff because when i first got it i thought it was just going to be like the last one a couple of weeks and ill be fine but especially that the symptoms have been lasting this long others felt communication especially to school personnel was handled appropriately and was helpful to their recovery jane highlighted yeah my mom emailed them i have four teachers because its middle school like you know each teacher for each subject one teacher for each subject theyve been really understanding and stuff but theyre just really awesome theyve been pretty awesome for the whole past week because of my concussion i dont know i couldnt ask for better teachers because theyre really understanding similarly julie noted so the trainer at our school she sent an email to all my teachers saying i might need extra time on things and that ive been out and she explained to them like the facts of like my concussion and stuff like that so they are like more understanding now about my absence stuff jack mentioned yeah i already talked to my counselor you know she said if you need help with something or if you dont remember or anything go talk to your teachers no matter what theyll be there for you discussion the current study aimed to evaluate patient experiences following a sportrelated concussion and outline social implications following injury participation in sport is often associated with positive social interactions and a desire to engage with friends and teammates thus removal from sport following a concussion can have significant social implications for adolescent athletes specifically the perceptions of peers parents and others regarding the injury can influence reporting of symptoms and recovery following concussion 16 these perceptions may result in additional psychosocial stress including depression mood disturbance and anxiety 28 as with any injury it is important to understand the patients experience beyond their physical deficits but also to examine the multidimensional impact of their injury on their psychosocial wellbeing and global hrqol 1229 the results of this study provided indepth testimony of adolescent athletes in this regard illustrating that sportrelated concussions present several unique challenges to an adolescents social experience through sport social importance of sport previous research has shown the importance of youth sport participation in providing a template for youth athletes and their families to strengthen their familial relationships develop peer friendships and positively engage with their communities participants in this study detailed their desire to capitalize on this positive social potential which often drove their decision to participate in youth sports throughout their development it is clear from our findings that sport plays an important role in the lives of these individuals and involvement in sport is a significant aspect of their social identity though shared sport experiences had historically facilitated social enjoyment among this sample the disruption to social normalcy caused by suffering a sportrelated concussion appeared to exacerbate these athletes degree of psychosocial distress previous literature has shown this experience to be common among injured athletes though the emerging themes of this study illustrate the importance of tailoring psychosocial treatment to the unique characteristics of adolescent athletes who suffer a sportrelated concussion 30 social perceptions of concussion misunderstanding of diagnosis compared to other injuries in which symptoms are more uniform and visibly apparent sportrelated concussions are more variable in their sequelae while the timeline for recovery is more ambiguous 31 these relatively less tangible characteristics of sportrelated concussions not only impact the athletes experience with their injury but are also impactful in their social interactions as participants navigated these challenges postconcussion they explained how their uncertain diagnosis caused them to question © the internet journal of allied health sciences and practice 2022 the degree to which they should continue their sport participation in turn casting doubt on their social role facilitating patients perceptions of being knowledgeable of their injury has been shown to aid in psychosocial wellbeing 32 for adolescents with sportrelated concussion proactive education of athletes and stakeholders about symptoms prevalence and prognosis of concussions may help them to be more effective and comfortable in recognizing and reporting their symptoms this would not only lessen the risks of negative physical consequences stemming from failing to report or remove the athletes from competition but also lessen the psychosocial strain they experience throughout the diagnostic and recovery process being ashamed of the concussion another emerging theme that is important to purposefully address was the feeling of shame several athletes reported feeling due to their removal from competition research has indicated that a patients comfort in seeking social support is a key factor in the successful maintenance of their postinjury wellbeing 33 in cases in which the athlete feels ashamed about sustaining a concussion it is logical that this would stem into their propensity to accurately report their symptoms be patient with their recovery timeline and seek social support 34 other studies have identified similar themes due to the invisibility of the injury and feeling the need to minimize concussion symptoms 161920 thus it is important to not only educate athletes but also associated stakeholders to ensure that the severity prevalence and potential consequences of sportrelated concussions are wellunderstood to destigmatize any inappropriate negative perceptions of the athletes injury and promote implicit social support another psychological construct that is relevant in discussing the shame felt by participants in this study is that of athletic identity 35 this refers to the strong sense of self pride and belonging tied to athletic status and sport participation 36 previous research has shown that a stronger sense of athletic identity is linked to a higher degree of psychosocial disruption after suffering an injury 37 thus the athletes in this sample who described feeling ashamed may be feeling a lesser sense of their normal self which negatively impacted their affective and cognitive response to their injury recommendations for mitigating the risk of disrupted athletic identity include maintaining involvement in team activities and a proactive effort to acknowledge this identity struggle while helping the athlete find fulfillment in other enjoyable activities may help to stabilize their psychosocial wellbeing 32 perceptions of others regarding the injury as adolescent athletes navigate the internal psychosocial rigors associated with sustaining a sportrelated concussion the external impact of their surrounding social environment also plays a key role 38 any sportrelated injury changes the nature of social interactions among teammates coaches and supporting stakeholders but the participants in this study indicated that the invisible nature of this injury cast doubt onto the nature of how others perceived their injury 39 while supporting stakeholders should make their recognition of this injury clear other qualitative work has found that a superfluous amount of social support may lead to the athlete doubting the fullness of their recovery and ability to return to sport 40 furthermore conflict over social support has been identified with differing views on the part of the patient and coach and teammate as to whether enough support had been provided 21 establishing clear channels of communication providing empathy but also striving to promote confidence in athletes as they recover and approach clearance for return to play can help athletes to feel more secure in the perceptions of their surrounding social system parentguardian and peer roles two critical roles in these athletes support systems are parentsguardians and peers and athletes become even more dependent on these stakeholders for support postinjury 4142 while athletic trainers coaches and teammates may keep their social interactions somewhat contained to sport settings the daytoday influence of parentguardians and peers permeate multiple facets of a recovering athletes hrqol participants expressed their parentsguardians and peers possessing misconceptions about the nature of this injury both in underestimating and exaggerating the nature of their symptoms these conflicts with parentsguardians and peers may also increase anxiety about the injury as these stakeholders are often the primary reason for sport participation in the first place as described in our first theme determining an appropriate level and type of support that each group should provide to the patient is likely an individual decision however understanding that patients need some level of support is critical to foster a positive environment 21 once again proactive efforts to educate parents and peers about the multidimensional impacts of sportrelated concussions can help in identifying symptoms communicating with nonsport related stakeholders in school settings and focusing strategies on specific support roles may enhance the ability of parents and peers to positively contribute to the recovering athletes psychosocial wellbeing 42 communication and expectations about the concussion finally patients reported that the quality of communication particularly in terms of expectations for their recovery experience were impactful on their psychosocial wellbeing throughout recovery it has been noted that athletes often experience elements of grief following a concussion as the concussion results in disruptions in their life social isolation and loss of athletic identity 19 this theme aligns with previous research which has identified that feeling informed knowledgeable and selfdetermined in recovery © the internet journal of allied health sciences and practice 2022 enhances a patients affective experience regardless of their injury 40 it is again important to note the characteristics of sportrelated concussions that differ from previous sportrelated injury research while the latter category tend to have more standardized timelines that may help in informing the patient and shaping expectations the sequelae associated with sportrelated concussions are less standardized 38 thus efforts can be made to individualize communication to the patients areas of disruption while also attempting to offer anticipatory guidance and education regarding possible signs and symptoms preand postinjury risk factors and recovery expectations 42 limitations and future directions our study is not without limitations we recruited participants from 15 schools in one geographic area who had been held out of sports participation for at least 10 days sampling from those with persisting symptoms these findings may not generalize to individuals who have a relatively uncomplicated recovery from their concussion or individuals from other racial and ethnic groups furthermore we did not have access to the participants medical histories to determine whether preexisting underlying issues related to emotional or psychosocial health were present however participants described their experiences following concussion in relation to their perceived preconcussion health status future studies should aim to evaluate the impact of concussion on other areas of hrqol and provide recommendations for clinicians in administering and interpreting patientoriented outcomes to assess these important domains additionally developing our understanding of how personal or contextual factors may influence the disruption and severity of areas of adolescent athletes social experiences after a sportrelated concussion may allow treatment and practical strategies to be increasingly effective conclusion participation in sport and removal from sport following a concussion have significant social implications for adolescent athletes specifically the desire to participate in sports is often to engage with family and peers the perceptions of peers parentsguardians and others regarding the injury can influence reporting of symptoms and recovery following concussion removal from participation and being asked to limit school and social activities can cause an athlete to lose their athletic identity limited communication regarding recovery and expectations postconcussion may cause undue social pressures to return to activity prematurely anticipatory guidance and adequate social support with education regarding the possible signs and symptoms risk factors preand postinjury and recovery expectations following a concussion are important to include in postinjury management

purpose purpose sportrelated concussion can affect many domains of a patients health status social functioning is an important consideration especially for adolescent athletes our purpose was to explore adolescent athletes social perspectives regarding sport and concussion methods methods using a qualitative study design we interviewed 12 interscholastic athletes who had sustained a sportrelated concussion the interviews focused on injury details and explored the physical psychosocial emotional and spiritual components of sport and health themes and categories were identified using the consensual qualitative research process by a threeperson research team a comprehensive codebook that captured the main themes and categories resulted results results following concussion participants discussed two primary themes perceptions regarding the social aspects of sport and social perspectives regarding their concussion specific categories related to the social aspects of sport included friendships and family and decision to participate based on peers specific categories regarding the social perspectives of the concussion included uncertainty of the diagnosis perceptions of others regarding their injury being ashamed of the concussion parent and peer roles and communication and expectation about their concussion conclusions conclusions participation in sport and removal from sport following a concussion have significant social implications for adolescent athletes specifically the perceptions of peers parentsguardians and others regarding the injury can influence reporting of symptoms and recovery following concussion limited communication regarding recovery and expectations postconcussion may cause undue social pressures to return to activity prematurely providing a supportive environment in which patients can recover from concussion while engaging with peers and teammates is important anticipatory guidance with education regarding the possible signs and symptoms risk factors preand postinjury and recovery expectations following a concussion are important to include in postinjury management and should be known to all stakeholders

introduction latest estimates from the united nations office on drugs and crime 1 and the world health organisation 2 refer to 210000 and 245000 drugrelated deaths per year worldwide and approximately half of these cases are attributed to acute overdoses fatal overdoses caused by the use of illicit drugs in europe account for an estimated 4 of premature death in young adults aged 1539 years 3 social and economic conditions shape risk behaviors and the health of drug users as they impact on drug use patterns and affect the availability of resources and access to social welfare systems 4 nonetheless fatal overdoses are avoidable to a large extend 5 the existence of inequalities in health and mortality between groups with different socioeconomic profiles has been extensively documented since the 1980s 6 7 8 9 research focusing on social and economic determinants of drugrelated mortality appears to be less prevalent although previous studies have reported associations between fatal overdoses and individual parameters such as poor educational attainment 10 11 12 unemployment 1314 low income 1415 poverty status 15 16 17 homelessness 1819 and poor psychosocial functioning 20 davoli et al 21 investigated risk factors for drug overdose mortality including 81 cases and 324 controls matched on sex and year of birth and found no association with the educational status of victims galea et al 22 applied a multilevel casecontrol study including 725 accidental overdose deaths and 453 accidental deaths due to other causes in various neighborhoods in new york city their findings showed increased odds of dying from overdose in neighborhoods with unequal income distribution as second level measure in a further ecological study including 59 residential community districts of new york city marzuk et al 16 showed that the mortality rates due to overdoses involving cocaine and opiates are associated with poverty status by comparing mortality rates according to causes and educational attainment in a crosssectional study design borrell et al 23 found highest relative risks of fatal drug overdose among victims with lowest educational profiles in the city of barcelona the study however included overdose deaths caused by both illicit and prescription drugs the objective of our study is to investigating the existence of a social gradient in fatal drug overdose cases related to nonprescribed opioids and cocaine use by addressing the question whether the odds of a fatal overdose incident increase proportionally with the accumulation of social and economic disadvantages our findings should contribute to improving knowledge on the pathways that may lead to overdose incidents and to reduce their occurrence and consequences by implementing evidencebased public health social and harm reduction policies methods in the present study a fatal overdose case is defined as an intentional or unintentional death for which an acute adverse reaction after the recent use of products containing nonprescription opioids andor cocaine was reported as the primary cause of death according to toxicological and forensic evidence concomitant use of other substances is not an exclusion criterion if the use of opioids andor cocaine is reported as the primary cause of death by forensic authorities data sources the following data sources have been linked and crossexamined in order to complete overdose victims profiles drug use patterns and life histories drug misuse surveillance data the national drug monitoring system is operated by the luxembourg focal point of the european monitoring centre on drugs and drug addiction and indexes drugrelated contacts with both drug demand and drug supply reduction institutions in a single and integrated database the relis network includes national psychiatric departments of general hospitals specialised inand outpatient drug care services including opioid substitution treatment offers and harm reduction services prisons and special drug law enforcement agencies indexed drug users are digitally anonymised by means of an encryption algorithm approved by the national commission on data protection the derived attribution code allows respondents tracing within single and between multiple data sources while guarantying anonymity of subjects as requested by national data protection authorities the relis data protocol includes routine items on sociodemographics educational socioeconomic and health status drug use patterns and histories treatment records and contacts with the penal system forensic evidence in case of a suspicious death case the public prosecutors office orders a toxicological investigation and an autopsy of the victim the forensic department of the national laboratory of health reports drugrelated death cases also to the ministry of health for public health surveillance and statistical purposes forensic reports contain data on substances detected in the victims as well as an assessment of the association of detected substances and the occurrence of death autopsy reports also contain contextual information and elements of victims life history toxicological reports have been anonymised and made available to the research team by the lnh following the authorisation of the public prosecutors office national law enforcement records of fatal overdose cases national judicial police authorities exhaustively list overdose deaths occurring on the national territory after forensic confirmation toxicological evidence as well as related police reports are compiled for each case linkage of data sources was possible as relis codes have been calculated and attributed to all overdose victims previously deidentified since persons included in the national relis database or in the police overdose record are anonymised by the same coding routine matching cases could be reliably detected matching procedures in the casecontrol setting a nested casecontrol study design was applied cases are defined as victims of a fatal overdose having occurred in luxembourg between 1994 and 2011 matched controls refer to persons indexed by the epidemiological surveillance system on drug users in contact with national services cases were matched with four controls for sex year of birth drug administration route and duration of drug use previous research has shown that matching more than four controls with each case does not significantly add statistical power to the analysis 2425 controls were never matched to more than one case and deceased users were excluded from the relis database in order to avoid that they were matched with cases matching variables are defined as follows • sex • year of birth • route of administration • duration of illicit drug use we used the relative index of inequality to determine socioeconomic inequalities within the study sample taking into account both the size of subgroups and the relative position of individuals within in the present study the rii measures the relative risk of a fatal overdose for the least advantaged group compared to the most advantaged group the higher the rii the more prevalent are socioeconomic inequalities within the study population the rii is a regression based index and only applies to linear changes in incidence rates according to socioeconomic position parameters to calculate the rii we stratified our study sample according to a social inequality accumulation score based onfactors and values presented in table 1 scores attributed to each value have been weighted to ensure that the total weight of each factor is equal siass have been attributed to cases and to controls to determine their respective socioeconomic position within the sample the lowest possible sias equals to 0 whereas the most beneficial socioeconomic position is quantified by a sias of 5 knowing that the study population is not comparable to the national general population in terms of socioeconomic parameters 12 mortality could not be assessed in absolute terms but based on the relative socioeconomic position that each individual occupies within the distribution of socioeconomic parameters of the study sample composed of cocaine andor opioids users only in order to determine the rii the sample has been stratified into 4 groups according to siass situated within the following intervals 1 1 and 2 2 and 3 3 we calculated respective overdose mortality rates as well as relative frequency and cumulative frequency of survivors both required to determine a parameter called ridit 26 for each of the 4 sias groups the study population is composed of according to the following formula r ¼ ½cf þ ðcf à rfþ2 weighted least squares linear regression analysis on overdose mortality rates and ridit scores were applied and the rii was calculated according to the formula provided by kunst and mackenbach 27 sex and age were not applied as adjustment variables to determine the rii since they were used as matching variables in the casecontrol selection process in order to account for missing values we performed multiple imputations using the fully conditional specification approach 28 on the entire data set and generated 10 imputation data sets results have been combined across the imputed sets of data according to the method recommended by rubin 29 and the overall rii estimate is the average of the individual rii estimates statistical analysis was conducted using spss version 210 results our sample was composed of 1328 persons including 272 fatal overdose cases and 1056 controls six cases had to be excluded from the sample as no matching controls were found for 3 4 and 15 cases respectively 1 2 or 3 controls only could be matched eightyone percent of controls matched cases for all matching variables 4 were closest matches for date of birth 13 for duration of drug use career and 2 for both matching variables the distribution of missing values for predictor variables is as follows professional status of father or legal guardian debt status legal income salary educational attainment and professional inactivityunemployment the overall characteristics of national fatal overdose victims and the casecontrol study sample were further described in previous publications 1230 descriptive results reveal that fod victims concentrate in lower sais classes the mean sias of fatal overdose victims is 122 compared to 185 for survivors table 3 presents overdose mortality rates according to sias classes as well as associated ridit scores a negative linear relationship is observed between the overdose mortality rate and the relative socioeconomic position determined by ridit scores associated to sias we found an absolute difference in mortality of 2922 overdose deaths per 100 drug users between the lowest sias class compared to the most advantaged class in terms of relative inequality index the overdose mortality rate of opioids and cocaine users with lowest in order to lay out the evolution of the rii and overdose mortality rates over time a separate regression analysis was performed for two consecutive 9 years periods results showed a marked decrease in the rii from 17 27 95 ci 3223132 for 1994 to 2003 to 579 95 ci 317840 in reference to the period 2003 to 2011 between the same time periods a decrease in national overdose mortality from 637 to 422 cases 100000 inhabitants aged 15 to 64 has been observed discussion key results this study investigated whether the odds of dying from opioid andor cocaine related overdose increase gradually down the socioeconomic positions users of these drugs occupy results suggest the existence of a marked social gradient in opioids and cocaine related overdose fatalities extending beyond the mere binary difference in mortality between the most and the least advantaged on the socioeconomic scale in other words adverse socioeconomic conditions affect the overdose mortality risk according to a doseresponse scheme in terms of prevention and harm reduction strategies this is a relevant finding as it suggests that any measure aiming at reducing social disparities even if isolated or targeted may have a positive and dynamic impact that counter the negative cumulative effect in terms of survival this strongly supports the idea that drugrelated harm reduction strategies exclusively focusing on reducing direct harm of drug use fail to address harm associated with the context of drug use such as homelessness violence and poverty 31 also harm reduction services should integrate socially supportive offers not only to reach their general goal of social reintegration but crucially because they can contribute to save lives generate years of life without major impairments and have a sustainable positive impact on drugrelated mortality and thus meet their first and overall objective reducing drugrelated morbidity and mortality added value and generalizability studies on the association between single socioeconomic indicators and fatal overdoses in reference to the general population 1432 and both fatal and nonfatal overdoses in crosssectional settings 33 have provided valuable outcomes in recent years however we could not identify previous casecontrol studies addressing inequalities in fatal overdose cases based on multiple socioeconomic parameters combined into a cumulative measurement tool moreover the present study included probably for the first time drug administration route and duration of drug use as matching variables in order to take due account of the risk exposition of both cases and controls these methodological aspects as well as the large number of cases and controls and the crossanalysis of longitudinal data from different sources and settings should add validity to our findings limitations and further research the scarcity of studies on socioeconomic determinants of fatal drug overdoses may partly be due to the difficulty to gather data on social profiles of drug users parameters such as education income financial wealth professional activity and socioeconomic situation of the family of origin are often not included in routine drug registration or monitoring systems also in a retrospective study design poor flexibility is given as to the selection of study variables additional data on income sources of subjects and the socioeconomic status of their parents could have contributed to a more refined stratification of subjects according to their respective socioeconomic position furthermore research on drug users mostly rely on episodic data covering the period from first or established drug use to the moment of data collection in a lifecourse perspective it would be beneficial to have access to early life and life trajectory data in order to allow a more indepth analysis of cumulative effects of socioeconomic determinants therefore a prospective cohort study design would have been most appropriate to address the present research topic bearing in mind however the resources and time consuming nature of such studies we found that the rii has markedly decreased during the observation period along with a parallel reduction of the average overdose mortality rate future research should beyond investigating the existence of socioeconomic inequalities in drug using populations further address the association between the amplitude and distribution of these inequalities and mortality risks this said social and economic parameters should not be seen as independent determinants and even more so should the concept of social inequalities be widened when applied to drugrelated mortality whereas the social status seems to hold a major role here family social and societal environments new communication means mobility migration and acculturation contexts as well as the emergence of new psychoactive substances new consume patterns and related risks are at play in the attempt to explain differences in terms of morbidity and mortality associated to drug use the challenge for future research will thus lie in the capacity to take into account the changing context and environments that next generations will experience and the way they will or will not succeed to sharing resources and distributing wealth in a healthy way study data have been deposited in harvard dataverse repository and can be accessed under doi 107910dvn29720

to determine the existence of a social gradient in fatal overdose cases related to nonprescribed opioids and cocaine use recorded in luxembourg between 1994 and 2011overdose cases were individually matched with four controls in a nested casecontrol study design according to sex year of birth drug administration route and duration of drug use the study sample composed of 272 cases and 1056 controls was stratified according to a social inequality accumulation score sias based on educational attainment employment income financial situation of subjects and the professional status of their father or legal guardian least squares linear regression analysis on overdose mortality rates and ridit scores were applied to determine the relative index of inequality rii of the study samplea negative linear relationship between the overdose mortality rate and the relative socioeconomic position was observed we found a difference in mortality of 2922 overdose deaths per 100 drug users in the lowest socioeconomic group compared to the most advantaged group in terms of the relative inequality index the overdose mortality rate of opioid and cocaine users with lowest socioeconomic profiles was 988 times as high as that of their peers from the highest socioeconomic group 95 ci 6491326 our findings suggest the existence of a marked social gradient in opioids and cocaine related overdose fatalities harm reduction services should integrate socially supportive offers not only because of their general aim of social re integration but crucially in order to meet their most important objective that is to reduce drugrelated mortality

introduction india reported about 274 million cases of covid19 as on 27 may 2021 strict nationwide lockdown restrictions were imposed during the first wave of the pandemic in may 2020 12 there is a paucity of data to quantify the impact of the pandemic on pwd who are more vulnerable and at higher risk from covid19 3 available evidence suggests that pwd often experience serious risks and consequences due to pandemic situations and they are currently facing unethical disadvantages in rationing for critical care and lifesaving treatment due to covid19 45 lack of disabilityinclusive response and preparedness for an emergency has exacerbated the existing structural disparities experienced by pwd lockdown restrictions meant additional risk to pwd because of disruption to essential services and support 6 7 8 this is especially so for a country such as india where access to health rehabilitation and social care services is very limited 9 10 11 12 the situation is further worsened as disability is both the cause and consequence of poverty 1314 according to the who survey conducted in 155 countries in may 2020 prevention and treatment services for disabling noncommunicable diseases were severely disrupted since the pandemic 15 inaccessibility to health and rehabilitation services functional decline due to reduced physical activity and disruption of personal and social networks have increased the vulnerabilities faced by pwd into manifolds 16 india reported 30 fewer acute cardiac emergencies reaching health facilities in rural areas in march 2020 compared to previous years 15 the underlying health conditions and exclusion from health care services rendered pwd more vulnerable to multiple health conditions including ncds 16 according to the rapid assessment survey conducted by the who 94 of the countries surveyed reported that human and financial resources were diverted towards the mitigation of covid19 and many public screening programs were reportedly disrupted 15 pwd have been excluded from even these initiatives related to mitigation and emergency preparedness 17 during the nationwide lockdown in india public transport facilities were suspended which were still not restored in many places by october 2020 18 this has further affected access to health care services for pwd which was already a challenge in indiaowing to the inaccessible physical infrastructure facilities and information 18 rehabilitation services in india are already scarce being mostly located at urbancentric tertiary level facilities this makes it particularly challenging for rural dwelling pwd with respect to accessibility availability and utilization of rehabilitation services 19 although telerehabilitation and teleconsultations emerged as a response to support pwd the evidence for safe effective and good quality service was lacking 20 lockdowns and the subsequent loss of employment and financial crisis could cause severe socioeconomic distress and mental health conditions 21 longer quarantines are shown to have a direct correlation with poor mental health outcomes 21 the pandemic also had a profound impact on childrens wellbeing particularly for children with disabilities the lockdown also led them to further disadvantage especially in the field of mainstream education 22 many pwd faced difficulty receiving pensions 23 the growing literature on the impact of covid19 on pwd clearly describes the neglect exclusion and vulnerability experienced by them globally 24 against this background we aimed to empirically explore the impact of covid19 and the associated countrywide lockdown restrictions on pwd in india during the first wave and generate evidence to inform actions for health emergency preparedness in the future objective to investigate the impact of covid19 and the associated countrywide lockdown restrictions on pwd in india during the first wave methods a crosssectional mixedmethods approach was adopted using a quantitative survey as well as qualitative indepth interviews and focus group discussions in this paper we report the quantitative findings first followed by the qualitative findings quantitative study data collection was carried out during the first wave of covid19 at two different points in timefirst during the lockdown restrictions and was repeated after six weeks when the lockdown restrictions were eased partially in each of the study sites data collection tool a structured survey questionnaire was specifically developed by domain experts with feedback from people implementing disability programs in the field it had five domains with several questions under each domain medical rehabilitation mental health education and livelihood empowerment and social participation questions had closedended options access to services and information medicines online consultation postponement of appointment due to lockdown fears and sources of support impact on pensions and participation twoday training of data collectors was conducted online the tool was piloted to see if there was any difficulty in the flow and comprehension of the questions the survey was conducted telephonically by five trained public health postgraduate interns informed verbal consent was obtained from each participant accepting to participate in the study the questionnaire is included as a supplementary file data analysis descriptive statistics were used to summarize the data we defined the primary outcome level of disruption due to covid19 as having a negative impact which was defined based on answers to questions in all five domains ie access to medical care and treatment rehabilitation mental health education and livelihood and social empowerment and participation factors associated with the negative impact were examined using the chisquare test for associations the paired comparisons between the lockdown with postlockdown phases are presented using mcnemars test and the marginal homogeneity test to compare the proportions qualitative study to gain indepth insights related to the answers provided in the survey selected participants were involved in either indepth interviews or focus group discussion through telephoneonline zoom calls an experienced qualitative researcher conducted the idis and fgds using separate topic guides developed specifically for this data collection an interview guide was used and the thematic axes around which the interviews revolved were the same as those of the questionnaire idis and fgds and were continued until saturation of each concept was reached and further data collection failed to contribute new information 25 debriefing meetings were held among the research team members at the end of each interview to ensure data quality and to share emerging findings data from digital recorders and any additional notes taken during interviews were transcribed using microsoft word each transcript was checked for consistency the transcripts were randomly compared with the recorded digital files for accuracy disagreements or issues needing further clarity were resolved through discussions and the triangulation of data sources the interview guide is included as a supplementary file data analysis qualitative data were analyzed using the framework approach the data audio was first transcribed verbatim after familiarization with the audio recording manual thematic analysis was performed for interviews based on exploring both predetermined issues of interest and looking for new issues raised by the respondents 26 codes were then identified after reading the first few transcripts and then those codes were used as a template for other transcripts and new codes if any were also identified themes representing a domain or topic area were listed and coded based on frequency and order of mention open coding was conducted and codes were grouped into categories and themes were identified as stipulated by graneheim and lundman 27 an indepth analysis was carried out for each of the themes and subthemes that emerged from the transcripts results quantitative findings during the lockdown phase 403 respondents with impairment were surveyed from 14 states across india representing different regions of the country for the post lockdown phase 107 persons were included of the 403 respondents the average age was 28 years with the minimum and maximum ages ranging from 3 to 67 years of these 111 were less than or equal to 19 years old more than half had physical impairment followed by visual intellectual speech and hearing developmental and mental health issues about half the respondents were married and majority of them had children more than half of the respondents were employed about 255 received government pensions with a median pension of inr 700 per month medical and rehabilitation services the majority of the respondents said that they did not need medical services during the lockdown and after the easing of lockdown a higher number of respondents found it difficult to access emergency medical services during lockdown compared to postlockdown a similar observation was found in accessing rehabilitation services no significant difference was observed in accessing other services during and post lockdown mental health about 757 of the respondents were apprehensive of the risk of infection during the lockdown and this increased to 916 post lockdown interruption of caregiving and genderbased violence was felt among respondents and was significantly higher in comparison to during postlockdown education and livelihood there was no statistically significant difference in education and livelihood during and post lockdown and in the participation and social empowerment of pwd during the lockdown phase 733 of the respondents felt that on being confined at home the children felt distressed 705 said that schools being shut down affected the childs learning 659 of the schools are not providing online teaching to children among the ones who received online teaching only 93 said that the teaching was not in accessible formats among four who reported that the online teaching was not in an accessible format two had speech and hearing impairment and one each had development and physical impairment out of the total 107 respondents in the post lockdown survey 729 hesitated to go to the hospital because of fear of getting covid 86 were scared to go out and meet others and 781 said they did not fear the lack of companionship more than 90 of the participants with either physical speech hearing or visual impairment were impacted by the lockdown in receiving rehabilitation services parents with children were significantly impacted due to lockdown in the areas of medical rehabilitation and mental health services among respondents with children 868 reported having been affected mentally compared to 738 who did not have children those receiving pensions were impacted in the areas of rehabilitation education livelihood and social empowerment the majority of those employed were impacted due to a lockdown in the areas of medical mental health and social empowerment among those who were employed 864 were impacted due to a lack of regular medical services table 4 provides the factors associated with the impact of the lockdown qualitative findings we conducted 11 indepth interviews and four focus group discussions just after the lockdown period table 5 depicts the profile of the respondents difficulties in daily life and management respondents felt that covid19 itself has not caused as much impact as the lockdown on pwds lives they felt it will take time for people to follow physical distancing and hand hygiene measures lockdown has had a huge negative psychological impact on pwd especially due to loss of income it was as such a gradual journey for persons with disability to become selfdependent their livelihood got affected very seriously due to lockdown they began losing hope and motivation which was gained after years of hard work i ask them to wash the hands but not everyone pays heed only few of them wash their hands for 20 s when i ask them to wear the masks they dont listen saying that nothing happens to us its a disease from another country when time comes everyone has to die access many faced difficulties in accessing basic necessities such as food mainly vegetables and pulses whereas rice was provided by the government access to medicines was difficult mainly due to travel restrictions in the region most of the information was not available in an accessible format the reasons why hand washing or maintaining distance was important were not clearly communicated even through informational messages some persons with disability have not eaten food for 8 days those who are on medication for mental health or serious disorders were completely dependent on free medicines their supplies had dried up but they were not allowed to go the district hospital for refills services most of the medical care was exclusively reserved for covid19 and there was a shortage of ambulances for pwd the minimum support and assistance required for pwd have not been added to the covid19 screening and treatment plan most of the rehabilitation services had come to a halt due to the lockdown similar to education and therapy services in the community not everyone has motorcycle or a bicycle there are difficulties in reaching the hospitals covid19 has broken our confidence if 5 pwd are sitting in a group joking and laughing and somebody coughs or sneezes automatically they may not tell on the outside but they fear about getting corona communication helplines were set up however not many could not use them due to inaccessible formats of communication the biggest challenge was to reach persons with disability and fulfil their needs we developed a helpline number with a psychologist for counselling and guidance 326 networks our biggest strength is our dpo the investment that we did over the years to build their capacity has helped us a lot during this time they are still doing it if someone is hungry somebody will ensure that that person is fed 327 compassion and government response government is not prepared for the next wave they should involve gram sabhas and bring in different agendas including disability it they are serious about planning for next disaster many reported that government guidelines during the covid19 outbreak were not inclusive and their need for assistance in terms of travel or covid19 screening or treatment was largely ignored if the government considers persons with disabilitys problems as that of its own familys then nobody will be unhappy finances the economic impact faced by pwd was uniformly reported by all interviewees pensions were affected loss of livelihood mainly among pwd with small businesses and petty shops pwd had to face hardships not only through the loss of income but the inability to travel to draw money from banks or to obtain essential groceries funding cuts were reported by stakeholders working in the ngo sector my child fell ill and i had no money i save money without my husbands knowledge which i had to take out and use my husband would have earned if there was no lock down and i would never have utilized my savings but that could not happen because of the situation lockdown has affected very badly economically the whole root cause is the poor economic situation 329 positive impact many reported that because of the lockdown pwd are avoiding buying nonessential items families are spending more time together and children are with their parents reduction in alcohol use and lesser disputes among family members were perceived to be positive impacts of the lockdown children got to see a different facepersonality of their parents yes as we are not buying many things from the market we are saving some money to summarize the main qualitative findings participant perceptions reiterated that lockdown has had a much harsher impact on persons with disability than covid19 itself there was little food and rations specifically due to the poor financial situation of pwd pensions were affected loss of jobs and livelihood from small businesses and petty shops the inability to travel to withdraw money from banks to obtain essential groceries further complicated matters there was a significant disruption in accessing medicines rehab services and essential health services due to travel bans and no travel passes some ngos helped pwd in providing necessities such as food kits dry rations as well as psychosocial support but it was inadequate discussion the covid19 pandemic and the associated lockdown restrictions during the first wave had a significant negative impact on the lives of pwd in india this is evident from the difficulties experienced by them in all aspects of their daily life such as access to information medical care and rehabilitation education livelihood and social participation the effect of the pandemic on medical care and rehabilitation of pwd was profound this was similar to other aspects of healthcare such as access to medicines hospital appointments and surgical procedures almost all respondents needed assistance for daily living and were dependent on family members as their carers many ngos provided food kits dry rations as well as psychosocial support but the livelihoods of persons with disability were affected and many of them had to borrow money during the lockdown with government disability pensions affecting among a third of the respondents other studies have also reported inconsistencies in financial support measures and recommendations for livelihood assistance have emerged from other countries 2829 a recent uk survey found that 60 of pwd experienced problems accessing food medicine and other necessities similar to what we found 30 threequarters of our respondents stated that children were distressed with school closures and it had affected learning similar findings of difficulty in continued accessible education were reported from south america 31 psychological reactions to covid19 among our respondents ranged from fear anxiety panic hopelessness and depression to fear of infection this led to a feeling of stigma discrimination and isolation combined with issues in relationships abandonment and violence likewise a recent online survey of pwd in india showed that threequarters of the respondents were living with anxiety depression and suicidal thoughts 27 the lockdown restrictions hindered pwd to engage effectively in their individual family and social roles when compared to before the pandemic this is especially important because organized systems were hardly available to meet the specific needs of pwd even before the pandemic this could be one of the reasons why only 17 of respondents required rehabilitation compared to 85 requiring assistance in activities of daily living families have been the only source of support for pwd both before and during the pandemic this was confirmed by more than half of the respondents who were confident of managing the situation if lockdowns were to be imposed again these findings have several implications for existing health social care and development systems in india particularly the need to optimize existing resources for the effective implementation of programs and policies for persons with disabilities all government websites and communication must be disabledfriendly with digital access to the information for pwd as laid down in the accessible india campaign 3 it is crucial for politicians policymakers and programmed planners to operationalize inclusion in the agenda for development in all sectors not just in health or social welfare similar to the recent debates on lives versus livelihood during the pandemic for pwd an inclusive response must be ensured to tackle such emergencies in the future for this to happen extensive information is needed to provide for the basic and social needs of pwd 329 advocacy with the governments on these issues is critical enabling telerehabilitation and supporting the needs of persons and children with disabilities online counseling for the management of stress fear and anxiety special financial assistance subsidies furlough schemes and clearing obstacles to avail cooperative loans best practices from organic farming and dairy schemes for pwd must be incentivized and the income from these initiatives must be promoted widely the government should ensure that pensions are not negatively impacted in the future online education for children in schools must be provided in accessible formats to avoid the pressure of buying smart phones by parents education must be provided in formats that are easy both economic and technology wise for instance special educators could prepare individualized lesson plans for children and train parents through phone or a school website podcast to our knowledge this is the first nationallevel study to evaluate the impact of the covid19 lockdown on persons with disabilities on a wide range of stakeholders the study was conducted across 14 states of india with a diverse mix of participants including policymakers program planners and implementers the study yielded rich data to substantiate the findings from varied perspectives primary data collection through telephonic surveys and interviews during the lockdown could be viewed as a strength given the context or a limitation given the approach doortodoor surveys could have arguably elicited richer details compared to remote interviews we could not obtain direct inputs from people with hearing impairment and used carers as a proxy if we had stratified pwd based on the severity of the disability we could have obtained insights into the extent and difference if any in the degree of impact of the pandemic conclusions covid19 and the associated lockdown restrictions have negatively impacted persons with disabilities during the first wave in india as shown by our quantitative and qualitative findings with a diverse mix of participants including policymakers program planners and implementers from 14 states in india this study yielded rich data to substantiate the findings from varied perspectives although the stratification of participants based on the severity of disability was not possible the findings reiterated the following it is critical to mainstream disability within the agenda for health and development with pragmatic contextspecific strategies and programs in the country the pandemic has reminded us yet again of the urgent need to generate research evidence targeting a disabilityinclusive approach for planning preparedness and mitigation of the subsequent covid19 waves as well as future health emergencies supplementary materials the following supporting information can be downloaded at 1 the survey questionnaire used for the quantitative study 2 the interview guide used for the qualitative study author contributions conceptualization st sk ss sv ah and gvsm data curation st and mgl formal analysis st sk and ss funding acquisition sv ah and gvsm investigation st sk and ss methodology st sk ss and gvsm project administration st and gvsm resources sv software mgl supervision st sk ss and gvsm validation st sk mgl sv ah and gvsm visualization mgl writingoriginal draft st and sk writingreview editing st sk ss sv ah and gvsm all authors have read and agreed to the published version of the manuscript informed consent statement informed consent was obtained from all subjects involved in the study data availability statement these data will be made available to others after receiving appropriate approval from the institution requests should be sent to

background there is a paucity of data to assess the impact of the covid19 pandemic on persons with disabilities pwds in india about 274 million cases were reported as of 27 may 2021 the continuing pandemic in the form of subsequent waves is expected to have negative repercussions for the disabled globally particularly in india where access to health rehabilitation and social care services is very limited therefore this study aimed to assess the impact of the covid19 pandemic and lockdown restrictions on pwds in india objective to determine the level of disruption due to covid19 and the associated countrywide lockdown restrictions on pwd in india during the first wave methods using a crosssectional mixedmethods approach data were collected from a representative sample of 403 persons with disabilities in 14 states in india during the covid19 first wave at two different points in time lockdown and postlockdown phase factors associated with the negative impact were examined using the chisquare test for associations the paired comparisons between lockdown with the postlockdown phase are presented using mcnemars test and the marginal homogeneity test to compare the proportions additionally a subsample of the participants in the survey was identified to participate in indepth interviews and focus group discussions to gain indepth insights on the study question and substantiate the quantitative findings the framework approach was used to conduct a thematic analysis of the qualitative data results about 60 of the pwds found it difficult to access emergency medical services during the lockdown and 46 post lockdown p 0001 likewise 12 found it difficult to access rehabilitation services during the lockdown and 5 post lockdown p 003 about 76 of respondents were apprehensive of the risk of infection during the lockdown and this increased to 92 post lockdown p 0001 parents with children were significantly impacted due to lockdown in the areas of medical p 0007 rehabilitation p 0001 and mental health services p 0001 the results from the qualitative study supported these quantitative findings pwds felt that the lockdown restrictions had negatively impacted their productivity social participation and overall engagement in everyday activities access to medicines and rehabilitation services was felt to be extremely difficult and detrimental to the therapeutic benefits that were gained by them during the prepandemic time none of the pandemic mitigation plans and services was specific or inclusive of pwds conclusions covid19 and the associated lockdown restrictions have negatively impacted persons with disabilities during the first wave in india it is critical to mainstream disability within the agenda for health and development with pragmatic contextspecific strategies and programs in the country

introduction along with the mental health services reform and efforts to change the logic of care in this area was recognized the magnitude of the global burden of mental disorders and the need for integrated and intersectoral responses the proposed organization of mental health services under the network logic is one of the strategies to broaden the care access and change the focus of the disease to the psychosocial needs of people with mental disorders such a network should be structured with points of care focused on both health care and social reintegration of individuals and families this proposal corroborates the world health organization recommendations of consolidation of universal health systems from an integral interprofessional perspective with priority of community spaces the recognition of the psychosocial care network as one of the priority thematic networks by the brazilian state has contributed to the visibility of mental health demands and influenced the development of research in this area studies have shown the variety of compositions and interactions between mental health services in each locality as the network is woven into the daily routine of services and in relationships between structures and social agents workers and managers play a fundamental role in mobilizing resources to meet users demands different researchers have highlighted that psychosocial care is not limited to specialized mental health services and involves building relationships with health institutions and other sectors in order to put into practice the psychosocial rehabilitation and insertion into territories the articulation of mental health services in the logic of networks has been the object of several studies despite the recognized importance of normative definitions decrees and ordinances for composing the psychosocial care network the differentiation and relationships between the scientific field and the bureaucratic field must be highlighted as well as the influences of relations conflicts and tensions between the various social agents in the daily routine of services studies have been developed from documentary analysis andor interviews with managers and professionals of specific categories but only two studies involved different professional categories one of them was performed with workers and managers of type iii psychosocial care centers of the state of são paulo and the other with higher level professionals from various points of the psychosocial care network in the western region of são paulo thus this study is justified by the need to address the various points of the municipal care network in order to produce evidence on how the psychosocial care network has been implemented in different locations it is about the sedimentation of studies related to the constitution of the psychosocial field and the capture of relations between network structures and the mediations performed by social agents in this regard the framework of pierre bourdieus constructionist structuralism was adopted to delineate the guiding question of the study what is the perception of workers and managers about the psychosocial care network of a mediumsized municipality in the inlands of the state of minas gerais objective to analyze the perception of workers and managers about the psychosocial care network in a mediumsized municipality in the inlands of the state of minas gerais method ethical aspects the project was approved by the research ethics committee and complied with the ethical precepts recommended by resolution number 4662012 of the national health council participants signed an informed consent form and received a copy of it each participant was identified by a number to ensure anonymity theoretical framework and type of study this is a qualitative descriptive and exploratory study in which pierre bourdieus constructionist structuralism was adopted as a theoretical framework this approach recognizes the existence in the social world of objective structures independent of agents consciousness and willingness that can guide or coerce their practices and representations at the same time there is a social genesis of the schemes of perception thought and action that constitute the … habitus and on the other there are social structures in particular of fields and groups according to bourdieu the adoption of the habitus construct derived from his interest in breaking with structuralism without falling into subjectivism habitus is understood as a system of durable and transposable dispositions which by integrating all past experiences functions at each moment as a matrix of perceptions appreciations and actions such a system is updated and recomposed at each moment and implemented in specific fields the fields are understood as a field of forces of battles fought sometimes for their transformation sometimes for their reproduction the allocation of specific capital ofin the field will conform its structure thus understanding the field of psychosocial care contributes significantly to the analysis of managers and workers perception about the psychosocial care network in the municipality studied and more specifically to the delineation of tensions in this field the plurality of capitals is emphasized by bourdieu who presents the economic cultural social and symbolic capitals all agents in their path of training performance and economic condition elaborate their capitals from which we can understand the positions taken over in the field the capitals of agents of the present study come from different spaces and express the way they fit into social reality groups and institutions in turn the perception about the network is related to these agents capitals and their positions in the psychosocial field in line with the adopted theoretical framework we sought to identify the matrix of perceptions of social agents which guides their representations of the psychosocial care network and their actions in the field of psychosocial practice in the exercise of this analysis were considered the relationships and tensions in the field from which we sought to identify the disposition of these social agents in relation to the reproduction of the status quo or transformation of their practices study scenario the mediumsized municipality in the inlands of minas gerais was intentionally selected because of the implementation of substitutive services already in the 1990s and the diversity of points of the care network the municipality had two type ii psychosocial care centers one municipal and one philanthropic a child and youth psychosocial care center one type iii alcohol and drugs psychosocial care center a psychiatric hospital a team from the street office program a team of the mental health matrix strategy five therapeutic residence services of which three municipal and two philanthropic data source the eligibility criteria were to work as manager or technical reference at any point of the psychosocial care network and be in the exercise of these duties during the study period exclusion criteria were being away from work at the time of data collection due to sick leave or vacation there were nine managers at the time of data collection namely one director of psychosocial care three managers of municipal psychosocial care centers two managers of the philanthropic psychosocial care center one administrative worker and one clinical worker a manager of the psychiatric hospital a manager of the three municipal therapeutic residence services a manager of the two philanthropic therapeutic residence services as the staff of the street office program and the mental health matrix strategy did not have managers the social worker and the nurse of the street office program and the psychiatrist of the mental health matrix strategy were interviewed twelve workers were eligible to participate and all joined the study table 1 presents the profile of participants guiding questions were what are the services offered in the institution in your opinion does the network offer the necessary conditions for the care of people with mental disorders and their families how do you understand the challenges faced by the institution and by the psychosocial care network the interviews were conducted by the lead researcher who has a degree in social sciences a phd in sociology and experience in qualitative research in places defined by participants with conditions of confidentiality and privacy the average duration of interviews was ninety minutes after transcription the audios were deleted a copy of the transcript was delivered to each person involved which is one of the requirements for the rigor of qualitative research no entries or deletions of information were requested by respondents data analysis pierre bourdieus framework of constructionist structuralism was used for the analysis focused on capturing the multiple relationships and positions taken over by the study participants in the psychosocial field and how they interact with other fields the process of data interpretation and analysis was conducted based on the structuralist research protocol according to which it is necessary to understand the structuring of the field where social agents build their perceptions and position themselves initially the composition of the psychosocial care network of the municipality of minas gerais was outlined the psychosocial care network was considered as the field from which were captured the habitus and capital expressed by the social agents based on the positions of study participants were outlined the relationships of institutions of psychosocial care network with one another and with other institutions thematic structure 2 workers and users element 11 mental health at the different levels of care • expectations regarding expanded acess to mental health care • infrastructure of the network services and conditions for workers element 12 relationship between mental health services other health services education and social protection • positive relationships and tensions between health services and mental health services • positive relationships and tensions between mental health services education services and social protection services element 21 psychosocial care and tensions in the workeruser relationship • aspects that guide psychosocial care • challenges of dealing with families • the prejudice that permeates the relationships of health professional with users thematic structure 1 workers and services figure 1 thematic structures elements and results data collection and organization recruitment of participants took place at their workplace data collection was performed through semistructured interviews the of psychosocial care network managers perception and tensions of the field querino ra borges rs almeida ly oliveira jl souza j the lead researcher performed successive readings of the transcripts and highlighted recurring topics and themes after completing the individual readings the convergences and divergences identified were jointly evaluated in order to delineate a group of relationships between the elements for the development of thematic structures at the end of this process two thematic structures were defined workers and services workers and users results the thematic structures and main results are presented in figure 1 thematic structure 1 workers and services element 11mental health at the different levels of care the results contemplated here relate to how participants understand mental health in the psychosocial care network the expectations regarding expanded access to care and challenges related to the network consolidation overall participants mentioned mental health actions at the different levels of care despite the still prevailing idea that mental health demands should be met only in specialized services the health care unit does not provide care because there they say look mental illness is not in our scope because we have no psychiatrist its a network still with a culture of specialized care focused very much on psychosocial care centers and the psychiatric hospital … the matrix strategy and training of primary care teams were mentioned as efforts to fulfill these demands with expectations regarding the expansion of mental health actions in primary care regarding workers conditions the need for more qualification and the issue of remuneration were mentioned we have been working like warriors because we earn very little we face a heavy workload to serve a difficult to manage population element 12 relations between mental health services other health services education and social protection the results on participants perception of the relationship between mental health services and other health services are described in figure 2 which was prepared from the perspective of social network mapping the following statements illustrate the relationships presented in figure 2 interactions between family health team professionals and therapeutic residences were described as follows the family health team doctor comes here the nurse community agent the dentist comes here they brush patients teeth do the mouthwash program with residents do the treatment the outpatient clinics were highlighted as less integrated with other network services in the electronic waiting list after five months we dont even find the user anymore the relationships established between the various psychosocial care centers and between these and other mental health institutions were also cited some resources that facilitate the articulation between services were mentioned figure 3 presents the relationships of mental health services with legal education and social protection institutions as reported by study participants the statements below illustrate some interlocutions with leisure and social protection institutions mentioned by participants element 21 psychosocial care and tensions in the workeruser relationship respondents emphasized that user care is provided by multiprofessional teams with priority of group approaches and resocialization activities they also mentioned user embracement listening and establishing bonds as a priority in the care of users most activities are done in groups … therapeutic groups … relapse prevention twelvestep philosophy support group … resocialization activities outside the psychosocial care center visits to universities parks shopping tours museum … the service that aims at user embracement listening listening in every way even listening to the silence to the users body and providing care for what he needs there the way you receive the user with neutral eyes i need to see the user as a person … the psychiatric hospital manager described hospitalizations as flexible and aimed at reintegration into the network we provide care on a more flexible therapeutic plan in the sense of a hospitalization that they call integral … it is the withdrawn from the crisis stabilization referral to the mental health network for continuity of treatment in the outpatient system actions related to health recreation and daily organization were also mentioned as part of the psychosocial care offered by therapeutic residence services families were recognized as part of psychosocial care for users however the challenge of including families in this care and the need to expand the work with them were emphasized another challenge mentioned was the tension between families and users themselves care to the family is not easy you know because they dont come its not just up to us theres no adherence of the family a bit of this difficulty is to bring the family closer to treatment to collaborate more participate more in the reality of this treatment … because by the ordinance of the prosecution service the therapeutic residence would be for those who do not have family ties these people have family here … their main reason for being in the therapeutic residence is by court order as the family does not want to care for them the prosecution passes the torch to the municipality to residence services prejudice was mentioned as a barrier to the access to health services and social care certain professionals do not even come close at the time of care they prefer that the person accompanying them the nursing technician or the nurse tells everything that is happening to the resident they do not listen to the resident … discussion in light of pierre bourdieus theoretical construct it was possible to capture the articulation between the various capitals of the social agents participating in the study the cultural capital is a set of qualifications knowledge and skills constructed by agents in which different scientific areas that form the psychosocial field are articulated as described in the results the set of social accesses expressed in the variety of contacts and relationships of social agents was evident in the speeches of interviewees who brought to light the relevance of this capital for the articulation of the various networks the symbolic capital in turn refers to the recognition of these social agents expressed by the role played in institutions and programs whether as managers or socially authorized professionals to speak on behalf of the service the complexity and interaction of these capitals support these agents representations of the psychosocial care network as pointed out in the results two major groups of relationships were identified from the perception of social agents 1 of workers with services and 2 of workers with users in the first group terms such as partnership support coparticipation dialogue good communication joint discussions assistance asking for help providing support giving feedback triggering good relationship and participation in the therapeutic project give nuances to the matrix of perceptions that guide the professionals representation of psychosocial care networks in their municipality as the orientation of agents practices and representations is not exempt from the interests of the field it is a fact that this predominantly positive perception about mental health in care services is crossed by different limits and challenges arising from the counterhegemonic model proposed by the notion of psychosocial care participants expressed their expectations of a broader access to mental health care especially more mental health actions in primary care and optimism about the potentiality of this level for mental health this perspective is consistent with the proposed network action which values the specificities of each institution and service in addition the strengthening of mental health in primary care is in line with the community approach and the perception of territories as an existential territory that involves spaces constructed as material and affective elements of the environment that when appropriated and managed expressively constitute places to live such strengthening can also contribute to mobilize other community resources and expand the support network of users and families which are fundamental for psychosocial rehabilitation in the municipality studied this insertion has occurred through the team of the mental health matrix strategy and the family health strategy efforts to value and involve workers from family health support centers basic health units and matrix units are urgent to ensure the performance of different primary care workers in mental health care nevertheless the emphasis on primary care as a key aspect for improving the psychosocial care network and the criticism on the lack of some components suggest that participants improvement expectations are more focused on unconsolidated actions and services and they have little consideration for the potential of improvements in their own locus of activity which is essential to complement the network qualification the analysis also showed that the institutions establish deep relationships with other health services education and social protection services that are essential for psychosocial rehabilitation these relationships should be expanded by adding other territorial resources most described relationships need improvement and outpatient clinics were identified as the least integrated in the network it is worth highlighting the specificity of the outpatient work process to the detriment of psychosocial care center proposals highlighting the notion of intensive care of psychosocial care network managers perception and tensions of the field querino ra borges rs almeida ly oliveira jl souza j and prioritization of social reintegration rather than a medicalizing approach focused exclusively on symptom reduction although outpatient clinics have different characteristics in relation to the psychosocial rehabilitation proposal they have been the focus of recent policies that recommend their expansion and raise the issue of field strengths and disputes regarding transformations or reproductions of certain care models on the other hand participants also reported some tensions regarding the network structure in the perception of these agents aspects such as low participation of some institutions components poor communication between the elements that make up the structure referrals and difficult access barrier to the continuity of care and delay in counterreferral services outlined these tensions however the tensions mentioned were more related to service partners than to the own participant suggesting again a tendency to understand that the network improvement depends more on external transformations than on the more effective disposition of ones own experiences in a previous study poor communication and difficulties with the articulation between the various network services were identified as challenges of priority networks the literature has indicated the mobilization of light technologies as a possibility for the greater activation of institutions and monitoring of cases hence the importance of investments in workers continuing education according to study participants there are resistances and barriers to the care of people with mental disorders in nonspecialized services which strengthens the focus on specialties the reports emphasized difficulties to meet urgent and emergency care a topic addressed in other studies a study involving 156 workers from different regions of the country enrolled in the course crisis and urgency in mental health offered in partnership by a federal university and the ministry of health revealed that care was provided primarily with drugs mechanical containment and hospitalization this highlights the importance of strengthening the action in network and investing in continuing education to consolidate care and overcome the centrality of the psychiatric hospital in crisis management nevertheless previous studies have problematized the idea that the solution to most limitations in the field of mental health is training since even among some highly specialized teams such limits are present as indicated in an international study difficulties with attending stigmarelated comorbidities have resulted in neglect of clinical demands and excess mortality of people with mental disorders which is in flagrant disagreement with equity and human rights a study conducted in the brazilian context revealed the permanence of users in the psychosocial care center for long periods due to the few opportunities for insertion in institutions and services which indicates the importance of expanding community spaces the socalled chronification can contribute to problematize psychosocial rehabilitation which is the objective to be achieved in an intersectoral way with protagonism of users and their families in this sense the organization of services according to the logic of the territory has profound consequences not only for users lives but also for communities it is about rehabilitating the territories in order to collectively build new forms of living with difference in the second group of relationships tensions were also identified in the relationship between mental health professionals families and users the approach and involvement of families in the care process have been highlighted as important strategies for mental health care and the strengthening of policies and services it is relevant to overcome disciplinary control and tutelage strategies and foster their emancipation and autonomy the prejudice of some professionals towards people with mental disorder was also emphasized barriers related to prejudice occur in many countries and are a challenge for access to health and the search for assistance in a review study were highlighted different types of stigmas namely the perceived public stigma personal attitudes toward members of a stigmatized group internalized or anticipated stigma and attitudes toward seeking help this typology is interesting to understand the findings of this study since according to respondents there are stigmas in the community among health professionals as well as in users positions and attitudes identifying them can contribute to envision coping strategies thus the tensions and conflicts observed in the psychosocial care network arising from the habitus and the positions of social agents represent possibilities for change in contrast the actions offered by services within a perspective of resocialization user embracement group and multiprofessional care as well as approaches of harm reduction recreation and daily organization were the resourcescapitals mentioned by participants such resourcescapital are in line with the psychiatric reform and demonstrate the search for sedimentation of the psychosocial care model study limitations the collection of data with different interest groups such as users and workers would certainly enrich the list of results and enable the triangulation of perceptions especially considering that within the psychosocial field there is a variety of positions and wide differentiation of social agents the involvement of managers and workers from institutions with which the various points of the psychosocial care network articulate would contribute to broaden the intersectoral approach the choice of individual interviews can be considered as a limitation of the study design because collective strategies for data construction would foster a joint reflection about the psychosocial care network the data collection process preceded the mental health policy changes determined by the federal government that brought a lack of financing of community services and setbacks in relation to the care model with emphasis on hospitalization therefore participants considerations about advances in the psychosocial care network should be understood in context and referenced to the previous policy contributions to public mental health policy although data collection has been delimited within the municipality this study contributes to important reflections on relationships and tensions in the psychosocial field and may foster debates and action plans related to the optimization and strengthening of the psychosocial care network one of the highlights of the study design were the contributions of pierre bourdieus theoretical perspective for valuing the relationships between social agents and the structures of the psychosocial care network in mental health care and the importance of understanding the symbolic disputes in the psychosocial field of psychosocial care network managers perception and tensions of the field querino ra borges rs almeida ly oliveira jl souza j the present study indicated relevant actions of psychosocial care improvements and recognized the legal advances in the last three decades however the model of care based on community services has experienced setbacks in relation to institutionalization which reinforces the existence of conflicts and tensions in the psychosocial field and in its relations with the health and social care fields different perspectives are in conflict and dispute in the field and understanding them can contribute to advances in the care model final considerations the study findings show that the perception matrix of participants originates from their position in the psychosocial field since most of them are managers it was somewhat expected there would be more references to positive aspects of the services where they work than to the existing limits most tensions and difficulties mentioned were related to services other than their own especially to other sectors in general the habitus of social agents was expressed much more by their disposition to transform than to reproduce the status quo such disposition was perceived in statements with expectation for the expansion of primary care actions and optimism about improvements in the psychosocial care network social agents demonstrated disposition to contribute to change processes in order to overcome the focus on specialties lack of training of some teams and lack of infrastructure and some components especially those related to leisure and community life

objective to analyze the perception of workers and managers about the psychosocial care network in a mediumsized municipality in the inlands of the state of minas gerais method qualitative descriptive and exploratory study involving twelve participants from different points of the network the semistructured interviews were analyzed in the light of pierre bourdieus framework of constructionist structuralism results the actions offered by the services were based on the perspectives of resocialization user embracement group and multiprofessional care and on approaches to harm reduction recreation and daily organization these were configured as the network resourcescapital tensions were identified in family embracement and in relationships between families and users as well as in the prejudice towards people with mental disorders final considerations the social agents were willing to contribute to processes of change in order to overcome the focus on specialties the lack of training of some teams lack of infrastructure and of some components especially those related to leisure and community life

introduction within the us lowincome youth of color many of whom reside within and attend schools in large urban centers have long experienced barriers in accessing decent work that offers a living wage and opportunities for advancement in recent years opportunities for stable employment have diminished along with increases in underemployment and growing income disparities between the rich and the poor across the globe 75 of workers are employed in temporary or shortterm positions contributing to the widening income inequality between those who are more affluent and highly educated and those who are not the international labour organization ilo an agency of the united nations maintains that all workers should have access to decent work that is integral to personal and family wellbeing and to social and economic advancement according to the international labour organization ilo decent work should offer a fair income protection from wage loss safe working conditions access to health care respect for social and family values and opportunities for social dialog and worker organization although the ilo purports that sufficient decent work opportunities should exist such that everyone who wants to work has the opportunity decent work is diminishing while temporary and parttime work are increasing as decent work opportunities in the us workforce shrink as a result of technological change and turbulence in the economy worldwide young people from lowincome backgrounds who have less education and who belong to a racial or ethnic minority group are often marginalized from the economic academic and social resources needed to compete for the stable and decent work opportunities that do exist indeed while many young people across the globe are challenged in their efforts to secure decent work those who are poor and from marginalized groups worldwide experience the greatest obstacles this study focuses on elucidating the posthigh school experiences of graduates of a us high school designed to prepare young people from urban and lowincome families for successful futures through workbased learning and entry into higher education and decent work by asking high school graduates from lowincome backgrounds to reflect on how their high school experiences prepared them for life and work we hope to gain insights into how students construct meaning about school and work and the perceived value of school and wbl in their preparation for the future these insights might inform further research and efforts to enhance the life chances and access to decent work for those young people most disenfranchised due to economic and social barriers education at the high school level and beyond is a precursor to attaining gainful employment and access to associated economic health and social benefits within the us and globally persons with higher educational status are less likely to be unemployed and more likely to enjoy physical and psychological wellbeing across the life span technological change in the workforce and the elimination of many unskilled jobs due to automation and outsourcing means that advanced education is increasingly critical for entry and advancement in the world of work despite the importance of advanced education 19 of us high school students do not graduate on time with a traditional high school diploma and 20 of those who do graduate enter college needing remedial courses academic underattainment is most prevalent among young people growing up in a context of economic poverty who often attend schools staffed with less experienced teachers and with high teacher turnover these students experience an opportunity gap in comparison with more affluent students and are more likely to drop out of high school reap less income over their lifetime and belong to the ranks of the unemployed for longer periods of time among high school graduates lowerses youth are also less likely to apply to and enroll in postsecondary education and are less likely to complete a 2 or 4year degree than students from highincome families in addition to academic and technical skills a host of noncognitive or soft skills are recognized as important for success in finding and retaining a job advancing at work and attaining a higher income and greater work security indeed an individuals employability or capacity to obtain and retain suitable employment entails not only vocational or jobrelated knowledge and skills but an array of psychosocial skills that enable individuals to adapt to the changing demands of the world of work and to identify and realize work opportunities a growing body of evidence across the fields of psychology sociology economics and positive youth development attests to the importance of this array of varied but interrelated nonacademic skills for doing well in work and school settings achieving desired goals and relating effectively with others this broad set of skills has been conceptualized and studied based on varying frameworks and rubrics such as developmental assets life skills character grit career adaptability emotional intelligence socialemotional learning and 21st century skills among others while each of these frameworks is unique some shared constructs emerge that relate to selfcontrol social and communication skills selfawareness selfconfidence and positive attitudes for the future despite the variety of skills and inconsistencies in defining and naming the constructs a converging body of research suggests that these skills are malleable in the adolescent years and have an impact on academic success engaged citizenship pyd career decisionmaking workplace success and life quality in general evidence is also emerging that these varied noncognitive skills are especially important for sustaining career progress and maintaining personal wellbeing during times of economic and social uncertainty moreover employers in the us and other nations are expecting employees to be ready for the workplace equipped with noncognitive assets as well as academic and vocational skills while we maintain that broad systemic change is important for reducing the range of structural inequities that create barriers to decent work we also believe that high quality school and outofschool experiences can help to equip young people with the academic and noncognitive skills vital for establishing a trajectory of positive academic social and vocational development the pyd perspective which is anchored in developmental systems theory emphasizes the important role of schools and other youthserving settings in offering experiences and supports that enable youth to develop the individual assets and competencies needed to thrive throughout adolescence and into adulthood according to developmental systems and pyd frameworks positive development results from an alignment between contextual and individual assets with regard to individual assets pyd recognizes the importance of academic and noncognitive skills for young people to thrive in school work and life schools represent one vital context that can play an essential role in teaching academic skills and providing opportunities to develop the noncognitive skills and social and emotional competencies that are vital for lifelong success workbased learning which encompasses learning in the workplace through internships apprenticeships informal learning on the job and other vocationalspecific curricula has engaged interest in many countries around the globe for its potential to facilitate transitions from school to work to ensure that training is aligned with labor market needs to provide opportunities for the ongoing development of transferrable skills to meet the needs of the changing workplace and to help students understand and adapt to the realities of the workplace although wbl programs are more often offered across higher education and vocational training wbl has also demonstrated promise at the secondary school level as a model for connecting academic learning to work preparation enhancing positive student attitudes academic motivation and goal articulation for school and career and equipping young people with both academic and noncognitive work readiness skills for the transition from high school into meaningful work and life wbl programs thus represent one youth setting that can potentially complement the academic learning environment to develop personal social and work readiness competencies although some countries such as switzerland germany singapore and the netherlands have highly developed or comprehensive wbl programs at the secondary school level wbl programs are not typical or systemic in the us in response to the concern for improving the academic achievement of youth growing up in poverty the cristo rey network an association of 26 catholic high schools across the us emerged with the intent to transform urban america one student at a time the schools which serve only youth from lowincome families integrate a number of unique features with the intent to provide a holistic education that fosters academic social civic moral and spiritual development in addition to offering a faithbased education they provide an academically rigorous college preparatory curriculum coupled with wbl in the cristo rey wbl model students engage in real work that the corporation would otherwise pay another individual to do with the salary paid by the corporation going toward the students high school tuition typically one fulltime entrylevel position is split among four students from the school with each student working 1 day each week every student works across all 4 years of high school in a corporate or nonprofit setting with a focus on developing noncognitive work readiness skills rather than the development or transfer of vocational or technical skills to the workplace the present qualitative study is designed to enhance understanding of students perceived academic and noncognitive skills the perceived value of their high school experiences and their experiences across the posthigh school transition to higher education and work underlying this study is an ethical stance that builds on the jesuit origins of the cristo rey network and analogous movements in psychological studies of education and work which collectively affirm the importance of establishing equality and social justice in the systems that frame students development when considering the cristo rey ideology in conjunction with recent calls for justice in scholarship and program development efforts in career development the commitment to unpacking sources of marginalization and resources that help students counter these oppressive forces serves as a cohering aspect of our project among students who graduated from an urban catholic high school affiliated with the cristo rey network we explored graduates perceptions of their adaptations to education work and life 1 year posthigh school and the meanings they ascribed to their high school academic and wbl experiences in relation to their current lives students perceptions of their challenges and the value they assigned to their high school experiences may provide valuable insights on how lowincome urban youth understand their personal pathways toward higher education and the adult world and the types of experiences they view as facilitating and impeding their progress this study will help to advance knowledge about the potential of intentional wbl as a viable means of promoting access to decent work among a population of youth who are often marginalized from the resources needed to find meaning and purpose in their adult work lives materials and methods procedure all 60 members of the prior graduating class were invited by mail to an alumni event held at the high school on graduation day 1 year after their graduation the research team spoke to the approximately 40 alumni in attendance explained the research study and invited graduates to participate in interviews about their posthigh school experiences those willing to share their experiences were individually interviewed for approximately 3045 min the procedure was approved by the high school administration and by the university committee that reviews and approves faculty research to ensure the safe and ethical treatment of research participants interview and analysis the interview consisted of openended questions that tapped students perceptions of their transition from high school to collegevocational programwork as well as their reflections on their high school and wbl experiences the complete interview is provided in the appendix interviews were taped and transcribed verbatim and subsequently coded by the research team using thematic coding and content analysis which is described more fully in the following paragraphs research team members read the first interview individually to identify emerging categories and then met as a group to compare initial codes this process was repeated with other interviews and distinct categories were identified through the use of constant comparison resulting in a codebook with category definitions and examples coding was both deductive using the structure of the interview questions and existing theory to identify meaningful themes and also inductive with the research team members looking for nuanced and context specific themes that may not have been directly elicited by the structure of the interview or highlighted in existing literature as new categories emerged the research team recoded the interviews as part of an iterative process resulting in a total of 23 categories the initial 23 codes are closely aligned with the interview questions and include student activities in the firstyear post graduation their major responsibilities across the past year their expectations prior to graduation their actual experiences in the past year with subcodes for difficulties surprises and other their perceived preparation from their high school with subcodes for the educational program religious orientation and wbl work site experience and holistic reflections seminar at the school their perceptions of social support across the posthigh school year student perceived growth in posthigh school year comparison of their maturity to peers their future goals among other codes the 23 categories were reviewed and grouped individually and then collectively by the research team into four broad themes students actual experiences postgraduation their future goals their perceived challenges and assets and their perceived academic and personal preparation from their high school and wbl experiences the categories and content organized under each theme was synthesized into four memos or summaries the research team members wrote reviewed and discussed the summaries and met to further clarify refine and elaborate on the overarching themes and to determine descriptive labels for these themes and subthemes for example the memos and the codes aligned with each memo were reviewed individually and collectively by members of the research team who identified perceived posthigh school challenges the varied and specific personal qualities that students felt that they had developed during high school that helped them to navigate these challenges and their attribution of these personal qualities to the academic wbl experience or holisticreflection components of their high school program as overarching themes that in addition to their stated posthigh school activities and future goals spanned the four memos the consensus on the overarching themes apparent across all interviews was reached through a process of review and discussion among the team members the interviewers transcribers and coders included three university faculty and graduateresearch assistants from three collaborating colleges and universities in the metropolitan area surrounding the participants high school members of the core research team identified as four white women and four white men with two asianamerican women one latina woman and one black woman also involved in various phases of this study the researchers continually addressed possible biases and evaluated interrater agreement by having twoperson teams code the same interview individually and then meet to compare codes in addition the team members were cognizant of the ethical stance that underscored their work on the project which helped to ensure that the interpretation of the findings incorporated a clear vision of how social and economic forces shape students experience furthermore a knowledgable auditor was present at the weekly meetings to review interviews facilitate critical discussion challenge assumptions pose alternative interpretations ensure all opinions are considered and facilitate consensus when considered collectively these procedures are designed to contribute to the validity of the results results overview the interviews revealed that the alumni had engaged in a variety of school and work activities since their graduation although all of the graduates had been accepted into some form of higher education not all graduates actually enrolled and some left before completing their first year the posthigh school transition was relatively smooth for some while others encountered life events that altered their immediate plans across the 18 interviews several broad themes emerged which describe the ways in which students viewed their development and preparation for the future as emerging through their unique high school experiences and their experiences in the transition from high school to work andor higher education although not all graduates were enrolled in higher education at the time of the interviews all described a sustained focus on pursuing further education and felt that their high school had helped prepare them in important ways for posthigh school life that is in addition to the academic preparation provided by their high school all students described personal qualities developed over the course of high school that prepared them for school and work posthigh school the narratives reveal furthermore how students perceived those qualities as having been fostered through the unique education and wbl settings in which they were immersed posthigh school experience the fall following high school graduation 11 of the 18 alumni enrolled in college programs varying in level of selectivity of the 11 college students two were also working fulltime to support themselves one was working fulltime as a collections officer and the other was working in retail sales in a shoe store two left college after one semester one left to due to the medical complications of a pregnancy and financial concerns but planned to enroll in a community college the next fall with another leaving for financial reasons the latter was a very strong student academically in high school who had made a successful academic adjustment to a 4year college while working parttime in a real estate office she left after the fall semester obtained her real estate license and was then working fulltime in real estate sales with plans to return to college in the fall after saving some money three graduates were enrolled fulltime in vocational or technical preparation programs for training as a massage therapist a pharmacy technician and an electrician four graduates had delayed their plans for posthigh school study and were working at the time of the interview yet expressed a firm commitment and evidence of active planning to enter college one of the graduates delayed attending college in order to care for her mother who became ill and to look after a younger sister she was working fulltime as a sales supervisor in a small department store another delayed college for a year because she was undecided on a course of study she was working at a jewelry counter in a department store with plans to attend college in the fall another graduate delayed his plans to enroll in college after her parents decided to return to their county of origin this graduate was now working in food services and living with siblings who remained in the us with plans to attend community college in the fall the final graduate who was working fulltime as a waitress and at the counter in a restaurant had always planned to attend college but did not think she could afford to go at this time a summary of graduates and their posthigh school experiences is provided in table 1 future orientation although not all of the graduates were enrolled in posthigh school study 1year following graduation all described a future orientation that included continuing their education twelve of the 18 alumni described a clear career goal that was grounded in a direct route from high school through college or vocational school the remainder expressed more uncertainty or the presence of life events that altered the clarity of their path karen studying health science at a 4year college exemplified those alumni expressing a clear career focus and pathway toward her goals she stated right now my goals are pretty simple my goal for school is to keep going at the rate im going i want to get my gpa up after that i want to get to med school by the end of the 3 years that i have left my goal for summer is just to get a job and get a permit for my car roman described a clear sense of direction through vocational training its like a 9month program just to get the apprentice license and then after that i have to join a company for 4 years get my hours to go to my journeymans license then one more year to get my masters license and then i can be a master electrician own my own business vanessa attending a 4year college and studying biochemistry felt that her career direction was stronger than other students at her college she explained its really strange to me to see the people even in my science classes right now telling me that they want to go to med school but not exactly knowing how to get there i think that internship here the work study fills in that gap although all of the alumni were not as clear about their career direction they nevertheless expressed a firm commitment to posthigh school study and future planning maria who was working fulltime in food services to save money described her strategy for getting to college yeah i am going to get another job because i want to save as much money as i can to pay for college because i always felt that when i went to college i wanted to have a parttime job and i would just be studying and study hard and thats what i really want to do jessica who was attending college fulltime discovered that she no longer wants to be a nurse but expressed a commitment to continuing in college and identifying a new career goal i went in as a nursing major but quickly found out thats not what i want to do so i continued as an undergrad student and now im taking summer school to kind of find my niche as to what i really want to pursue as a career in considering possible options for the future jessica reflects on her wbl experience at an aquarium during high school i liked to do work there at the aquarium so i could have that type of experience when i try to pursue my career as a veterinarian alumnis perceptions of challenges and preparedness the alumni noted varied challenges in their posthigh school year as well as ways in which their high school and the workstudy programs helped to prepare them for life after high school with regard to challenges alumni commonly mentioned the need to hold themselves responsible with less adult supervision and the amount of work required in higher education judy who left college to have a baby and planned to return the following fall described the challenge of adult responsibilities she explained a lot of work to live life after high school like i said before you know you have to grow up youre an adult now youre not just a student you have to try to like some people have to live on campus and try to make it on their own you dont have your mother there at all times leyla who was working fulltime and attending college parttime commented i mean it really isnt easy you get a lot of free will youre not forced to go to class youre not forced to be there but you need to know the consequences if youre not in comparing the demands of her life in high school and college she noted that she is working every day of the week not just 1 day so its a lot harder among those who enrolled in higher education all students felt prepared academically although several identified the increased workload and higher expectations as challenging with regard to academic preparation for college vanessa stated northeast prepared me really well for it i give most of my credit to the english department at northeast science was not tough at all like i thought it was going to be it was all very much like stuff i had learned here roman found the academic work at the technical school easier than in high school so he enrolled in community college to take more advanced math coursework in precalculus maya who left college for financial reasons after one semester found the academic work manageable i thought in my mind that it would be a lot harder but i guess i was wellprepared and it got me in a good position in college for me it wasnt hard at all linda a college premed student felt prepared academically but was among those who commented on the work volume she noted i was prepared because of the way northeast prepared us um we not only went about going to school but we also basically had jobs while we were here so as far as me being prepared to work i felt like that i felt like that i was the only thing i wasnt prepared for was the amount of work because obviously in high school we dont get as much work and as timeconsuming work as you would call it in addition to academic preparation alumni highlighted their preparedness for posthigh school life as encompassing three sets of interrelated noncognitive skills including a sense of selfcontrol and selfregulation self and other awareness and social skills and professionalism although all of the alumni articulated ways in which their high school experience had prepared them for the year following graduation they highlighted different benefits selfcontrol and selfregulation more than half of the graduates spoke about their preparedness in relation to qualities of selfcontrol and selfregulation these qualities were viewed as important with regard to persistence time management and relational management in their current posthigh school work and education alberto enrolled in a 4year college was one of the graduates who spoke about the importance of hard work and persistence stating nothing comes easy you have to work for everything you want in college in school in anything anything you want you have to work for cassandra who was enrolled in a massage therapy program had struggled academically during high school but described how she persisted toward completing her degree i wasnt like the best the best of grades and everything but i hung on by a thread and you know i got to the point where my thread snapped and i wasnt able to graduate with my class but i did not let that stop me so i came back here and did what i had to do and passed the work and i just continued on with my mission marcos a 4year college student was among the alumni who described the wbl program as instrumental in fostering his maturity he stated and then i just look at the factors to my level of maturity and i see like any experiences in life and then i see my high school and the wbl program that really helped my level of maturity and then i just think some of these students probably didnt go to a corporate workstudy program the odds are that a lot of them probably havent and that could be a reason why their level of maturity is different from my level of maturity northeast helps students learn so many things you learn responsibilities you learn time management you learn all these things that can make a young adult a very good adult selfregulation was also exemplified in social relations and choice of friends sebastian who was studying computer science commented i try and find people who are the same as me you know outgoing but somewhat compatible to me i dont hang around people who smoke and drink and whatnot and if they do i just leave he noted how the work experience exposed graduates to a set of rules and consequences in the world outside of school here at northeast youre like were following rules and if you messed up this is what happens and you know its a guideline when you step out of here you have to make your own guideline and you have to follow your own rules and you know the consequences of work its not just detention anymore but i like it i feel i was well prepared some graduates also noted how the wbl experience had prepared them to manage multiple responsibilities maya who left college after one semester to work fulltime and save for her return to college stated having an outside job and going to school and having all other responsibilities helped me manage my life so much and that taught me so much like when i moved out of my parents house i was prepared already because i knew that its not easy working and going to school doing all that and paying bills so i had an idea already maya also described how the wbl program played a role in fostering personal strength the training that they gave us in the beginning that definitely helped me so much it gave me more character personality and i became like a stronger person selfreflection and other awareness the majority of the graduates described themselves as possessing a level of self and other awareness which differentiated them from their college and work peers as they described their selfawareness 14 of the 18 graduates made frequent reference to their high school wbl experience and to the holistic reflection seminar that was designed by the school to accompany the wbl program roman in technical school training to become an electrician described the wbl program as fostering awareness of self and the world beyond high school i mean a lot of the kids here were just kinda closed off to what the real world was and then now with the internship program it kinda opens up you know everyones minds how it actually is out there and i kinda like seeing that monica who took a year off to earn money to pay for college also viewed the wbl experience as fostering awareness of the larger world she stated other graduates commented on how the weekly holistic reflection seminar held at the school taught them how to be selfreflective and learn from past experiences thereby enhancing selfawareness and selfunderstanding for example sebastian studying computer technology at a 4year college commented when we did the reflections about work and stuff it helped me a lot to think about the way i deal with certain situations at work now liz who was working fulltime in retail also spoke of the benefits of the holistic reflection seminar it was just good to talk about work and just reflect on everything that happens and sometimes i needed that if i had a long week at work sometimes i just need to sit back and think about oh maybe i should have done this or maybe i should have done that but it did it was pretty good it did help somewhat karen studying health science at a 4year college also valued the lessons associated with the reflection seminar she commented they had a lot of quotes and a lot of things that told you to step back from the situation and look at it or like you know focus things like that help you realize that when things get really hectic step back look at whats really going and then deal with it kinda like small steps is what i feel i took out of reflection jessica attending a 4year college and undecided about her major commented i love the holistic reflections um they helped a lot um theyre very strategic in the way that they made the sessions the questions that they asked us were very very good they help you think basically and helped you figure out ways to go about situations concerning school or the work study how to go about it in a better way a more constructive way a more respectful way and stuff like that so it helped you to be more mature basically it kind of helped me that way cassandra training as a massage therapist appreciated the opportunity through the reflection seminar to express herself and get feedback from students and teachers she said being able to speak up being able to be heard being able to have people comment on what your issue is being able to have somebody to relate to you whos been there before so you dont feel like youre alone that helped me a lot too she also valued the personal and social knowledge she had learned from her teachers and the service experiences at the school there are two teachers here that i can say truly taught me the meaning of peace and community theres things i never knew i would do like volunteer and get into the community and just for them to put me at a homeless shelter i was like now i see things differently cassandra developed a personal philosophy that helped her to persist when challenged she explained theres lessons in life that you got to learn and you got to do something different you gotta approach things differently when you are in a situation you look at both sides put yourself in that persons shoes its certain things i ask myself just to get through monica who was working fulltime with the intention of enrolling in community college in the fall described her experiences in the reflection seminar and in interactions with teachers within the seminar and beyond they teach you to be proud of who you are to become better at what youre doing and what you do to become good and feel prepared they dont want you to be ashamed if youre latino they want you to be a human being who makes a mistake and youre able to learn monica also attributed a heightened sense of selfawareness and confidence to her religion teacher explaining shes a really good teacher she was always pushing me like roll through just dont get scared maybe shes more of a model for my life because shes so selfconfident shes not scared what people are thinking about her like shes really strong religiously as a person so i learned that that you need to be strong and fight for what you want and thats in my mind most of the time so i really appreciate what she did for me social skills and workplace communication many of the graduates described confidence in their social skills and communication for the workplace vanessa a 4year college biochemistry major explained i think like youre always professional even though you dont try to be its just there its just there and i think they kind of ingrained that a lot in school relatedly cassandra commented on how she learned to communicate professionally through wbl she reported being able to be out there in the corporate world being able to have like corporate communications knowing how to be professional and knowing when to tone down your attitude you know once you step in the door you know what im saying like i said its not about you anymore its about whos the client for the day the majority of the graduates commented explicitly on how the wbl experience had equipped them with valuable skills related to workplace communication jessica enrolled at a 4year college gained an understanding of the value of a substantive resume through the wbl program she stated i just want to express that the wbl program did help me a lot um i just filled out my resume and when i was looking back at it and really thinking about all the firms that i have been to its just really a blessing to have experienced that several students noted how the experience prepared them to interact with adults roman studying to become an electrician commented like socially it just helped me talk to adults because i was so used to talking with people my age and my boss was like fifty and i had no idea how to really approach her but after the 2 years we really became close and she was almost like a second mother to me because she gave me a lot of advice marcos a 4year college student reflected similarly working at a corporate workstudy program helped me learn how to speak and how to communicate with adults i need to know how to speak to an adult how to like say things in a way that an adult would understand i cant just use i cant just speak to adults the way i speak to my friends graduates noted the importance of the social skills they learned while in high school for posthigh school employment liz who was working fulltime in retail while also caring for her ill mother commented that is what this school is for to prepare you for the future yeah the working and the dress code and how we all have to act professional and it is just a good set up for what is supposed to come after high school latoya who was working fulltime with plans to enroll in college in the upcoming fall also commented on the preparation she had received for the workplace i knew what to do and what not to do and being here they showed you how to dress for the corporate stuff for the workplace discussion during the year after their high school graduation the 18 young people interviewed in this study experienced varying levels of school and work successes and disappointments they encountered many of the developmental challenges typical of young people their age along with additional challenges more common among young people who have limited access to economic resources and social capital as a result of their social status while the transitions to higher education and work were relatively smooth for some of the high school graduates for others the transition was marked by postponements and altered plans following unexpected life events all of the alumni however maintained focus on further education and described a range of academic and noncognitive skills that have been associated with workforce preparation and positive developmental trajectories while growing up in lowincome neighborhoods has been shown to have a profoundly deleterious effect on high school graduation rates the young people in our sample exemplified some level of success through their completion of high school acceptance into posthigh school education and entry into either higher education employment or both while statistics indicate that 15 of high school graduates in the us and 23 of those with less than a high school diploma between the ages of 16 and 24 are neither in school or employed all of the alumni we interviewed were engaged in school work or both the percentage of young people who are neither in school or work is as high as 50 in countries with emerging economies in contrast to the prevailing criticism of high schools as not preparing young people for college and career these young people described their high school and wbl experiences as equipping them with varied academic and noncognitive skills that they valued in navigating posthigh school challenges the noncognitive skills described by these young people are similar to those identified as valuable in prior research selfcontrol intentional selfregulation and future orientation for example are highlighted in pyd research they are also similar to those identified by vocational psychologists as related to employability career adaptability and as critical for navigating life and work in a time of uncertainty conceptually related but distinct concepts such as grit and perseverance have also received significant attention in recent research on youth academic and life success in a broad sense our alumni fit the descriptions of gritty youth who demonstrate the capacity to regulate their time attention emotions and social interactions and sustain perseverance despite ongoing life challenges in addition to the intrapersonal skills associated with selfcontrol and selfawareness many of these young people described confidence in their social and interpersonal competencies as well as capacities for selfreflection and self and other awareness which have been identified as important competencies in research on social and emotional learning and for career decision making in this sense these young people appear to be equipped with a number of the 21st century skills which many employers observe as lacking in young people today given the paucity of knowledge concerning the contextual bases for the development of noncognitive skills the narratives offer insight into how some young people perceive their schools and specific aspects of their school programs as preparing them for life after high school while the level and source of their noncognitive skills are not verifiable from our data these young people directly attributed many of these skills to the programs and relationships experienced in their high school the idea that positive development for these young people stems from an alignment between their strengths and the assets of their context is consistent with the developmental systems perspective and pyd model the narratives of these youth reflect an understanding of human development as a dynamic interactive process in which the environment and the individual are both key in shaping outcomes recent attention to the role of grit or perseverance toward longterm goals has been challenged by some critics who maintain that that a focus on individual qualities may overlook the role of structural and systemic barriers that lie at the roots of the opportunity gap our findings serve to contextualize the understanding of noncognitive skills as alumni describe how realworld learning experiences in the workplace the presence of caring adults at school and work and a space in the school curriculum to reflect on and give meaning to their work experiences contributed to their perceived noncognitive strengths and preparation for the future also consistent with developmental systems and pyd frameworks our findings reveal how contextual factors beyond the individuals and their school present substantive challenges for entry into and success in higher education and decent work youth with low economic resources often experience unique and complex hurdles in the transition to college some of the graduates in our sample for example delayed posthigh school study or dropped out of college for reasons less typical of the middle class college student such as the need to support oneself when parents return to their country of origin or due to the complications of an unplanned and medically difficult pregnancy postponing college entry to care for a sick mother and sister was also cited as a reason for delaying college perhaps associated with low economic resources andor cultural values emphasizing family commitment and genderbased valuing of personal care work over market based employment lack of economic resources along with uncertainty regarding major or course of study were also noted as reasons for not entering college immediately after high school the life stories of the northeast alumni are thus consistent with prior research revealing that lowincome high school graduates may change their plans to enroll in postsecondary education over the summer months as a result of complicating life events and concerns about the costs and the economic benefits of higher education while the experiences of these students are uniquely embedded in the us context they are consistent with global evidence documenting how economic and social barriers impede the academic and work achievements of young people growing up in low resource settings the findings have relevance to exploring the challenges that face many youth as they transition from school to the world of work and then optimally to an adult life that includes decent work their stories illustrate the inevitable interrelation of work and nonwork experiences and the ways in which social cultural and economic factors shape the journey from school to decent work as reflected in the ilos contributions many of the antecedents of decent work occur at the macro level involving access to education safe neighborhoods good health care and a host of other economic and social factors however individual and more proximal systemic factors also play a major role in the complex array of factors that promote decent work as the narratives suggest in this study the graduates of the wbl program at northeast cristo rey faced numerous challenges once they left high school however some managed to make adaptive transitions to postsecondary training while others struggled the prevalence of external barriers seemed to overwhelm some of the participants which underscores the need for equitable systemic solutions that will allow people to thrive and flourish in their educational and vocational lives for many of the participants though the wbl experience was key in exploring the meaning of work in relation to their own values and to the development of a future orientation and an array of noncognitive skills which offered important internal resources in the struggle for meaningful work and life although the alumni interviewed in this study highlight the capacity of schools and wbl programs to foster the development of noncognitive skills in addition to academic development the limitations of the study must be considered with regard to generalizability the participants represent a select sample of the high school graduates who chose to attend an alumni event although our participants experienced various levels of academic success during and after high school it is likely that those students who felt disconnected from the high school did not attend the alumni event the generalizability of our findings is also limited by the nature and structure of this particular school this is a private catholic school in the us northeast that serves only lowincome students the specific qualities of the students who choose to attend this school and the emotional support they receive from their families to enroll in and persist at this challenging high school are not clear although the findings from this study may be generalizable to other cristo rey high schools in the us offering a similar wbl model the applicability for students in other wbl programs in the us and in other nations is not clear the retrospective nature of students comments is of course subject to revisionist bias and should be viewed with caution the interviews were conducted only 1 year after graduation so that the longrange posthigh school success and career attainment of the graduates is unknown further research is needed to address limitations of the current study followup of a random sample of graduates over a longer period of time is necessary to provide an understanding of their immediate and longrange experiences along a pathway to decent work future research should include the perspectives of key stakeholders from the high school higher education posthigh school employment and family contexts including individuals within these overlapping spheres of influence can overcome the limitations of reliance on individual selfreport and inform a broader understanding of how contextual and individual factors interact in creating and limiting access to decent work although we found the pyd framework to be helpful in guiding this study further research can serve to deepen understanding of role of sociocultural contextual and structural factors in preparation for meaningful work and life and access to decent work for lowincome youth varied stakeholders might further illuminate the internal proximal and distal resources that young people might access in gaining entry into decent work further research at the distal level is needed to understand how workplace and broader economic policies interact with individual skills in impacting access to decent work comparing the experiences of graduates of this high school to graduates of other schools in the network across the us and other secondary school wbl models in the us and across the globe will also be important in gaining a broader understanding how students understand their high school experiences as preparing them for the future of decent work given the limitations of this study implications for policy and practice are considered tentative in the context of ongoing educational policy debates in which creating a culture of college and career readiness is a priority in the us our study participants were able to reflect thoughtfully on how their high school and wbl experiences contributed to academic and noncognitive skills that they have relied on to navigate myriad subsequent challenges while we cannot infer causality and more research is needed positive features of the wbl program and supportive and reflective learning experiences at school may be applicable in other school settings as vehicles to prepare lowincome youth academically socially and motivationally for the ongoing challenges of young adult life these characteristics have been noted in previous reviews of high school reform efforts in the us that highlight the importance of addressing the social emotional and motivational capacities youth as well as their academic skills and have been noted in international research on effective wbl programs beyond the high school and wbl contexts our overall findings suggest the need for a multifaceted and systemic approach for enhancing access to decent work for lowincome youth employability depends not only on welldeveloped individual skills but also on organizational and broader contextual factors such as the status of the labor market blustein et al have labeled interventions that seek to enhance noncognitive skills as promising microlevel initiatives potentially relevant in removing barriers to upward mobility but acknowledge the necessity for further macrolevel initiatives for work preparation poverty reduction and the expansion of decent work the types of work in which most of the alumni were engaged reflect retail and food services positions that offer little long term security or room for advancement consistent with the pyd perspective efforts to enhance resources across school work and public policy contexts are needed the type of publicprivate partnerships exemplified by wbl might for example be expanded in creating more effective decent work pathways and opportunities for all young people wbl programs might also be enhanced consistent with best practice in countries such as switzerland and germany to provide a direct pathway from internships or apprenticeships to meaningful employment and to offer a system of ongoing career guidance beyond secondary school although recent us national initiatives suggest that all students who graduate from high school should be prepared for college and career our analysis suggests that some graduates may not have the interest or vocational clarity to pursue higher education immediately after graduation such that enhanced and ongoing career counseling and posthigh school employment might make sense for those figuring out a goal or course of study although further research is needed to address limitations of the current study and to more fully understand the role of contextual influences our findings give voice to the meaning that urban high school students ascribe to their high school and posthigh school experiences and offer insights concerning their varied pathways from high school toward higher education and meaningful work and life supplementary material the supplementary material for this article can be found online at 201600286 conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

the challenges confronted by lowincome high school students throughout school and across the transition to higher education and employment are welldocumented in the us and many other nations adopting a positive youth development perspective lerner et al 2005 this study reports findings from interviews with 18 lowincome racially and ethnically diverse graduates of an urban catholic high school in the us the interviews were designed to shed light on the posthigh school experiences of urban high school graduates and to understand how students construct meaning about the value of school and workbased learning wbl in their preparation for meaningful work and life the interviews highlight the perceived value of the academic and noncognitive preparation students experienced through high school and wbl in relation to the challenges they encountered along the pathway to posthigh school success and decent work overall the findings suggest the potential of wbl for lowincome youth in facilitating access to resources that build academic and psychologicalnoncognitive assets while also illustrating the role of structural and contextual factors in shaping posthigh school transitions and access to meaningful work and life opportunities

introduction p ersistent lack of immunization in certain groups of children is one of the main challenges in immunization campaigns this problem cannot be sufficiently addressed by strategies directed at the general population but the management of immunization programmes can be improved through preliminary identification of groups with deficient vaccination coverage 12 numerous factors have been identified as determinants of deficient immunization rates in infancy and childhood however the reasons for these low levels of coverage are not fully understood and studies to date have not demonstrated which factors are the most important 3 the effect of some factors depends on countryspecific circumstances for example on the way of vaccine delivery 4 or on parents attitudes and beliefs regarding vaccination 5 6 7 8 9 10 11 12 in the uk and scandinavian countries vaccinations are given by trained nurses in specific baby clinics whereas in other countries like austria vaccinations are administered only by the general practitioner paediatrician or the health service 4 also beliefs of the public and healthcare professionals regarding vaccine safety play an important role in vaccine uptake 13 14 15 for example widespread public concerns about triple vaccination against measles mumps and rubella in the uk arose during the 1990s and have been described as barriers to measles vaccination uptake 3 15 16 17 attitudes towards vaccination appear to be less important than sociodemographic factors in determining the immunization status 69 other factors seem to be consistently associated with deficient vaccination rates in most countries the first group of these factors concerns the social position of the parents such as the educational status 91824 family income 7810 22 23 24 or occupational position 25 and demographic factors such as the age of the child 223 childs birth order 810 age of the mother 912 geographical mobility 9 cultural elements 68 19 20 21 22 23 24 and population density 1626 a second group of consistently associated factors which is related to the first group concerns social support and life circumstances of the family and conditions of child care such as the number of children in the family 2691220 family dysfunction 7 marital status of the mother 102223 employment status of parents 8 19 20 21 22 living environment with respect to urban or rural place of residence 21621 support in child care and oneparent family status 6 although the last group of factors which can be interpreted as measures that suggest greater demands on family resources were investigated in several studies only very few studies included variables on support in child care in their analysis 6 from a viewpoint of conceptual hierarchical frameworks 27 childcare variables can be seen as proximate determinants of vaccination status whereas social and demographic factors are referred to as distal determinants the latter are most likely to act directly on vaccination status and through a number of interrelated proximate determinants such as childcare resources failure to take hierarchical structures into consideration may lead to underestimation of the effects of distal determinants ie overadjustment bias 27 therefore for building conceptual model we distinguished three hierarchical levels based on assumptions about the causal interrelationships among all variables the aim of this study was to assess the effect of both the resources for child care and the parental social status on measles immunization coverage a further aim was to explore the complex interrelationships between these factors by means of a hierarchical analysis in order to identify important explanatory variables to this end we surveyed the parents of schoolchildren in styria austria for hierarchical analysis we used the socalled graphical modelling approach 2829 methods the actual vaccination guidelines in austria 30 recommend two doses of measlesmumpsrubella in the second year of life a second dose is recommended to all children at least 28 days after the first dose but preferably before reaching 15 years of age mmr vaccination is government funded and offered free of charge to all children up to 16 years of age paediatricians general practitioners and public health institutions may administer the vaccine all mothers receive a socalled motherandchild passport when pregnant this includes an inoculation and vaccination record during the regular postnatal visits with the general practitioner or paediatrician an appointment for the vaccination is organized there is no active reminder or recall system but the second dose of mmr is also administered in primary schools by school doctors in regular catchup programmes for the 6to 7yearold children study population and data collection a questionnaire survey was conducted in styria a county of austria of about 12 million inhabitants randomly selected schoolchildren of the first fourth and seventh grade and their parents were the target sample of this crosssectional study we used a stratified cluster sample design consisting of 176 randomly selected classrooms of primary schools and high schools as primary sampling units a list of all classrooms was obtained from the styrian school authority we stratified the sample according to the grade of the child and residence in order to obtain a sufficient number of cases in each stratum all teachers of the selected children received 30 questionnaires and a letter of invitation to participate in the vaccination study by the internal post service of the styrian school authority all children in a selected classroom were included in the sample the size of the clusters varied between 6 and 25 subjects we received questionnaires from the parents of 3037 children representing a 73 sample of the 41 417 schoolchildren of the same grades in styria the distribution and collection of the questionnaires by means of schoolteachers ensured the comparatively high response rate of 798 we excluded all cases with missing values on at least one of the variables therefore a total of 2386 subjects have been included in the ultimate data analyses to check for nonresponse bias our analysis sample was compared with the sample of excluded subjects the two groups did not differ in measles vaccination rates and in demographic determinants definition of variables parents were asked to report the number of vaccinations using mmr mm or measles vaccine received by their child to date the dependent variable for data analysis was the binary variable vaccination status defined as 1 if at least one mmr mm or measles vaccination was received and 0 otherwise to increase the reliability of the answers the parents were additionally requested to report the exact date each vaccination was administered therefore we assume that the parents were forced to use the inoculation and vaccination record as reference document it has been shown 31 that validity of parental recall depends on the number of shots of the vaccination and that recall is high for single dose vaccinations as is the mmr vaccination according to our hierarchical model two groups of independent variables were distinguished the first group exclusively contained variables that cannot be determined by the other variables of the study and was referred to as sociodemographic status this group included two demographic variables of the child and two variables that were considered to be stable characteristics of parental social position not influenced by current life circumstances or variables of the second hierarchical level these variables were as follows the grade of the child the childs gender the highest educational level of the father and the mother categorized as compulsory education apprenticeship high school university we did not include variables on ethnicity or immigration status in our study because of the high ethnic homogeneity of the styrian population 32 regarding barriers influencing access to health care providers we did not consider childs health insurance status because 100 of the children are covered by the austrian health insurance programme the second group of independent variables referred to as childcare resources described current conditions of child care including factors of the social microenvironment and living conditions as these variables potentially depend on firstlevel variables and may influence the vaccination coverage they formed the second hierarchical level of our model this included the number of children in the family current employment status of parents one parent family support in child care at home by friends relatives neighbours or nursery teachers and place of residence coded as urban or rural although the number of children in the family can be judged as a demographic factor we decided not to include it in the first level the number of children is potentially influenced by factors of the second level and moreover it is an indication of differences in the conditions for child care statistical analyses bivariate statistical analyses were performed first using spss statistics for windows group differences were assessed with the pearsons chisquare test and using the gcoefficient 33 as association measure for ordered qualitative variables to incorporate our conceptual hierarchical model into the analysis we performed a second analysis utilizing recursive graphical models graphical models are a multivariate statistical method particularly useful for explaining and describing direct and indirect interrelationships between several variables they can be seen as a generalization of regression models in the sense thatwith necessary modelbased restrictionseach variable in the model is simultaneously evaluated as a dependent variable then potential causal pathways and intervening variables can be modelled graphical models were introduced by darroch et al 28 and lauritzen 29 edwards 34 published a detailed and readable introduction to applications graphical models determinants of vaccination coverage in schoolchildren are visualized by an independence graph where vertices represent variables and lines or arrows symbolize undirected or directed conditional relationships ie significant associations between two variables we used the software package digram 35 for hierarchical analysis which is designed for recursive graphical models with qualitatively scaled variables the partial gcoefficient was used in the hierarchical analysis for the description of conditional relationships between each pair of variables and was included here for comparison corresponding to our conceptual hierarchical model we set up for the digram analysis a threelevel graphical model with the third level as the dependent variable vaccination status the second level as the resources for childcare variables and the first level as the sociodemographic status variables the first step of the digram analysis consisted of a preanalysis of the saturated model this is a model that assumes that there are connections between all variables as in the case of backward elimination regression analysis using the screening procedure of digram all nonsignificant conditional relationships with level of significance of 015 were excluded from the model the resulting model was further analysed using the backward selection procedure of digram with a chosen level of significance of 005 results bivariate analysis the mean age of the children was 65 years in the first grade 96 years in the fourth grade and 131 years in the seventh grade thus corresponding to an age difference between grades of 3 years the frequency distributions of the different variables within each category are listed in table 1 the complete administration dates of the reported vaccinations were only missing in 41 of the vaccinated children table 1 displays the unadjusted measles vaccination rates for each category of all investigated factors lower vaccination coverage was significantly associated with higher grade a lower level of paternal and maternal education a higher number of children in the family no support in child care and a rural place of residence no significant association with coverage was found for childs gender the employment status of parents and for single mothers or fathers hierarchical analysis figure 1 presents the final model of the graphical backward elimination analysis visualized by the independence graph where arrows indicate directed associations between different levels and lines show relations of variables within the same level table 2 gives the gcorrelation coefficients and the pvalues for all statistically significant associations seen in the independence graph the sign of the gcoefficients indicates the direction of the relationship three factors showed a significant direct effect on vaccination status the grade the number of children in the family and the educational level of the father concerning the resources for child care none of them showed a direct relation to the vaccination rate with the exception of the number of children variable there was no direct association of the level of parental education with the number of children but there were direct associations with both the parental employment status and the urbanrural place of residence which in turn were related to the number of children thus the level of the education of the father was directly associated with the vaccination status of the child whereas indirectly by family size hence it seems to be of focal interest concerning the sociodemographic factors concerning the resources for child care the factor of focal interest was the number of children the other assessed childcare variables were associated only indirectly with the vaccination coverage in multivariate analysis since the level of education of the father and grade are assumed not to be causally influenced by resources for child care solely the number of children may act as an intervening factor between childcare resources and vaccination status the results suggest that the number of children were directly associated with an urban place of residence being a oneparent family and employment of both parents therefore these factors might indirectly correlate with the likelihood of vaccination but seemed to be of no direct relevance for a family of fixed size discussion the major objective of our study was to identify factors that may explain deficiencies in measles vaccination coverage of schoolchildren and to provide information about their interrelationships we focused on the role of childcare resources and their interrelationship with sociodemographic factors bivariate analyses showed significant associations for grade education of the father and the mother number of children in the family support in child care and place of residence no associations were found for childs gender parental employment status and oneparent family vaccination coverage of the children of the first and fourth grade is comparable with other european countries 36 whereas coverage in seventhgrade children is lower the higher rates in the first and fourth grade can be attributed to a second vaccination at school entry introduced by the recent measles vaccination programme in the graphical modelling procedure numerous plausible and welldocumented relationships appeared within and between the first two levels a closer look at the interrelationships between the different levels reveals that a low educational level of the father is a main distal explanatory variable related directly and through intermediate variables to the vaccination status of the child another previous study 24 analysed fathers and mothers educational level separately and found similar to our results a stronger correlation of vaccination rates with the fathers than with the mothers educational level a low educational level of the father and mother is associated with a lower employment of the parents with a lower likelihood of support in child care and with living in a rural region these resources are in turn related to a higher number of children in the family a variable consistently related to a deficiency in vaccination coverage in our study and in previous investigations 2691220 the vaccination coverage is not directly related to urban vs rural place but through other factors like the family size or the parental educational status this result suggests that in comparing the rural with the urban conditions there may be no other placespecific determinants of relevance than the factors included in the model this seems to be in accordance with the situation in austria where the ways of vaccination delivery and uptake are very similar in urban and rural areas the indirect association of the resources for child care may indicate potential indirect causal effects of these resources on the vaccination coverage in this case a low parental educational status may be directly and mediated by resources for child care associated with deficient coverage a look at the independence graph of our model enables us to discern the function of intervening variables and their dependencies on distal sociodemographic factors the main mediating variable was the number of children in the family it was the only investigated childcare factor directly associated with the vaccination coverage childcare factors directly associated with this mediating variable were living as oneparent family urbanrural place of residence and parental employment status the latter two variables were associated with the educational status of both parents therefore a low level of education of the father and the mother is an indirect predictor of a low coverage through their correlation with deficient resources for child care comparing the gcoefficient between vaccination status and education of the father of 020 with the partial gcoefficient from graphical analysis of 016 illustrates the problem of underestimating the effect of distal predictors as described by victora et al 27 two conclusions are to be made first the overall effect of the educational status must be evaluated without improper adjustment for proximate factors ie through bivariate analysis and not by regression analysis second an assessment of proximate factors associated with deficient vaccination coverage in children without adjusting for the social status of the parents may lead to biased results as an overall conclusion this study indicates that parental social status measured by the level of education is a major predictor of measles vaccination coverage in schoolchildren the size of the family seems to be an important predictor of the life circumstances of the family concerning child care our results suggest that for a given number of children in the family resources for child care are not associated with the measles vaccination status of the child thus our results add to the existing literature as in previous studies we were not able to explain through which pathways the number of children is related to a deficient vaccination coverage vaccination programmes should therefore mainly focus on families with many children or parents of low educational level and not on the whole population approved methods include mass media campaigns directed towards target populations and notification of nonvaccinated children to local health professionals and parents 37 furthermore the results suggest that the targets of primary prevention should include the improvement of the general educational level of the whole population with respect to the applied methodology it can be stated that the evaluation through hierarchical graphical modelling allowed a refined constitution analysis and interpretation of the data compared to regression analysis the graphical models method offers the decisive advantage of pointing out the associations of predictors within the same hierarchical level on the one hand and lending support to the theorybased and hypothesized pathways on the other the major drawback of graphical modelling is the lack of a unique and interpretable effect measure such as the odds ratio or relative risk conflict of interest none declared key points the effect of both the resources for child care and the parental social status on measles immunization coverage in austrian schoolchildren was investigated the highest strength of association with deficient vaccination coverage was found for the number of children in the family a low educational level of the father and the mother and a high grade were also independently related to low coverage the results indicate that the only independent factor associated with child care is the number of children in the family whereas the other investigated resources for child care are only indirectly associated with vaccination coverage vaccination programmes should mainly focus on families with many children or parents of low educational level and not on the whole population

background numerous socioeconomic and demographic factors have been identified as being associated with low vaccination coverage in children however the complex interrelation between these factors is not fully understood we focused our study on the less wellestablished associations of familial resources for child care with vaccination coverage and their interrelationship with sociodemographic factors methods this crosssectional study n 2386 focuses on parental social status and on resources for child care as determinants of measles vaccination coverage of schoolchildren aged 613 years in styria austria in order to reveal the relationships among these factors an analysis based on a conceptual hierarchical model was performed the socalled graphical modelling approach was used for the multivariate analysis of the hierarchically structured determinants results the findings indicate that vaccination coverage is directly associated with a large number of children in the family p 00001 and directly as well as indirectly associated with a low level of education of the father p 0001 all other included childcare resources are only indirectly associated with a low coverage whereby the number of children acts as main mediating factor conclusions the results suggest that vaccination programmes should mainly focus on families with many children or parents of low educational level and not on the whole population

children are those born outside the united states to nonus citizen parents the term cif includes both those who are foreign born and those who are born in the united states and have at least 1 parent who was foreign born in 2015 43 million people representing 13 of the us population were immigrants approaching the historic high of 148 in 1890 12 currently 3 of us children are foreign born and 25 of us children live in immigrant families 34 it is projected that by 2065 18 of the us population will be foreign born and an additional 18 will be usborn children of immigrants 2 immigrant children and cif reside in all 50 states children immigrate to the united states with or without their parents for diverse and complex reasons including but not limited to economic needs educational pursuits international adoption human trafficking or escape from threatening conditions in pursuit of safe haven immigrants may arrive with temporary visas have or obtain permanent permission to remain in the united states come with refugee status seek legal protection on arrival to the united states or remain without legal status refugees who obtain legal status before arrival and asylees who can obtain legal status after arrival in the united states must have a wellfounded fear of persecution based on race religion nationality sexualgender orientation political opinion or membership in a particular social group 5 lprs and refugees can apply for citizenship after 5 years of living in the united states 6 in addition to asylum other forms of protection may also be available to particular children and families seeking safe haven in the united states 7 if parents or children do not qualify for a legal form of protection they may choose to remain in the united states without legal status specifically approximately 111 million individuals in the united states lack current legal status 8 and 51 million us children live with at least 1 figure 1 population of immigrant children in the united states 2017 reprinted with permission from the annie e casey foundation kids count data center figure 2 cif 2016 reprinted with permission from the annie e casey foundation kids count data center immigrant parent without legal status 9 in 2016 half of the 225 million refugees worldwide were 18 years or younger and less than 1 are resettled annually 10 ongoing humanitarian needs are acutely exacerbated by global migration crises exemplified by the displacement of nearly 12 million syrians by the end of 2015 10 the number of refugees entering the united states is set annually by congress and the president and historically has fluctuated on the basis of sociopolitical events all 50 states with the exception of wyoming have refugee resettlement programs 11 migration to the united states varies on the basis of global poverty armed conflict and exceedingly complex sociopolitical circumstances despite these complexities the united nations convention on the rights of the child endorsed by the american academy of pediatrics but not ratified by the us government is an internationally recognized legal framework for the protection of childrens basic rights regardless of the reasons children migrate 12 13 the aap policy statement the effects of armed conflict on children delineates the impact of armed conflict on children and the role of child health professionals in a global response 14 responses to migration and especially migration of children are equally varied and complicated 15 for instance increasing arrivals of unaccompanied children and family units from guatemala honduras el salvador and mexico at the southern us border beginning in 2014 triggered a series of governmental responses including escalating detention of immigrant children described in detail in the aap policy statement detention of immigrant children 716 additionally the deferred action for childhood arrivals program was developed to allow young adults who had arrived in the united states as children without legal status but had grown up in the united states to apply for deportation relief and work permits 15 a related program deferred action for parents of americans and lawful permanent residents would have offered similar protections for parents without legal status who have usborn children but it was halted in federal courts and was subsequently rescinded by presidential executive order before it could be implemented 1517 in 2017 the president signed new executive orders focused on heightened immigration enforcement increased border security and limits to the us refugee program furthermore changes to temporary protected status granted to individuals physically present in the united states who are from countries designated by the secretary of the us department of homeland security as unsafe to accept their return have created uncertainty for the nearly 320 000 tps beneficiaries and their families 18 in addition to changes in the numbers and demographics of immigrants and the legal protections afforded them family immigration status represents an important and oftenneglected social determinant of health the immigration status of children and their parents relates directly to their subsequent access to and use of health care perceived health status and health outcomes 7 19 20 21 22 23 24 25 26 family immigration status is intertwined with other social determinants of health including poverty 27 food insecurity 2829 housing instability 3031 discrimination 3233 and health literacy 34 35 36 37 resilience and integration despite the challenges that immigrant children and families often face many offer tremendous assets and demonstrate remarkable resilience on first arrival in the united states immigrant children may be healthier than nativeborn peers a phenomenon often described as the immigrant paradox or the healthy immigrant effect 2733 a strengthsbased approach to immigrant child health celebrates assets of immigrant families and populations buffers marginalization and supports integration understanding cultural assets such as ethnicracial identity and cultural values may offer opportunities to build resilience among immigrant children 38 39 40 furthermore recognizing assets facilitates productive dialogue that supports immigrant families not as threats but as valuable resources to our society 40 cultural humility and safety when caring for cif health care providers must recognize the role culture plays in understanding illness without reflexively assuming that challenges are always attributable to cultural differences 41 42 43 44 45 because culture is dynamic cultural competency is never fully realized 46 but rather serves as a developmental process 47 providers bring personal cultural biases as well as biases of biomedicine that can implicitly or explicitly affect the provision of care 4849 cultural humility is the concept of openness and respect for differences 50 51 52 cultural safety reflects the recognition of the power differences and inequities in health and the clinical encounter that result from social historical economic and political circumstances 6566 however disparities in access to care for cif and especially for those with special health care needs have persisted 2425 67 68 69 70 71 72 immigrant families particularly those with children with special health care needs often benefit from intensive supports in negotiating a complex medical system special education system and network of community resources pediatric providers can play a lead role for the medical home team in implementing and educating on core competencies that are meant to build health equity for cif core resources for the provision of care for cif include but are not limited to the aap immigrant child health toolkit 44 and the centers for disease control and prevention refugee health guidelines 73 crosscultural approach rather than learning generalities of a given culture a practical framework can guide the clinical approach 7475 a classic patientbased model recommends assessing for core crosscultural issues exploring the meaning of the illness determining the social context and engaging in negotiation around treatment plans 76 core crosscultural issues include styles of communication trust family dynamics traditions and spirituality and sexual and gender considerations 75 kleinman and bensons 45 7 questions for cultural assessment are helpful to explore patients perspectives most crucially this includes what matters most to the patient and family within the context of illness and treatment the efficacy of treatment may need to be understood within the scope of cultural beliefs and not that of the scientific evidence 7778 therefore there may be need for crosscultural negotiation facilitated through tools like learn 5779 knowledge and skills can be developed regarding crosscultural patient care migration health issues and unique vulnerabilities and strengths of immigrant families although all children and families are unique origincountry profiles may be helpful to provide generalized information about immigrant groups 80 81 82 migration health issues care of immigrant children requires knowledge of unique health issues in the childs country of origin and country or countries of refuge before arrival as well as an understanding of the challenges of resettlement and acculturation once within the united states when taking a medical history it is therefore necessary to elicit details of migration 73 as well as the childs birth medical immunization developmental social and family history and exposure to trauma and violence 7383 past medical and immunization records may require translation as well as awareness and management of different global immunization schedules 8485 cif often return to their families countries of origin to visit relatives and providers need to be familiar with travel risks prophylactic medications and unique vaccine needs 86 communicable disease when screening for and treating infectious diseases a public health approach is advantageous 4487 for refugees some screenings may have been performed in another country and presumptive treatments may have been provided through the international organization for migration 88 depending on the migration history immigrant children may need screening on arrival in the united states for infectious diseases 44 87 88 89 90 91 92 93 94 comprehensive reproductive and mental health services are warranted for immigrant children with a history of sexual activity trafficking exploitation or victimization oral health the global burden of oral diseases is high 95 caries risk varies depending on previous country of residence 9697 differences in oral health may reflect cultural practices and norms related to weaning and brushing dietary changes and limited oral health literacy 98 99 100 101 access to dental services and education on oral health is essential for immigrant children 102 noncommunicable disease the incidence of noncommunicable diseases globally has grown 103 104 105 rates of asthma obesity autism 106 107 108 109 110 depression anxiety and posttraumatic stress disorder may be similar or disproportionately increased in immigrant children 71 111 112 113 114 in addition newly arrived immigrant children may present with diseases not yet diagnosed or further progressed examples include genetic conditions related to consanguinity furthermore newborn screening for hearing loss hypothyroidism metabolic diseases or hemoglobinopathies may not have been performed 94115 vision problems and elevated blood lead concentrations are also common and must be considered 94 116 117 118 119 120 nutrition and growth during assessment of nutrition and growth on entry into medical care immigrant children may be recognized as wasted having underweight having overweight or stunted 97 121 122 123 124 health care providers will need to be familiar with global diets dietary restrictions and vitamin and nutrient sources 124 125 126 anemia thalassemia glucose6phosphate dehydrogenase deficiency and micronutrient deficiencies may exist 97 127 128 129 families can be screened for food insecurity and connected to relevant resources 126130131 developmental and educational considerations ageappropriate developmental and behavioral screening is possible with the use of validated multilingual screening tools such as the ages and stages questionnaire 132 and the survey of wellbeing of young children 133 and with historical assessment of milestones 134135 care must be taken to recognize cultural 45 reprinted under the terms of the creative commons attribution license bias and experiential differences in skill development 136 137 138 139 screening needs to be sensitive to cultural differences in parenting 140141 and disparities in reading or sharing books with children 142 but referral should not be delayed if screening results are concerning 143 ageappropriate vision and hearing screening is essential 144 providers encouragement of a languagerich environment in the parents primary language recognizes the strengths of bilingualism 145 146 147 148 149 150 one in 10 students from kindergarten to 12th grade in the united states is an englishlanguage learner 151 duallanguage learners defined as children younger than 8 years with at least 1 parent who speaks another language in the home other than english make up onethird of young children in the united states currently duallanguage learners are less likely to be enrolled in highquality early child care and preschools compared with peers potentially limiting kindergarten readiness 152153 all children are entitled to free public education and specialized educational services regardless of immigration status 154 immigrant children may face particular academic challenges 155156 before arrival to the united states some children may have had no opportunity for formal schooling or may have faced protracted educational interruptions students with interrupted or no schooling may lack strong literacy skills ageappropriate content knowledge and socioemotional skills in addition they may need to learn the english language 157 learning may also be affected by traumatic brain injury cerebral malaria malnutrition personal trauma in utero exposures 94 and toxic exposures 116 117 118 119 120 testing for developmental and learning challenges in the school setting may result in overrepresentation of students with limited english proficiency in special education 158 159 160 161 through collaboration with parents and schools pediatricians can facilitate thoughtful consideration of learning difficulties in the setting of lep supplemental anticipatory guidance may include recognition of family strengths and differences in parentchild relationships childrearing practices and discipline dietary preferences safety risks and use of car restraints and safe sleep practices and acculturation 162 163 164 165 166 167 168 mental health many immigrant children and youth may have had disruptions to the basic experiences that allow for healthy development 169 immigrant children and their families may experience trauma before migration during their journey on arrival at our borders and while integrating into american communities 170 171 172 173 174 175 176 and as a result of their increased risk require health and related services of a type or amount beyond that required by children generally 177 trauma may include personal history of physical or sexual abuse witnessing interpersonal violence human trafficking actual or threatened separation from parents or exposure to armed conflict 173174176178 traumatized children with traumatized parents may be at risk for toxic stress or prolonged serious stress in the absence of buffering relationships 179 in addition to intergenerational transfer of mental health problems core stressors include trauma acculturation isolation and resettlement 172 in particular acculturation includes stressors that families experience as they navigate between the culture of their country of origin and the culture in their new country 172 on arrival many refugee and unaccompanied children have high levels of anxiety depression and ptsd 174 180 181 182 183 184 185 186 compared with usorigin youth refugee youth have higher rates of community violence exposure dissociative symptoms traumatic grief somatization and phobic disorder 187 unaccompanied minors have even higher levels of ptsd compared with accompanied immigrants 188 which may be further heightened if they are seeking asylum 189 immigrationrelated trauma history may be shared over time as a trusting relationship develops with the physician 190 some cif who were born in the united states may face difficulty with emotional and behavioral problems relating to identity formation 191 initial and ongoing screening for mental and behavioral health problems with multiple crossculturally validated tools facilitates recognition of distress and concerns 44132133 192 193 194 195 by understanding the interplay of biological social environmental and psychological risk and protective factors emotional disorders can be modulated on population community and individual levels 196 protective factors and sources of resilience observed in immigrants include having a positive outlook having strong coping skills having positive parental coping strategies connection to prosocial organizations such as places of worship and athletics and cultural pride reinforcement 32 197 198 199 200 resilience is fostered through strong family relationships and community support 201 bicultural identity a strong attachment to ones culture of origin in addition to a sense of belonging within the culture of residence promotes resilience 140202 because of the shame and stigma associated with mental health problems families may be reluctant to seek treatment 203 providers can increase access and minimize stigma by integrating culturally tailored mental health services into the medical home in the school setting and through engagement with community mental health resources 78175204 including home visitation 205 communitywide strategies that foster belonging reduce discrimination and provide social supports can facilitate healing and reduce stigma traditional health care and cultural practices traditional healing and cultural practices common among some immigrant populations warrant awareness by health care providers 206 patients may not disclose use of herbal and traditional treatments unless directly asked 42207 some immigrant families use traditional forms of protection for vulnerable infants such as prayer amulets kohl or myrrh other immigrant families use traditional practices to treat illness and stigmata of these traditional treatments may be observed on examination and may be misinterpreted as abuse 208209 female genital cutting or mutilation is still practiced in some communities in africa in the middle east and in parts of asia despite increased efforts to educate on risks 210211 performing fgcm is against the law in the united states and has been defined as torture by the united nations but foreignborn girls may have experienced this before entry into the united states 210212 resources exist regarding the types of fgcm complications that can result recommended documentation in the medical record and strategies to sensitively discuss this with families 213214 in 2013 the united states passed the transport for female genital mutilation act which prohibits knowingly transporting a girl out of the united states for the purpose of vacation cutting 215 the need to screen for fgcm further underscores the importance of examining the external genitalia of children at all preventive visits in addition to sensitively counseling families regarding the laws and other concerns regarding fgmc practicelevel barriers and potential opportunities communication challenges between families with lep and health care providers must be addressed to provide highquality care fiftyfour percent of cif have resident parents who have difficulty speaking english 3 parental lep is associated with worse health care access and quality for children 216 217 218 219 220 national standards for culturally and linguistically appropriate services in health care were issued by the us department of health and human services in accordance with title vi of the civil rights act culturally and linguistically appropriate services in health care standards describe the federal expectation that health care organizations receiving federal funding must provide meaningful access to verbal and writtenlanguage services for patients with lep 221222 interpreters are an integral part of the medical home team for cif and hold the same confidentiality standards as the physician 6768 most state insurance programs and private insurers do not offer reimbursement for language services although teaching health care providers when and how to work with interpreters can improve care few providers receive such training 223224 for these and other reasons some providers inappropriately use family members as ad hoc interpreters 225 however family members friends and especially children are not acceptable substitutes for trained interpreters 226227 trained medical interpreters via phone or tablet or inperson facilitate mutual understanding and a high quality of communication 228229 use of trained interpreters maintains confidentiality reduces errors and cost and increases the quality of health care delivery 227228 230 231 232 interpretation requires that extra time be allotted to health care encounters qualified bicultural and bilingual staff can receive medical interpreter training if expected to perform as interpreters and bilingual providers can ideally demonstrate duallanguage proficiency before engaging with families in their preferred language without an interpreter 233 234 235 access can be further improved by the use of multilingual signage screening tools handouts and other key documents that are prepared by qualified translators although some immigrant families integrate without hardship many cif face inequities resulting from complex determinants including poverty immigration status insurance status education and discrimination on the basis of race andor ethnicity 3233 for some fear regarding family immigration status threatens childrens health development and access to care 2232 236 237 238 for others growing up in 2parent families and having environmental stimulation at home particularly for those with low socioeconomic status may be protective 33239 screening for social determinants of health can trigger referrals to communitybased supports 240 the hallmarks of the medical home comprehensive care and enhanced care coordination are important supports for immigrant families integrated mental health nutrition social work and patient navigation services allow for ease of access and for reduction in stigma and barriers community health workers who are members of immigrant communities have been effective in reducing disparity and improving health outcomes 241 242 243 244 245 246 interagency partnerships with the local health department homevisiting programs community mental health providers schools and immigrant service organizations facilitate access to medical homes and crosssector communication warm handoffs or inperson transfer of care between health care team members with patients and families present can help to ensure linkage between providers and relevant resources 247 systemslevel barriers and potential opportunities health literacy challenges experienced by cif include not only language comprehension but also the myriad of system barriers in the health care network limited health literacy can complicate enrollment in public benefits for cif immigrant children are specifically less likely to have a medical home 6768 and health insurance resulting in delayed or foregone care 248 249 250 251 252 253 only a minority of states offer health coverage to children regardless of immigration status 252253 additionally immigrant children without legal status including daca youth are excluded from eligibility for most federal programs including health insurance although some states have included andor are considering inclusion of daca youth as eligible for programs such as instate tuition or professional licensing 254255 opportunities to mitigate these literacy access and health insurance enrollment challenges include systemwide use and funding of interpreters and multilingual tools and use of community health workers and patient navigators to reduce barriers through facilitation education and advocacy 435859256257 for cif without health coverage federally qualified health centers public health departments free clinics and charity care systems may offer access to consistent care homevisiting programs can support immigrant parents and parents with lep who may be isolated and unable to access public services 152258 attention to cultural safety is particularly critical when engaging in homebased services quality afterschool programming with support of school social work can also facilitate integration and build resilience for cif 259260 immigration and related legal issues federal immigration policies can adversely affect immigrant health coverage access and outcomes immigration status of children andor their parents continues to affect access to services and public benefits despite some improvement 33261262 increased fears about the use of public programs and immigration status has deterred immigrants from accessing programs regardless of eligibility 263 264 265 in addition immigration enforcement activities that occur at or near sensitive locations such as hospitals may prevent families from accessing needed medical care 264 sensitive locations include medical treatment and health care facilities places of worship and schools and us immigration and customs enforcement actions including apprehension interviews searches or surveillance should not occur at these locations 266267 fear of immigration enforcement or discrimination may exacerbate transportation barriers and worsen perceived access to care 23237 268 269 270 271 discrimination relating to immigration may intersect with religion and race in complex ways 264 272 273 274 discrimination and immigration enforcement policies may also create fear and uncertainty which threaten the mental health of immigrant children 275 and their families 19236264276 families living on the usmexico border face particular risk of mistreatment and victimization 277 policies that offer protection from deportation such as daca may confer large mental health benefits for youth and for the children of parenting youth 278279 immigrant children who have been detained and are in immigration proceedings face almost universal traumatic histories and ongoing stress including actual or threatened separation from their parents at the border 7 immigrant children including unaccompanied children are not guaranteed a right to legal counsel and as such roughly 50 of children arriving in the united states have no one to represent them in immigration court 280 lack of guaranteed legal representation for immigrant children and families at risk for deportation is further complicated by funding restrictions specifically medicallegal partnerships receiving federal funding that operate under legal services corporation guidelines cannot accept most cases related to immigration 281 many nongovernmental efforts have sought to address lack of legal representation for children but opportunities remain to better provide immigrationspecific legal support for immigrant families 282283 including novel medicallegal partnerships with different funding streams that do not exclude people without legal status and offer representation in immigration court in addition traumatized immigrant children can benefit from systemlevel supports for integration of mental health and social work supports into schools the medical home and protected community settings 284 evidencebased programs can systematically build resilience among cif by supporting integration into us culture while preserving home cultural heritage although specific evidence regarding cif is limited homevisiting programs offer opportunities to celebrate unique strengths and mitigate stress in a natural environment 258285 programs that support literacy and encourage play such as reach out and read can reinforce parentchild relationships build parenting skills support development and prepare children for academic success 150286287 for children experiencing parental reunification after prolonged separation mental health services and educational support are particularly critical 238 given the strong role of communities in many cultures communitybased interventions may be particularly effective for immigrant families opportunities to investigate strategies mitigate barriers and optimize health and wellbeing for cif include research medical education and community engagement including communitybased participatory research and health education research used to examine acculturative stress and resilience of immigrant children over time is limited among cif diversity within and between racial and ethnic groups and between cif of varying socioeconomic statuses is also understudied and underappreciated 288 medical education has become increasingly responsive to health disparities for immigrants and to the opportunities for experiential broadening of global health by implementing core competencies in the care of immigrant populations trainees can learn to support a culture of health equity for cif pediatricians can support families within and beyond the medical home through efforts supported by crosssector community collaboration including fields such as education and law innovative research and thoughtful advocacy to inspire progressive policy 171180289 grants that are focused on minority and underserved pediatric populations have the potential to mitigate inequities for immigrant children 171 summary and recommendations with everincreasing levels of migration worldwide the population of cif residing in the united states grows the following practiceand policylevel recommendations offer guidance for pediatricians caring for cif although it is aspirational to fully implement all recommendations in all situations most are achievable by intentionally enacting practiceand systemsbased changes over time practicelevel recommendations 1 all pediatricians are encouraged to recognize their inherent biases and work to improve their skills in cultural humility and effective communication through professional development 2 cif benefit from comprehensive coordinated continuous and culturally and linguistically effective care in a quality medical home with an identified primary care provider

children in immigrant families cif who represent 1 in 4 children in the united states represent a growing and ever more diverse us demographic that pediatric medical providers nationwide will increasingly encounter in clinical care immigrant children are those born outside the united states to nonus citizen parents and cif are defined as those who are either foreign born or have at least 1 parent who is foreign born some families immigrate for economic or educational reasons and others come fleeing persecution and seeking safe haven some usborn children with a foreignborn parent may share vulnerabilities with children who themselves are foreign born particularly regarding access to care and other social determinants of health therefore the larger umbrella term of cif is used in this statement cif like all children have diverse experiences that interact with their biopsychosocial development cif may face inequities that can threaten their health and wellbeing and cif also offer strengths and embody resilience that can surpass challenges experienced before and during integration this policy statement describes the evolving population of cif in the united states briefly introduces core competencies to enhance care within a framework of cultural humility and safety and discusses barriers and opportunities at the practice and systems levels practicelevel recommendations describe how pediatricians can promote health equity for cif through careful attention to core competencies in clinical care thoughtful community engagement and systemlevel support advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for cifhealth care of children in immigrant families cif in the united states has received increasing attention over the past decade in part because of increasing migration of children caused by conflicts globally greater diversity among migrant populations and divisive sociopolitical discussion regarding immigration policy definitions regarding immigrant children vary but for the purposes of this policy statement immigrant

introduction violent crime an unacceptable act punishable by law has been of key public interest as it weakens the security governance architecture of communities nations continue to battle with the issue of crime violence and victimization leading to communities experiencing little public protection and security unodc noted that gang wars domestic violence and sexual assault in public spaces have been features of less protected communities baker ellis and roberts wrote that the denials of the ontological needs of couples with other societal cares in the progressively teeming towns and cities in asia for instance were to be blamed for the surge in crime levels such overtones heighten both the uncertainties of daily living and the sometimes adventurous or antisocial coping strategies that individuals employ to live the institute for economics and peace projected that the annual global public expenditures for the suppression of crime and violent victimization alone in 2014 rose to us 1989 trillion according to saferspaces the global annual death toll due to violence is over 16 million it reported that the overall impact of violence to the world economy in 2015 for instance was projected at 136 trilliona figure corresponding to 133 of global gdp this according to marfo baduyeboah and gyader shows how crime negatively impacts nations thereby necessitating a new approach to its control the evolving nature of crime requires comprehensive and innovative interventions targeting its prevention control and the protection of the public strategic security governance targeting crime prevention and control may thus require social incorporation collaboration and education as espoused by international centre for the prevention of crime violent crime suggests another kind of criminal behaviour by implication some crimes are devoid of violence or are nonviolent in nature who conceptualized violence as the intentional use of physical force or power threat or action against oneself another person or against a group or community that either results in or has a high likelihood of resulting in injury death psychological harm maldevelopment or deprivation uniform crime reporting construed violent crime to compose of four offenses namely murder and nonnegligent manslaughter forcible rape robbery and aggravated assault these crimes as defined involve force or threat of force the criminal code of ghana act 1960 has no such kind of classification nonetheless murder manslaughter rape and robbery are construed as heinous crimes and classified as first degree felony which invites severe sanctions such as death imprisonment for life or any lesser punishment aggravated assault as indicated by ucr program may be compared to what the criminal code of ghana refers to as causing harm harm is defined by the same code as any bodily hurt disease or disorder whether permanent or temporary every crime negatively impacts the life of people however the forgoing explanations suggest that crimes labeled as violent have much more repercussion on the society in this regard all criminal acts that cause harm to a person as outlined in the criminal offenses code act 1960 of ghana fall within the purview of this current study generally ghanas crime rates are significantly low as opposed to most developed economies and construed as one of the peaceful countries in africa the country nonetheless battles with crime especially in urban communities the topic under examination is informed by the steady growth of violent crime in sawlatunakalba district the study locality in a short period between 2019 and 2022 in particular the study community in recent times has become a flash point for violent crime in the savannah region crime statistics from sawlatunakalba district police command showed that the district recorded only two murder cases each in 2019 and 2020 respectively however the figure rose up to 7 cases in 2021 and dropped to 3 in 2022 the data indicated that all levels of crime shot up especially in 2021 and declined in 2022 this could suggest that more swift and robust security measures or interventions might have been carried out by critical stakeholders in 2022 translating into the downward trend of all reported cases in 2022 going by the who explanation of violence it could be premised that violent crime is prevalent in sawlatunakalba district as depicted by the police crime statistics these revelations point to an imminent threat to the overall security in the area the question is why in spite of the police and other critical stake holders such as the chiefs neighborhood watch committees assembly members unit committees and other law enforcement bodies marshalling all efforts to ensure law and order violent crime continues to afflict the people of sawlatunakalba district especially coming into the year 2021 and 2022 admittedly some scholars have researched into the issue of violent crime and policing arrangements in the country yet the fact that the problem still persists and intensifies in the study area requires that there is the need for further research into the problem to add more knowledge to policy decisions as noted by may crime is a very complex phenomenon with a changing pattern of criminal modus of operations which demand a more comprehensive and concerted research violent crime undermines communities and individual peace and security as espoused by cawthra this requires that we constantly conduct empirical studies to appraise the factors which militate against the provision of an assured security of the inhabitants this is the niche of the current study parker stressed that the prevention of criminal acts by actual or potential physical intervention has been the primary task of the police in criminal justice intended to instill the fear of apprehension conviction and punishment in wouldbe criminals this according to him restricts criminal actions thereby resulting in crime repression this conception is in line with the policing concept in ghana both traditionally and in contemporary times appiahenegyamfi espoused that african societies had utilized their own social control mechanisms which were enforced by council of elders chiefs and village heads before the advent of western penal system these dynamics however have changed in contemporary times as crime is primarily controlled by various state agencies notably the police section 200 of the 1992 republican constitution of ghana places the internal security of ghana primarily within the domain of the police service article 200 of the 1992 constitution makes the ghana police service a monopolistic institution in the country responsible for internal security the 1992 constitution of ghana the police service act 1970 the police service regulations 2012 the criminal and other offenses act act 2960 and the police service instructions variously define the roles of the police to include the protection of life and property the prevention and detection of crime apprehension and prosecution of offenders preservation of peace and good order and the due enforcement of all laws and regulations with which it is directly charged the statutory role of the police is an indication that the social stability of the country is contingent primarily on the police given its essential role all efforts should be galvanized to ensure that the ghana police service achieves its mandated objectives as suggested by may crime keeps on changing and this requires an update on innovative thinking and approach this requires concerted efforts to build a comprehensive security architecture that requires the application of both formal and institutionalised mechanisms as proposed by owusu et al according to unodc tactical security governance averts crime and victimization and most significantly stimulates citizens sense of safety according to icpc any prevention strategy seeks to eliminate or at least reduce violence a study conducted by craig swatt shellie and sean revealed that policepublic collaboration resulted in high level of citizens satisfaction with police services and reduction in the fear of crime as witnessed in houston newark flint michigan and baltimore this underscores the philosophy of policecommunity oriented policing the public contribution in the administration of the criminal justice system is of critical importance crime control thus demands collaborative efforts apparently across the globe effective security governance has been constrained by a number of factors extant literature have cited bribery and corruption crime craft inadequate logistics and interference among others as issues which militate against crime control among nations this means for a nation and its communities to realize the economic and social security and development of the people there is the need for close collaboration between and among the police the citizenry and the government while the police have to undertake appropriate overhauling measures to reclaim their lost glory due to negative views held about them the citizens and the government should provide them with all the resources for effective functioning this explains why the study was grounded in the collaborative theory of policing the theory holds that dialogues coproduction and transfers of knowledge between the police and the citizenry improve policing arrangements and security governance various empirical studies conducted across the globe have found that policeacademic partnerships tremendously improved policing practices in recent years as argued by fyfe and wilson partnership between the police and the citizenry through mutual exchange of inputs promotes the practice of policing it is envisaged that the police in the study locality and the citizens would have a common security governance plan towards the safety of the citizens the police and crime control the study area sawlatunakalba district is one of the seven districts in the savannah region of ghana with sawla as the district capital sawlatunakalba district assembly is located in the western part of the savannah region and has its coordinates as 9º 171 n2º 251w with a total area of 4601km2 the district shares boundaries with four other administrative districts namely wa west and wa east districts bole district and west gonja district it also shares boundaries with la cote divoire and burkina faso respectively to the west the total population for the study locality stood at 112664 comprising 53004 males and 59660 females the figure shows that the female population is about 53 compared to 47 for males if women are generally construed as vulnerable then all efforts have to be made to guarantee their safety the presence of high crime incidence could jeopardize their overall development and the populace in general research design the convergent sequential mixed method design as espoused by creswell and creswell was used in this study it enabled the researcher to collect both qualitative and quantitative information at the same time with this design the researcher was able to tabulate along a continuum in a numerical form and also to describe categories of information of interest such as gender among others the convergent sequential mixed method design was considered appropriate as it afforded the researcher the opportunity to probe into the respondents views on violent crime its ramifications and the maintenance of security in the study locality population of the study the target population for the study was made up of officials of the police the sawlatunakalba district assembly market associations mobile money operators drivers association store operators association and traditional authorities sawla tuna and kalba communities were the prime focus as they are among the four communities classified as urban areas with their population ranging from 5000 majority of the targeted respondents however came from sawla township because it is the district capital and has also been the epicenter of most of the violent crimes in the study locality sample and sampling procedure in this study probability sampling techniques purposive sampling proportional sampling and systematic sampling procedures were used to select the respondents besides purposive sampling was used to select the key informants in all 102 respondents made up of 71 males and 31 females from different backgrounds were selected for the study all the sectional heads of the police district command namely the head of the police criminal investigations department domestic violence and victim support unit the district police command and the documents and photo unit of the district police command were purposively selected in addition all the 26 available and accessible assembly members of the sawlatunakalba district assembly were equally surveyed according to marfo availability in sampling process refers to the physical presence of the respondent whilst accessibility connotes the willingness of a respondent to be interviewed besides the chairpersons of the ghana private road transport union from the three communities were selected purposely together with the executives of the market associations mobile money operators and store operators association from the selected communities three traditional heads were also selected purposely these categories of respondents were purposely selected because they have strategic valuable information relevant to the study the nature of the study required respondents of diverse backgrounds interests and knowledge the youngest respondent was 29 years with the oldest being 73 years to be able to sample from the remaining 50 police personnel within the district the yamane sample size determination was adopted given as follows to be able to arrive at the 44 police respondents the police population was stratified into males and females and a proportional sample was then applied the 44 police respondents were selected using miller and brewer the combined total sample distribution is shown on table 3 below data collection methods for the purpose of this study with the exception of all the key informants who were interviewed with the aid of interview guides questionnaires were used as primary data collection tool to solicit information from the rest of the respondents as noted by robson questionnaires are best with standardised questions that could be confidently interpreted the same way by all respondents the researcher adopted the intervieweradministered questionnaires approach in the view of saunders lewis and thornhill this approach enables a researcher to be sure that the respondent from whom data is gathered is the one who has really been chosen for the study as contrasting with the distribution and collecting of questionnaires to ensure accuracy and validity of data the questionnaires were proofread and pretested in damango which shares similar characteristics with the study communities the field work took place between october 2022 and january 2023 literature relevant to the study including journal articles newsletters official websites and official reports were also reviewed to generate secondary information to augment the primary data this enabled the researcher to have a full depiction of the problem which inspired the work both quantitative and qualitative data were gathered within the same period data presentation and analysis ader wrote that data analysis involves editing cleaning transforming and modeling of data with the goal of highlighting useful information suggestions drawing conclusions and supporting decision making quantitative data were statistically analyzed with spss software version 160 frequency distributions and percentages were used to present the information qualitative information on the other hand was analysed thematically the audio recorded information was first transcribed edited and categorized according to the set objectives the two sources of information were then carefully weaved together in the discussion of the findings ethical consideration de vos highlights that the subject of inquiry in social sciences is human beings which gives rise to ethical issues that are not presented in the controlled laboratory environments of the natural sciences it is in this vein that babbie and mouton wrote that the right to the collection of data by a scientist should not be exercised at the expense of the rights of other members of society against these cautions the researcher explained the rationale of the study to the respondents and emphasized on their rights regarding voluntary participation anonymity and confidentiality results factors that militate against the police in combating crime in sawlatunakalba district security is a collaborative enterprise nonetheless the 1992 constitution of ghana places the maintenance of internal security under the domain of the police service the police therefore have an urgent task to guarantee the social and economic safety of the people and the country as a whole given its crucial role it is expected that all efforts and resources would be mobilised to realise the set mandate of the police given this background the study interrogated the factors militating against the efforts of the police in combating crime in the study locality six broad issues were raised by the respondents namely bribery and corruption failure to prosecute offenders policecriminal friendship stakeholder interference inadequate police personnel and inadequate logistics discussions some 85 respondents of the public were of the view that bribery and corruption on the part of the police challenged any effective security governance in the area as they undermine communities sense of trust confidence and cooperation further 63 indicated that failure of the police to prosecute offenders in the law court militates against any efforts to combat crime in the study locality this assertion was not strange as a check found that the sawlatunakalba district had no single court of judicature another 54 asserted that the league between the police and criminals defeats any meaningful arrangement to combat crime the information gathered suggests that the attitude of some police officers such as bribery and crime trade undermines their own efforts to maintain effective security governance these allegations as raised by the public against the police may be seen as chronic problems bedeviling the police organisation a number of scholarly works from different countries have identified low communitypolice teamwork due to certain negative police practices such as breach of trust bribery crime trade lack of respect and brutality 2008faull 2011schanzer et al 2016wekesa andmuturi 2016 manaliyo 2016adegoke 2016amagnya 2017marfo baduyeboah and gyader 2021 as negative factors militating against policecommunity collaboration these findings imply that the negative attitude of the police is not peculiar to ghana they also suggest that the police as an organization needs to undergo some form of transformation to salvage its sinking image so as to regain public sympathy and support in ghana faull s study in south africa found that the purported corruption and incompetence of the criminal justice system especially the south africa police service defeated any expressive crime control strategies in the country marfo et al found that the practice where the police set criminals free or engage with them for material and other benefits has affected the public commitment in complementing the role of the police in combating crime in the wa community in ghana atuguba also found that a good number of ghanaians are displeased with the ghana police service and labeled it as among the most corrupt institutions in the country kane found that community members decisions to participate in crime prevention activities are strongly influenced by their perception of the local police and other government institutions the study concluded that the poor relationships with the police and lack of trust weaken community participation in crime control from the perspective of the police inadequate police personnel stakeholders interference and inadequate logistics were identified as the critical challenging factors restraining them from any effective crime control virtually all the police respondents bemoaned the strength of the police further 63 indicated that stakeholders interference has been a major problem to crime control another 81 were concerned with the logistics situation in the district in an interview a key informant indicated we operate in a district without a court where people can seek justice we rely on bole district court tamale and wa for any justice administration the public blame us for not prosecuting offenders whilst due to distance and cost to the various courts they are often discouraged from seeking justice from the court but prefer settling criminal cases at home or refuse to cooperate with the police by supplying the needed evidence corroborating the above another key informant stated the district police command has no standard cells where we can lock suspects we have no female and juvenile cells where such persons can be separated from their counterparts as we speak the whole district has only three police stations taking care of over two hundred communities the emerging theme is that the fundamental human rights and freedoms enshrined in article 12 of the constitution of the republic of ghana in respect of the individuals right to justice and dignity are to some extent violated the views of the police suggest that they work under distress conditions without the necessary logistics these findings buttress a contemporary work by marfo et al their study revealed that key challenges confronting the police in the northern region of ghana have been inadequate serviceable vehicles lack of cells for juveniles at the police stations inadequate government budgetary support lack of remand home for juveniles and stateowned temporary shelter for victims of abuse their study concluded that the police stations were virtually neither childfriendly nor gender sensitive in the view of decker and marteache lack of juvenile cells is a major challenge across developing countries the police are often constrained to function as expected due to interference as found in dinyes study in kenya interference in the police comes from various people including administrators directors the clergy traditional authorities and politicians being the worse among all writing about road safety in the wa community in ghana emelia found that political leaders often use their powers to free people who fail to comply with the law from the required punishment as required by the law the study revealed that such interferences sometimes come with threats of transfer among others this according to emelia weakens effective road safety regulations enforcement and for that matter compliance the current study agrees with bishop and barber work where they found that the attempts to regulate the motorcycle business in uganda have largely been unsuccessful due to political interference the findings suggest that effective violent crime control requires the efforts of the police the public and the government anything devoid of this will make crime control a mere empty talk as the collaborative theory advocates policing practice requires a high level of cooperation between the police and other critical stake holders in the country the perceived defective security governance in the study area resulting in increase in crime levels as found in the current study could be attributed to the blame game between the police and the citizenry the police the state and the citizens each have important roles to play to ensure the safety of the populace as argued by marfo et al in as much as the police require transformation in its approach to security engineering it equally behoves the state and the populace to provide them with the needed logistics and assistance to function as expected conclusion and recommendation the study sought to unravel the challenges militating against meaningful security governance in the sawlatunakalba district of ghana amidst crime hikes in the said district the study found that lack of court and regular prosecution of offenders policecriminal fraternity inadequate logistics and personnel coupled with bribery and corruption have undermined the security architecture of the district as the collaborative theory of policing espouses the police the government and the public mutually have essential roles to play to promote the desired security for the study locality on the basis of the findings the study recommends a multisector collaborative security network involving the government the police and the public this is because crime impacts multiple facets of society in ways that the police and government may not be aware of until those interests are taken into consideration during project planning and execution it was found that the police do not have the resources needed to function effectively the service needs to be retooled by the government so that it can carry out its constitutional duties the government as an urgency should provide the district with a court of judicature to settle and adjudicate cases among potential offenders and litigants juvenile and female cells as remand homes for juveniles should also be provided as a matter of urgency to ensure juvenile justice but not at the expense of the human rights and dignity of the people police officials found in league with any criminal elements should be prosecuted so as to rebuild the lost public confidence and trust in the institution

violent crime such as robbery assault murder sexual and domestic violence undermine the economic and social rights of the people and distorts societys attempts to achieve a decent and dignified life for all to reverse the situation in ghana the police have been charged with the primary responsibility of maintaining domestic security the emerging development in the country however has been the blame game between the police and the public in respect of the perceived failure in security governance for the citizenry this study examined this blame game using sawlatunakalba district of savannah region as a case study to be able to achieve the intended objective 102 respondents were selected through both probability and nonprobability sampling techniques in a convergent sequential mixed method design expert administered questionnaire and interviews were employed as the main methods of data collection the study found that nonprosecution of criminals bribery and corruption policecriminal relationship inadequate logistics and police personnel and stakeholders interference in security management

introduction in a democratic country like the philippines citizens hold critical views against political and social issues in the present age of mainstream media and with the influence of todays generation the social creation that is on the rise in expressing sociopolitical views and opinions is the woke culture besides political expression and discourses are more widespread in social media with the rapid growth of social media new forms of engagement in political aspects have emerged from its origin in the black activist community the term woke now covers every social issue ranging from politics race hatred gender and sexuality to religion the term rose to national prominence in 2012 because of the black lives matter movement and that wokeness even entered the national discourse the term woke has primarily been used by african americans since the 1940s it was a concept within black communities since a black person michael brown was killed by a police officer the phrase set off as awareness of people who advocate black lives matter dedicated to battling racism towards black people however through the years the woke culture became derogatory and toxic the said term that was previously noble has now become twisted or polluted and implies contrary to what it means in philippine history the relevant date wherein woke culture was inflamed is in the 1970s during the marcos era when nick joaquin a writer and journalist stood his ground in ensuring his friend jose f lacabas freedom also in 1986 during the people power revolution millions of filipinos formed a resistance they protested against the dictatorship of former president ferdinand marcos which led to the end of his regime in the current cultural and political state the said term and phrase are primarily used in a sneering and pejorative sense just like republicans opposing democrats and centrist democrats opposing liberals generally woke means being aware of societys injustices and other forms of oppression frequently wokeness or in what filipino term refers to how mindful we are and how we construct our interpretations and beliefs for a social cause that later criticizes our intellectualism along the way it resurfaced from describing awareness into something weaponized its meaning is diluted and corrupted in the philippines sociopolitical wokeness measures an ideology on the current political situation and social issues and how a particular person is vocal about hisher stance when someone stands up and expresses themselves they are seen as conscious and educated or socially and politically aware some label them as pawoke and smartshames those with different views especially on sociopolitical issues hence it devalues intellectual pursuits besides another toxicity that arises around woke culture is that the term also applies to people who start making issues out of minor matters complicating them and hurting or insulting someone in the process the purpose of this study is to deeply understand the sociopolitical wokeness of filipino citizens in terms of the present socialpolitical issues that have been adding weight to the existing and systematic problems surfacing in the contested democratic status of the country its intent includes assessing what the latter and the woke culture in general means to filipino society analyzing if wokeness is a positive sentiment or a plain insult to social norms for pursuing personal validation rather than engaging in a deepseated conviction and disingenuous argument several articles have been written about wokeness or woke culture especially in the united states of america however no studies are examining how filipinos accept woke culture as a part of the modernity brought by society also there are no related local issues on wokeness in davao city only national issues or articles in addition this study aims to examine the history of woke culture and its link to cultural undertones of the awareness of filipinos in every relevant social issue in the country including the tale of the war of the present political parties and the political labels they have received for their critique also the participants of this documentary were the selected filipinos who are more active in different digital spaces grassroots activism social scientists and journalists who debunk or analyze filipinos notion of the said culture this study was anchored on three communication theories first lev vygotskys social constructivism theory states that knowledge is coconstructed and individuals learn from one another hence it means that a persons development is through exchanging information and knowledge negotiated between humans in which cultural values and beliefs are obtained hence this theory describes learning as a social process in woke culture wokeness is associated with social interaction which significantly shapes an individuals sociopolitical wokeness second is the uses and gratifications theory this theory suggests how people use the media for their needs and get satisfied when they are fulfilled media is the primary source of information and motions about the current political sphere it establishes the agenda for public discourses on current issues providing the people with a forum to express their political views and opinions hence media plays a vital role in shaping ones political wokeness woke people or those people who are sociopolitically aware are media users lastly is the participatory communication theory this theory allows everyone to speak or share their opinions perceptions and views among the various stakeholders facilitating empowerment the approach based on dialogue is not just about exchanging information and experiences but also aims to explore new knowledge on social issues that need improvement method research design this study utilized the creative works format creative works is a type of research brought about through the initiatives and assessment of research outputs collection research productivity index and more recently the excellence in research for australia framework this directed more prominent recognition of creative works this acknowledges that research and contribution to new knowledge may be shown in different ways and through forms in the creative arts creative research is a nontraditional product created through writing composing designing creating performing and recording more so this study is categorized as recorded or rendered creative work thus producing a documentary magazine in producing such creative and informative output the researchers referred to numerous books pdf books news and journal articles and interviews with experts instruments the researchers developed a documentary output entitled culture explained with its particular segment entitled wokenam juans new dogma the researchers researched read and referred to studies literature publications and videos as a requirement to create a context for the documentary to know what footage and other visuals were needed what content of interviews would appear and to create a script for the whole narration the researchers have applied the tools found on the internet these digital and traditional platforms help support the news magazine documentarythe primary genre of this creative documentary also online electronic communication for interviews includes google meet and zoom besides that audio and video scripts during the production process editing software like adobe premiere adobe animate adobe illustrator adobe edition and sony vegas pro 17 was present furthermore shooting equipment such as a tripod dslr cameras with different lenses audio recorders and microphones were used in gathering data and information necessary for the study the researchers spent most of their time meeting and discussing online via google meet and telegram these sessions addressed and discussed significant concerns issues and progress the demand for the distribution of tasks to each member was projected this was to organize the whole process meet the goals on time and progress daily data gathering procedure this research used indepth interviews to gather data from the participants this technique implies intensive individual interviews to explore their viewpoints on a particular idea issue or situation the interviews were conducted through video conferencing to follow the universitys datagathering guidelines and protect the researchers and participants health and safety researchers prepared questions as guidelines and made additional clarificatory questions during the interviews to gather the data needed for this study the researchers secured permission from the dean of the college of arts and sciences education to conduct an interview and collect data before the interview each participant received an invitation through their email and social media accounts to ask for their voluntary participation in the study the confirmed participants were sent another communication consisting of informed consent an interview guide questionnaire and a letter to the participant they were also asked for preferred interview schedules alongside the documents sent the recorded interviews were then transcribed and analyzed the analyzed responses were scrutinized and selected to support the study and the documentary film production method this method consists of three production stages preproduction production and postproduction preproduction stage the researchers developed a documentary output entitled culture explained with its segment entitled wokenam juans new dogma the researchers have researched read and referred to studies literature publications and videos as a requirement to create a context for the documentary to know what footage and other visuals are needed what content of interviews will appear and to create a script for the whole narration moreover the storytelling ways or approach and visual or art direction were based on the visual references mentioned in the first chapter in gathering data and information necessary for the study the researchers spent most of their time meeting and discussing online via google meet and telegram these sessions addressed and discussed significant concerns issues and progress the demand for the distribution of tasks to each member was assigned to organize the whole process meet the goals on time and progress daily the documentary was conducted primarily online due to the critical preventive measures to prevent the spread of covid19 the interviews for both the social scientists and participants were done online via zoom during their respective schedules the shooting of the hosts spiels was done inside the house and maximized the space and equipment the production output of this study is a news magazine documentary no studio shots included all interviews were done online except for the documentary where the host needed a production team to shoot the documentarys spiel the documentarys production processes are discussed online via telegram and google meet a stable internet connection is essential during this process since there is no other way for the researchers to meet and confer production stage the production process involves capturing or shooting the footage and scenes that can be seen in the documentary hence putting into action the concepts and preparations made during the preproduction postproduction in this phase the editor used editing software such as adobe premiere or sony vegas pro 17 to edit videos add transitions and compile shots on the other hand the editor also used adobe animate to create moving images and animate the documentarys official logo and third lines in contrast adobe illustrator was used for graphics design and poster the editor used adobe audition for good audio or sound quality the editor used adobe premiere and sony vegas pro for a smooth transition cinematic color visual graphics and adding or removing videos the foreshadowing effect the first documentary sequence was used the color grading used in the opening part of the documentary and other necessary videos that need unconventional effects thus did not appear in the remaining parts of the documentary the color grading depended on the videos but the art direction itself is colorful based on the colors and trends of pop culture the editor used adobe audition for the sound design as researchers have mentioned in the first part a natural sound supported the interviews while other videos have background music and sfx to hook the audience the editor inserted pinoy pops instrumental sound effects with traditional and modern music for a pinoy popular culture news magazine for the moving images animated logos and overlaying of the interactive texts have been applied through adobe animate pop colors dominated the video to achieve an interactive visual and a lively art tone for the poster and graphic design adobe illustrator is evident as software instead of photoshop since the art direction of the documentarys official poster is maximalist colorful and imaginative and some elements were vectorbased there was some photo manipulation but the remaining elements were caricatured to emphasize real pop art data analysis this study utilized the following tools to analyze the study first is the onion tool formally known as the positions interests and needs tool it is a concept from conflict analysis adopted as an investigative tool under conflictsensitive journalism the name onion tool can be traced back to peace and conflict studies wherein conflict dynamics like an onion can be peeled layer by layer to expose everything hence the onion tool is one of the essential csj tools that can help establish the entire study the researchers use this tool to reveal or divulge the hidden sentiments of the characters and participants involved in the study this tool also answers the question what drives or motivates these citizens to participate and become woke in the sociopolitical spectrum another conflictsensitive journalism tool used to support the study is the timeline tool which helps chronologically review and sort significant events thus the researchers can visualize the studys narrative from its origin and involvement to its current status in modern society timeline tool further explains the gaps of the study as it also curates the events of the woke culture along the way and how human society perceives it from time to time ethical consideration the researchers collected necessary information from a social scientist a journalist and studentsyouths to create the documentary they were informed of the purpose of the study their responses to our questions that will be used and who will have passage to its outcome hence permission and informed consent were secured by the researchers hence the voluntary participation of the participants was ensured in any part of the study or documentary the researchers were keen enough to conduct the study to avoid liability for any loss or damage upon having this reliable information when something untoward may happen besides the researchers have followed the university rules and guidelines provided by the dean of the college the program head of the communication department the thesis adviser and the research coordinator results and discussion interviewed participants in this documentary were provided with questions about the woke culture the documentary started with a voiceover of the history of woke culture explaining its origin and spread across spaces the title was revealed at the end of the opening statement and then trailed by an opening oncam spiels of the host where woke culture in the philippines was introduced as the creative work advances to reach the gist of its story it then showcases the different answers of the interviewees to each question they remain to be interviewed with all honesty and no personal biases to have a transparent investigation the documentary ends with a cbb with anon cam final spiel from the host wherein the answers are dissected scrutinized and evaluated to make a firm conclusion the researchers presented four research questions each with a corresponding identifying question and probe questions related to the research questionnaires the researchers provided some national discourses presently discussed in this woke culture and connected to the questions the first research question highlighted the perception of the filipinos in the woke culture that originated long ago according to alec gabrielle gonzales and rigo babas woke culture deals with active engagement in social and political discourses however gonzales stated that she never delved into the culture though she was just aware of the political situation meanwhile babas addressed its stereotypes the term is mainly associated with blatant and later on called pawoke i have never really like delved into the woke culture and i dont consider myself being woke it is just that i am active and aware of engaging in our current climate but when one of my cousins has said your generation is full of woke people and i am like oh my god is it a bad thing or a good thing for me the woke culture is mostly about the sort of generalization and categorizations to those who are vocal whether it be against or in accordance with the administration most of the time the term woke is associated with those who always complain that is why they are called pawoke it just became a stereotype for people who are very vocal to the administration or those with different opinions regarding national concerns for the second identifying question which discusses the neocolonialism linked to this culture christianne kelsey hadjirul also emphasized that this culture is deeply rooted in societal issues if there is a social issue that is going on that is where the term comes from that is what i see on the other hand two participants shared their beliefs on the identifying question highlighting the evolution of this denoted term rigo specified that the woke culture evolves by becoming more public min soo kim also claimed that social media holds significant power in the evolution of this culture it has evolved throughout the years by becoming more public it became more sort of diverse and very flexible unlike before when social media was only used for gaming sharing asking for requests now it became a medium to express to market to vent out before social media people just went and protested because there were no social mediathere was no medium for them to express themselves they just really protested and protesting has a limited scopeit is just within themselves within their area within their region so since social media is here they could spread worldwide for the last identifying question kelsey pointed out that the world has become too politically correct and sensitive due to the woke phenomenon she also discussed that the said culture somehow brings positive results since social issues have been acknowledged and discussed i feel like because in the woke culture we become more open to discussion because many people have been voicing out their opinions it is also very good because we have social issues that are already being discussed in addition given that woke culture is usually observed in digital spaces especially on twitter and the chosen respondents actively participate in such sociopolitical discourses the second research question intends to recognize how confident they are in their opinions min soo stated that whenever he discusses an issue with someone it is not just his emotions he would first study it and read different references about it yes because whenever i discuss it with someone i would really study it beforehand i have lots of references here lots of books because i make sure that if i were to speak out my opinions its not just purely opinions its not all emotions it also comes from other references there is a climate of opinion as people engage in social and political issues so the researchers want to know how the various opinions of other people affect their stance according to rigo this cognitive bias is a systematic error in thinking that occurs when people are processing and interpreting information in the world around them and affects their decisions and judgments so he is willing to listen to other peoples opinions meanwhile according to min soo he ensures that he is not peer pressured by engaging in such discourses with people who have their views it also affects my stance because i also want to hear from the other side because ours in psychologythere is a term called cognitive bias where we just want to see what we want to hear what we believe is what we believe in i make sure that im not peer pressured by a lot of things as the respondents participated in the different current sociopolitical issues stated in this paper they were asked if such action is a manifestation of being aware based on the answer of min soo it is a manifestation of being aware when someone is wellinformed about his or her political environment though he added that it is not enough if you are just aware you also need to take action the fact that you were knowledgeable about your political surroundings is very much a manifestation that you are aware however its not enough that you only know it you have to also participate in civil groups in civil activities as the researchers asked the respondents if they received any harmful comments and fallacies from people who relived their belief all five answered yes according to rigo and kelsey they often experience harmful comments or backlashes likewise rigo said that frequently on twitter and even on facebook also alec stated that consequences are anticipated as she participates in sociopolitical discourses chad errol booc noted that many naysayers are redtagging and mostly it comes from trolls being a up student itself is already a death world engaging in this field we are already fully aware of the consequences of redtagging always a lot of times especially on twitter i get mocked a lot of times even on facebook from my friends most of the time yes there are a lot of naysayers red tagging but my observation is most of them are from trolls some people continually block the political beliefs and opinions of the respondents they state how they handle such reproaches from those people rigo explained that when he started to engage in the discourses he did not know how to react or respond because many people were attacking him in the digital spaces back then when i was so threatened or when i was affected by all the backlash i just remained silent i didnt know how to respond i didnt know how to how to start a debate because there was actually too many given that it is the constitutional right of a filipino citizen to participate socially and politically the participants explained what drives them to engage in the current issues alec explained that what drives her is that she wants to be the peoples voice especially those who are oppressed and vulnerable i really want to be a source of not just information but the voice of every filipino especially those who are marginalized and those who do not have any platform also i also want to be a catalyst of positive societal changes additionally when asked about wokes positive and negative sentiments as part of the last research question rigo expressed that positive wokeness comes from a healthy discourse while negative wokeness is about normalizing and raising false information it would be a positive wokeness if people would be willing to listen and change their opinion or have a proper discourse with other people and it would be a negative wokeness if people would be so stubborn with their opinions or share information that is not correct according to kelsey woke culture brings more positive changes as it helps more people become more aware this culture has collective camaraderie and i also saw that sometimes especially when you are privileged that you dont experience what other sectors are experiencing those social issues are distant from you you tend not to care but because of the woke culture because of the collective unity of other people they become aware of various social issues that also help them to care speak and intensify gradually so thats what woke culture really did for me for the last identifying question all respondents rate themselves based on the level of their wokeness the researchers asked about their awareness and these were their answers yes i am woke enough to represent the woke culture but it does not mean i am aware of every issues present in our society but i am trying to stay educated and educate the public mine currently would be nine because i am under a lot of organizations and movements right now here in davao we are volunteering we have been coordinating with other people to campaign for our presidential candidates i say it is nine because currently i am actually very active with people in higher positions i think i am really aware not only of social media but also of recognizing and seeing the concrete that is happening in the country as much as possible i try to engage on all platforms whether on the streets in schools in various communities with relatives and friends and so on if we define woke as something that has a connotation especially if it is negative expressing whatever your feelings attacking other people i hope i am not politically woke i just really love discourses that really gives you history facts and trivia thats the wokeness i like during the entire course of this study a social scientist in the name of michael charleston xiao chua a public historian and associate history professor at dela salle universitymanila and janella a eugenio a journalist at summit media philippines were invited to share their standpoints on this existed culture identifying and probing questions were provided as long as they connected to the central ideas of the research questionnaires having the perspective of a social scientist when it comes to woke culture strengthens the aims of this research charles chua defined woke culture by how it is defined in contemporary societybeing woke is being aware of the issues happening however he noted that there is a problem with the said culture wherein being woke or woke is more claimed and identified through the democratic party while unwoke are those who are republicans i will define it in how society defines it now being woke for some people it is being aware of the issues thus woke but there is a problem woke is like being claimed at least by a certain sector of the people especially those we call liberals not a liberal party but liberals basically these are the people well they also advance human rights and democratic rights including the different sectors who believe in liberalism than those we call conservative so woke is more on the democratic country woke is more identified in democrats while those who are not woke are supposedly republicans for ms ara woke culture is about being aware of particular issues and being open to the social realities present in our environment her viewpoints on the culture made her realize that the term has been widely used due to our political climate furthermore charles chua also added another point of the problem of being woke is that there is a certain condescension whenever someone calls himself or herself woke it appears that those people who are not educated are not woke to be honest at first woke seems okay but my problem is although i am really for political correctness there is a certain condescension that i feel every time someone calls himself or herself woke because sometimes it comes off that most of the woke have the condescension to those people who were not able to go to school what happens is you are woke and others are not in the modern world there are different forms of ostracism and one of them associated with woke culture is the cancel culture which charles chua also mentioned as he explained cancel culture is when the action or attitude of someone is different or unacceptable by others that person is rejected and people no longer support him or her one correlation to woke is cancel culture wherein you cancel someone who does not agree or is accustomed to your liberal attitude based on belief and life experiences in addition filipinos have this toxic trait where they will attack the person and resort to ad hominem arguments once their opinion is unheeded charles chua was asked if the filipinos have the right to do it even though they are on the right side his opinion about this does not support the said fallacy he mentioned that filipinos have rights hence freedom of expression however it is not the right thing to do because personal attacks do not address the argument in any issue they have all the right because of freedom of expression but is it right is it proper i dont think so because ad hominem triggers irritation and if the person is already irritated about who you call and attacks thru ad hominem the discourse ends a lot of people proclaim themselves as woke the researchers asked charles chua if it is okay to proclaim wokeness to oneself according to him he has discomfort for those people who do so because if someone proclaims that he or she is woke and others are not then there is this treatment or labeling of people differently and the latter seems to be inferior to those woke people that is when i have discomfort because like when we say that we are woke or you should be woke it is a reminder that you should just be aware but once you proclaim wokeness then you are woke and others are not and so there is othering that is happening charles chua also added that being condescending will not work in todays society there is a need for radical empathy and creative resistance to have an effective conversation we need radical empathy and creative resistance we just dont fight we have to be effective in our messaging and this is the battle of the narrative now so being condescending is not allowed because nobody will listen to you in the second research question the researcher asked her about delivering stories or framing in writing ms ara further concluded that her personal biases are often evident in her articles of course you try as much as you can to be objective and that means getting all sides as possible but framing is really informed by the point of view or where does the writer come from in particular i consider myself as progressive in terms of what views i support and that i think is evident in my stories finally since there is this entrenched culture from spaniards where youths are forbidden to meddle in adult topics ms ara said that there is a reason why her beat as a journalist is to explore the experiences of young generations for mr chua youths are welcome to the adult table which infers ones openness well in my work in particular i usually talk about the experiences of gen z so these are young people aged 26year old i think theres a reason why im in this beat and i feel fulfilled to be really here at the end of the day we its young people who will like inherent those or whatever comes from our decision today older people always say that they are older and so they know better i am welcoming it its good that people are being open what i do not like is that you tend to disregard humility in your opinion and you think you are the only right person in the room and many times a lot of woke people are like that but a lot of the woke are like that thinking they are right we have to give leeway to the other side to understand why they think that and we cannot just say this selfrighteousness that i am woke so what we must talk about what things we can do together to better our country evaluations after thoroughly investigating and analyzing the proponents the participants answers manifested that the said culture arose from societal issues as people learned to talk and resist openly it became more public throughout the years the influence of social media has made every sociopolitical issue spread to a larger audience and some even circulated worldwide moreover the participants wokeness is based on the actual events and issues painted in our mainstream media the participants awareness is not solely because of peer pressure looking edgy and having societys approval in the study the researchers identified the wokeness of the filipinos and contrary to the popular notion is not the parameter to measure ones intelligence instead it only manifests one thing these participants are aware of what has been happening around their society further to break down the general findings weighed by the researchers these students perceived themselves as woke due to the nature of their background and participation in their community though they are active in digital spaces their answers emphasize that being woke does not only mean being active in social media a woke person must do more in engaging in civic group activities to ignite impact development and changes they use digital spaces such as twitter and facebook drawing a larger audience to disseminate informative information on particular issues they have a significant following on social media so they try to make their information more comprehensive refined and articulated in this culture it is expected that negative views would foster when your opinion cannot be submitted to another side of political affiliations the former would call you out and frequently lead to cancel culture which is a modern form of ostracism where someone is shoving out of social circleswhether it be online on social media or in person the respondents have all received different cancellations or backlashes from those who disagree however the only commonalities they have shared were that they treat counterattacks as usual insults considering that woke culture has been like that instead of arguing with them they tend to be more professional by enlightening them on particular issues the respondents are woke enough to engage in sociopolitical discourses but when asked about the constructive ideas of this culture respondents said that people are now becoming aware in addition to its positive impact woke culture tells us that many more issues need to be discovered and rediscovered and they recognize this practiced culture for awakening many people who isolated themselves in a dark castle of ignorance they are willing to be labeled as woke but do not want the woke culture to disparage or backbite them they tried to be acquainted with the problems surrounding our present realm by reading books knowing the real root of the issue utilizing grassroots to engage with their community dealing with people and identifying the needs of minorities by organizing causes they classify the term as a good thing if it is being used in an exemplary manner but if it is being used to silence them why would they decide to be open in the first place finally these respondents opted to be in the pitfalls of woke culture not engaging in healthy discourse diminishes open enriching political discourse and it is the harmful side of this culture for they believe that each others opinion though they are different it is more admirable if we start to consider them as valid the professionals mr chua and ms ara both had the same explanation or perception of woke culture being aware and open about the surrounding issues however aside from the mentioned criticism and counterattacks of this culture it is also anchored with a patronizing attitude wherein the socalled woke people have the condescension to those who are not welleducated or those who do not profoundly criticize and engage in the sphere of sociopolitical issues and discourses this then discomforts charles chua for him you can be woke in such issues but learn to be humble when giving an opinion because sometimes wokes are not like that this belief held by wokes should not be praised thinking that if one is attentive they are more intelligent and more informed while uneducated if you do not practice being woke instead of arguing with each other he added that individuals must discuss good things for a progressive nation according to both of them perhaps a good attitude toward this culture is being sensitive or politically correct while considering another persons point of view to connect more deeply with them additionally for the professionals youths of today are very much welcome to participate in adult discussions where social injustices political matters and other societal issues are served at the table on a serious note ms ara is glad to be in her current journalism beat where she did cover pop culture in politics and the experiences of generation z or youths for her it is a positive move that young people are continuously engaging in discourses because these youths know the future of our society as the old adage goes papunta palang tayo pabalik palang sila such language usage is merely an example of rampant political polarization in other countries and the philippines filipinos in this era still assume that people who do not blend themselves in trends like this are misinformed or downright idiotic which is the downside of woke culture there are still filipinos who restrict the definition of this to activism and intelligence perhaps we can broaden the definition of woke by including virtuous characteristics such as respecting opinion from both sides of the political spectrum implication political polarization is apparent in woke culture the evidence can be traced back to its beginning what is more when the word surged its fame in the digital ecosystems you can see people combative against each other for their beliefs and slashing someone for disagreeing with their ideology this term has a common conception on the left wing or the believers of democracy social equality and egalitarianism to be woke means identifying themselves as devoted social justice activist keen on investigating contemporary political concerns on the other hand the right woke speaks undesirable volumes they speak nothing but political correctness performativity and phony which were weaponized by the conservatives to silence these progressives later on however in this study researchers found that heaving reproaches and fallacies are used by the woke critique and are familiar to those with progressive views they are canceling each other because of their political spectrum calling out nomenclatures because they are divided into their goals in the philippine setting woke culture is further evident in leftwing parties they are social justice advocates and activists who mostly conduct grassroots activism in the street protest against the government and promote social media activism filipino slang is currently buzzing in the philippine media landscapes especially on twitter after this antiwokeness or antiprogressives pigeonholed them as a slang word used to silence their vocal standpoints on social and political mantras woke cultures critics described elitist individuals with a superiority complex and hypocrisy they are more into logical fallacies when discoursing and anyone who disagrees with them thinks that their words are the truth that will enlighten anyone in the dark more so they are always the subject of these antiintellectualism words such as for sharing their sentiments in effect when they receive this they tend to cancel culturecanceling everyone who tries to relive their belief the haters of woke see this culture as toxic or vicious as the supporters of this perceived themselves as suitable which triggers the former the silent problem in woke culture is that people cancel each other as time passes they get selective especially when everything does not favor their opinion today as the culture is exposed to the mainstream more people will acknowledge it and if they let their pride drip on how they perceive things people cannot be united the political division will always have a domino effect from this woke culture will be painted as negative and positive the importance of this study focuses mainly on the sociopolitical wokeness of filipino citizens in the current political system its intent includes analyzing the wideranging concept of woke culture in the filipino society examining the sentiments of wokeness to society the researchers created a documentary output that will serve as the backbone of this study therefore all gathered information from the respondents will be projected in the news magazine documentary although the label of wokeness can be seen in social media especially applied nowadays to activists many of whom are embracing the clicktivist lifestyle there are still no recent related studies about woke culture in the philippines and that is the main reason why researchers are fervent to discuss the culture in the round table insights the term woke culture is familiar to the researchers considering they are more active in digital media spaces tweeting that supports causes is close to being woke meanwhile reposting publication materials with the progressives and antiprogressives views on it manifests awareness and sharing stories by other peoples experiences may be about political chaunts implies engagement in the culture the researchers already executed these given situations thus conducting this study entitled wokenam new dogma by the title woke a slang term equivalent to western neologism was created by filipino netizens to describe the filipino wokes who have extreme views on political and social injustices the word is the national personification of the country often used to represent the filipino everyman the word dogma denotes belief or a set of ideologies normalized by many to puzzle out the words being introduced and expand them woke culture has been in the system even before the neoliberalism colonized the peoples mentality however the term connotes different meaning and the expression wokenam has entered the chat which the filipinos are normalizing in every discourse either to insult someone or to commend themselves for their consciousness the desire to learn pop culture and political journalism topics has pushed the researchers to continue this study where only sociologists political journalists social scientists and students who are mainly acquainted with this ongoing culture were tapped to answer the welldetailed questions connected to the concept they were interviewed via zoom and communicated via google mail twitter and facebook the researchers asked them to share some information about their general background and they did not hesitate to provide it further this insight is supplemented with the level of their wokeness which is the core objective of this study we first communicated with alec gabrielle gonzales of the university of the philippines mindanao where she studies communication and media arts she has been active in raising her opinion on twitter against the present administration and believes that being woke is good as long as we try to use it effectively second rigo babas a psychology major at san pedro college of davao city was once a target of smartshaming and cancel culture for being a critique of the government however he then realized that it is his responsibility as a youth to amplify voices for the countrys common good he is an active member of the citys external organizations and grassroots movements and currently supporting a presidential candidate for the 2022 national elections third we have christianne kelsey hadjirul a student at miriam college manila currently working as save san roques main organizer this community organization supports the poor urban community of san roque her perception of woke culture is somehow insightful she tries to be woke in social media and the outside world by engaging with communities fourth chad errol booc is a human rights defender environmentalist and studentlumad teacher based at the university of the philippines diliman mr chad did not want to classify himself as a politically correct individual but he acknowledged the significant changes made by being aware for the fifth respondent we have min soo kim a 3rd year foreign service student majoring in diplomacy at lyceum of the philippines universitymanila college of international relations he is woke enough of his political and social surroundings because he is more into digging into issues by supplementing his mind with books however he did not want to be called woke if such culture presages negative meanings moreover a particular social scientist public historian and associate history professor michael charleston xiao chua of dela salle university was present in this study to debunk and educate us further on the derivation of this culture his participation only shows that he is interested in talking about this culture he firmly believes that wokeness is now a symbol of intellectualism which should not be he concluded the interview by informing the youths of today to be more engaged in social and political discourses but to never resort to violence on the other hand journalist janella ara eugenio of summit media philippines also shared her views on this debatable matter ms ara a journalist who mostly shares her articles on pop culture politics reasoned that objectivity in journalism is a myth when she produces articles her personal biases are sometimes evident in her storiesinformative biases that can help people be wellinformed on the subject she frames ms ara also told the researchers that wokeness signifies that one is aware of the happenings and there is nothing wrong with that this study will be beneficial for the researchers the researchers learn to understand each others ideas and stances in the woke culture it was not just a simple interview but rather a fiery one because the respondents answered the researchers questions straightly there is nothing to be ashamed of being woke or aware of it only worsens when people start to weaponize this when they continue to use it to slash someone due to his intellect in systemic oppression injustices and politics furthermore the researchers believed that every filipino has the right to submit their opinionative side as long as their statements will not create disarray and foster more healthy discourse the philippines as a democratic country should allow woke culture to be practiced or performed however constituents should learn how to raise their political stance or express their views on an issue that they think caused dysfunctions particularly on the internet political affiliations are not the problem because we all decide how we perceive things in fact despite the political stance of the respondents interviewed for their study they still believe that wokeness is vital because it is an indicator of being aware of our surroundings but it should not be used to affront someone just because they practice the latter recommendations future researchers can create advocacy promote social awareness and educate the public on social issues that have been happening in the country they can give importance to the development of this culture from traditional to its ubiquitous status in the mainstream media

the call to stay woke emerged in the early 19th century as a metaphor for social justice however despite early exposure this globally perceived culture was obscured in some communities the proponents utilized creative research and interviewed active individuals in this echo chamber one public historian and a professor one journalist who writes primarily on pop culture to debunk the roots of this culture and five participants from different universities and organizations in the philippines who are actively participating in the social and political discourses the researcher found that the term woke is more prevalent within left politics while the critics are rightwinged however both could be a target especially if their political stance no longer favors the government with the help of existing studies and respondents the proponents have magnified the idea contrary to the widespread presumptions the wokeness of filipinos is the effect of social realities and activism is a norm in such culture furthermore the creation is apparent in philippine democracy it has been subject to democratic pitfalls because of political polarization resulting from canceling culture today slang embraces progressive activism and is evident in our information ecosystems this study is vital to human society regardless of their stance and affiliated circle

introduction in december 2019 the world learned about a novel coronavirus that was spreading throughout the chinese province of wuhan in a matter of weeks the sarscov2 virus spread across the globe causing the worst pandemic in over a century and leading countries to enact mandatory quarantines and infection prevention regulations at the time of writing covid19 the infection caused by the novel coronavirus has infected over 99 million people worldwide and caused more than 2 million deaths 1 several infection prevention and control measures have been adopted in different jurisdictions across canada from mandatory use of facemasks to the banning of indoor gatherings and keeping two meters of physical distance from others at all times these public health guidelines have reshaped our social mores normalizing behaviours previously considered antisocial and causing anxiety or concern over those who refuse to comply with them the imposition of various provincial and federal guidelines to control the spread of covid19 in canada were met with criticism with some arguing these measures should have been adopted earlier or should be more stringent while others rejected them as a violation of civil liberties compounding these tensions is the foundation of canadas confederation where the division of powers and responsibilities over public health and health service delivery vary drastically in addition the primary spokesperson for communicating the status of the disease and control measures differed between jurisdictions the variability of covid19 prevalence and concerted efforts to not impose a onesizefitsall approach resulted in different public health control measures being invoked in different provinces and territories and indeed within different regions within a given jurisdiction over time we examined newspaper coverage of covid19 to assess how these public health guidelines have been discussed in editorials columns and letters to the editor we argue that the normalization of infection prevention behaviours led to a moral panic which is expressed in opinion pieces through a claimsmaking process in which compliance with public health guidelines is construed as a moral imperative and a civic duty those who fail to comply with these guidelines were shamed and discursively censured as a threat to public health and moral order moral panics moral panics are episodes of intense concern about the behaviour of a group or a particular event these moments tend to be volatile as they emerge suddenly and then quickly dissipate 2 this concern usually involves some hostility against those considered at fault and a disproportionate depiction of the threat as well as a broad and consensual reaction 3 during moral panics deviant groups are considered a threat to societal values and interests 3 these groups are identified and perceived as folk devils 2 marginalized groups that embody the social anxieties of the dominant group 4 moral panics however are not random and irrational episodes but are rather moments of power struggle between various asymmetrical interests 5 news media play a central role in the construction of moral panics 6 social reaction to the contentious issue can be more or less consensual and news media reproduce both moral discourses and counterdiscourses they inform what constitutes immoral and deviant behaviour as various social actors engage in claimsmaking processes including socalled folk devils 46 therefore the feeling of threat is further magnified in media discourse through stereotypical representations of deviants and the expression of moral outrage by righteous figures and experts 2 some moral panics dissipate without long lasting effects while others translate into policy changes that remain after the panic has subsided cf 78 moral panics also vary in intensity duration and social impact depending on the extent to which the discourse resonates with wider sociocultural anxieties 3 for example news coverage of outbreaks of vaccinepreventable diseases tend to focus on antivaxxers a derogatory term used to refer to those who oppose vaccination despite the many degrees and reasons for vaccine hesitancy 9 within such news coverage antivaxxers are portrayed as folk devils that endanger the community exaggerating the actual proportion of unvaccinated people in a population and demanding the punishment of those who ignore their moral duty of vaccinating themselves and their children for the protection of others 10 ungar 11 refers to moments of moral panic during health crises as viral moral panics which are often localized phenomena that involve the use of morality to regulate public behaviours moral obligations can include selfisolating when symptomatic conforming to quarantine regulations and getting vaccinated when recommended furthermore these episodes of widespread attention and fear become part of the collective memory and are evoked whenever a new outbreak occurs for example the 1918 flu pandemic is frequently evoked as a metaphor of the worstcase pandemic scenario a trope that has been used in media coverage of recent outbreaks and resulting in exaggerated claims that did not materialize 11 media coverage of health crises moral panics generated by diseases are common as some medical conditions are imbued with stigma or become racialized 12 for example syphilis in the 19th century hivaids in the 1980s and sars in 2003 health crises such as pandemics provoke anxiety and feelings of dread about particular groups of people and specific behaviours 1314 which are then reproduced and reinforced in media coverage 1215 the general public usually learns about novel health risks such as covid19 through news media 16 which also play a key role in the formation of moral panics by amplifying the feelings of threat and fear that some groups represent to others 6 media narratives stereotype and misidentify deviance which in the case of health panics in particular can produce socially harmful representations that stigmatize certain groups 12 opinion discourse in particular offers readers a distinctive and authoritative voice that will speak to them directly in the face of troubling or problematic circumstances 17 canadian news media has contributed to health panics by reinforcing the stigmatization and discrimination of specific groups in canada news coverage of the 2003 sars outbreak depicted chinese canadians as both a biomedical and moral risk by associating this group with the origin of the outbreak in hong kong and directing fears and anxieties against them 1819 sars quickly caused a moral panic and people who were infected were stigmatized and blamed for endangering others 20 moral panics about epidemics and pandemics can extend into social media platforms as news stories magnifying the threat posed by certain groups are shared thousands of times 21 the first case of covid19 in canada was detected in a toronto hospital on january 25 th 2020 22 evoking torontos experience as the epicentre of the 2003 sars epidemic in canada which caused 43 deaths and over 400 suspected cases 23 since then covid19 has been the leading news story every day in canada including guidelines and restrictions to minimize the spread of the virus and asking individuals and organizations to rapidly shift professional and social practices in the process personal protective measures have been formulated and new social norms have emerged regarding what is appropriate contact with others we examined opinion pieces published in canadian newspapers to assess how these new social norms have been discussed and interpreted and whether they have elicited the expression of a moral panic materials and methods we conducted a claimsmaking analysis 24 of newspaper coverage of covid19 to assess how public health guidelines and noncompliance have been discussed in editorials columns and letters to the editor more specifically we sought to determine whether three specific characteristics of moral panics were present in opinion discourse moral concern about a groups behaviour hostility against individuals in that group who are portrayed as deviants and moral entrepreneurs demanding punitive action the presence of these three expressions of moral reprobation in opinion discourse would be indicative of a moral panic due to the high volume of news coverage of the pandemic we focused our analysis on six topics featuring high levels of scientific uncertainty andor debate and how journalists made sense of them in this article we focus on three of these topics that contributed to the construction of a moral panic travel isolation and quarantine use of facemasks and physical distancing our sample for analysis included print and online coverage in seven canadian newspapers including both hard news and opinion discourse two with national distribution and five with a more regional focus we searched the database factiva using various combinations of the keywords covid19 covid19 coronavirus quarantine isolation travel model � guideline test � mask � aerosol � airborne distancing occurring between march and midjuly 2020 we ended data collection for a specific topic at logical moments when news coverage of the topics waned in favour of new issues gaining greater salience the sample for each topic encompassed at least 2 weeks of coverage to a maximum of 10 weeks news articles that mentioned these topics only tangentially were not considered for analysis the sample was composed of 1143 articles we comply with all terms and services required by factiva and necessary permissions for use the relevant articles were uploaded to nvivo12 for open coding analysis we developed an initial codebook with five main codes while iteratively adding new code categories as these emerged during the analysis the stories were also coded for type of story geographical focus and whether or not the reporter was a specialist sciencehealth journalist a second level of analysis was then conducted on the coded data to identify whether the three elements of a moral panic were present the sample for each topic was established according to its salience in news coverage over time acknowledging both overlap in time between topics as well as differences in how much coverage specific topics received we coded one topic at a time to ensure the coding process was focused on how public health guidelines were discussed in each specific case the lead author coded the entire sample and the senior author coded a subset of news articles to ensure coding agreement disagreements were resolved through discussion for the sample subset where double coding was completed the final overall cohens kappa coefficient for intercoder reliability was 97 findings we identified three moments in the news coverage of covid19 in which columnists and commentators expressed concerns that suggest a moral panic about infection prevention behaviour first they identified the desirable behaviour as a moral duty second those who failed to comply with public health guidelines were shamed and represented as folk devils and third punishment for deviants was demanded in opinion pieces within these stages however there were some alternative narratives focusing on political responsibility and leadership versus an overly simplified view characteristic of a moral panic that emphasizes the role of individual behaviour selfregulation as moral duty complying with physical distancing and staying at home except to get food and medicines were the first guidelines that canadians received from public health authorities on march 15 th 2020 columnists and commentators reflected on this and other public health directives as they were announced in the following weeks and months often presenting these actions as necessary in opinion pieces stopping the spread of covid19 was discussed in terms of individual responsibility for the common good with references to prime minister trudeaus pleas for canadians to stay home as a call to war and a national duty for example an editorial in the globe and mail on march 23 rd referred to the public health response to covid19 in military terms calling it a generational call to national duty a request to do our part in the war on the coronavirus 25 a similar opinion was expressed the following day by a columnist in the winnipeg free press who referred to compliance with public health guidelines as a civic duty and spoke of the role citizens have in stopping the spread of covid19 highlighting that individuals have to do their part by staying home practicing social distancing and not hanging around in groups 26 another columnist in the vancouver sun claimed on march 20 th that public health authorities were asking canadians to make a few sacrifices for the greater good and to be our best selves good citizens and neighbours even in long grocery lineups 27 in the opinion pieces there was constant acknowledgement of the important cultural shift that public health measures were demanding therefore adapting individual behaviour was considered not only good it was portrayed as a selfless sacrifice for the protection of the wider community columnists claimed that staying away from friends and family and even strangers goes against our cultural norms and how we have been socialized while acknowledging the pandemic has changed our cultural understandings of how friendliness and politeness should be expressed a columnist in the toronto star reflected on the challenge this cultural change imposes in the context of people who have been denounced in news media and social media for violating public health restrictions this follows the closing of national and provincial parks and various conservation areas across ontario after photos and videos of irresponsible people clumping together last weekend were circulated some of those clumpers were probably willful idiots some just ignorant but ive being thinking about how difficult it is conceptually to practise physical distancing walking away from and far around people goes against everything weve been taught it feels so rude though its now the ultimate show of social respect and trust 28 in this opinion piece the columnist points to an important cultural shift that occurred in a matter of weeks claiming that keeping physical distance is no longer unfriendly but has become an expression of consideration and respect therefore those who still attend crowded events are either ignorant or idiots but above all they are described as irresponsible similarly health columnist andre ´picard noted this in the globe and mail and highlighted the symbolic meaning that facemasks have acquired the evidence for maskwearing as a means of infectious disease prevention remains mixed at best increasingly however making and wearing a mask in public is becoming a demonstration of civicmindedness a public acknowledgment of the risks coronavirus poses and a fitting symbol for the new normal 29 preventing the spread of covid19 is therefore framed as an individual responsibility for the good of the collective which writers claimed is a moral duty an act of selflessness and a show of respect and kindness literally a matter of life and death 30 those who do not respect the rules either willfully or by ignorance are considered irresponsible and immoral shaming transgressors covidiots young adults and snowbirds frequently documented in columns editorials and letters to the editor was the feeling that the burden of infection prevention and control measures is being carried unevenly in canada in these pieces there is a strong focus on transgressors who are shamed as covidiots a label used to designate people who do not wear facemasks do not keep physical distance and do not selfisolate as instructed at the beginning of the pandemic news coverage of selfisolation and physical distancing guidelines focused on the various challenges people faced in order to comply with guidance measures for example the difficult situation that selfisolation posed for people living alone the challenges parents faced by keeping their children at home as well as the risk that not having access to parks and openair spaces all negatively contributed to everyones mental health but soon the tone of the coverage shifted from empathetic humaninterest stories to news reports of people not complying with public health guidelines this shift was also reflected in opinion pieces as writers expressed anger and frustration over people who did not respect restrictions for example a columnist in the toronto star explained that scenes of people converging on beaches and in parks raised the ire of many giving rise to one more new covid19related termcovidiots 31 the columnist also noted that even prime minister justin trudeaus tone had changed from one of positive reinforcement to one of calling out and shaming those who do not comply with safe distancing guidelines enough is enough he said finally addressing the covidiots amongst us those who fail to quarantine now risk being fined this was also noted in an editorial published in the winnipeg free press on march 27 th which not only referred to travellers not complying with the quarantine but also claimed that violators do not care about the threat they pose to others hello snowbirds welcome back go directly home do not go shopping the federal government which had previously urged canadians returning from abroad to selfisolate for two weeks has now declared that quarantine mandatory why the suddenly urgent tone because apparently too many canadians dont get it there are many who just dont seem to care and are stopping in at stores when they get across the border this must stop do not go shopping go directly home 32 in this editorial travellers crossing the border from the united states in cars and campers also called snowbirds because they spend winter in warmer zones are described as ignorant and selfish as well as failing to respect their civil and moral duty the editorial also refers to the federal government invoking the quarantine act which mandates quarantines for travellers and deems it quite frankly embarrassing that travellers would need to be coerced with legal action as opposed to selfisolating voluntarily a columnist in the toronto star sought to ridicule people who do not respect safedistance guidelines by claiming that even a preschooler can understand the new pandemic rules my kindergartenaged niece informed me via facetime that the news said there were to be no play dates so she was going to play with her siblings instead it seems many adults are not being as compliant as my niece 33 meanwhile another columnist in the montreal gazette reinforced the notion of personal responsibility by urging people to comply with public health guidelines for the greater good dont be the idiot who ruins it for everyone 34 columnists focused most of their criticism on young adults and snowbirds who were qualified in a winnipeg free press column as covid19 deniers this angst generally produces two reactions those who accept the reality of the pandemic and those who foolishly do not among a long list of deniers have been teenagers on spring break frolicking on florida beaches until local officials shut most of them down the recent crowds of people in vancouver parading up and down stanley parks popular seawall path with little regard for social distancing 35 however despite the paralyzing effect that an unprecedented pandemic can elicit another columnist in the winnipeg free press explained that most canadians are complying with public health measures we track legitimate sources of information listen to the experts and accept that the threat is real and not exaggerated 36 the columnist however also criticized those who keep on with their lives and ignore the severity of the risk as of last week canadians were still flying out for winter vacations college students from across the united states were flocking to springbreak resorts and they are not alone one in eight canadians believes the pandemic is overblown and as a result are less likely to wash their hands maintain social distance and avoid large public gatherings besides describing them as idiots irresponsible reckless shameless and careless the opinion piece writers also raised the issue of the potential threat that noncomplying individuals can pose to others due to asymptomatic transmission transgressors are construed in the opinion pieces as an invisible threat to public health one reckless individual can contaminate hundreds of doorknobs handles railings buses taxis and subway cars 37 in another column it was emphasized that public health officials had been begging the public to practice social distancing and that the message had been crystal clear and it is not a hard concept to grasp keep your distance 30 a similar view was expressed by a columnist in the winnipeg free press who stated that in the case of covid19 it only takes a few deniers to sustain the threat from this virus the columnist then exhorted those deviant individuals to take note we need you to stop denying the obvious and get with the program you are literally killing us 36 a similar point was made by a globe and mail editorialist on the same day who stated that it is unconscionable at this point to act as though the pandemic doesnt involve you or to assume that your individual actions arent risky the virus could also continue to feast on the indifference of a small but significant number of people who consider themselves above the fray 38 readers also expressed concern in letters to the editor regarding lack of compliance with public health guidelines particularly physical distancing in a letter to the editor in the globe and mail a reader wrote on march 23 rd i believe the biggest challenge is the failure of a segment of society to follow the direction of our leaders especially in regard to the clear and repeated guideline to adhere to social distancing 39 letters to the editor expressed more frustration as the first weeks of the pandemic went by for example admitting to being mad at those who refuse to stay at home except to get necessities or who are not social distancing 40 or feeling anxious over people around them not complying with physical distancing in public spaces such as walking in the middle of the sidewalk or not paying attention to their surroundings and walking around aimlessly 41 in a letter to the editor in the vancouver sun a reader warned that if we dont behave and follow the rules this social isolation is going to go on for a long time and asked if maybe the police should be enforcing the rules all over the city do we want that 42 the moral outrage and condemnation of people who do not comply with public health rules from social distancing and wearing a mask to the twoweek isolation after travelling was expressed in a column in the national post on april 18 th which expressed the sense of risk and panic the author feels whenever a stranger stands too close to him as everybody must be assumed to be risky and refers to the new politeness in which individuals are expected to keep their distance i treat pedestrians as though they are radioactive veering out of their way as if to avoid oncoming shrouds of toxins and i expect other people to act the same waybecause social distancing only works if everybody is on board so it seemed to me a flagrant transgression hovering in my immediate periphery as we waited for our companions to do their shopping and yet my reactiona curt excuse me combined with a reproving glarewas itself received as transgression indeed causing the culprit to roll his eyes and scoff 43 marsh also expressed surprise that this stubbornness remains inexplicably common for example people who walk handinhand on narrow sidewalks or mild acquaintances stop to chat while walking their dogs clogging up park paths or people who look with reprobation when you move out of their way or pause to give them space the columnist refers to these people as antidistancers who despite their flagrant violations look at those who comply with public health guidelines as if youre the one irrationally panicking the opinion pieces expressed outrage and moral condemnation of people who do not follow public health guidelines and whose behaviour is deemed a moral and physical threat transgressors are stigmatized whereas those who comply with prevention guidelines are considered selfless civicminded and good citizens demanding punishment for deviants after defining what is moral and immoral behaviour and identifying a group of transgressors many readers and commentators reflected on the urgency to act fast to contain the pandemic writers claimed that action needed to be taken as punishment for not following public health guidelines notably suggestions included arresting and fining violators a column in the front page of the vancouver sun on march 23 rd noted that the opportunity to supress this pandemic is rapidly closing and weve been put on notice that we can do this the easier way we can wash our hands keep our distance and stay home or we can do it the harder way with more sickness more deaths and police officers pulled away from more pressing duties to enforce those orders 44 columnists in the globe and mail and montreal gazette echoed this idea arguing that masks should be mandatory on trains and buses many of the worlds major cities including singapore berlin rome and bangkok have already taken this step 45 and that montreal police should ticket anyone not respecting socialdistancing norms 34 a national post columnist went even further arguing that canadians should forgo some of their privacy rights to do surveillance of returning travellers the columnist expressed disappointment that when the canadian government announced a mandatory 14day selfisolation period for travellers returning from abroad who would be punished with up to 6 months in prison andor a substantive fine if they did not selfisolate no surveillance measures were implemented to ensure travellers complied the columnist argued for enhanced surveillance of travellers and the use of technology to ensure compliance with selfisolation stating that the federal government must unleash the big brother bazooka by deploying technology laws fines and punishments already exist but arent working nor is public shaming tracking canadians using technology will keep everyone honest 37 eventually public health officers followed up with travellers in isolation through phone calls and physical checks a similar argument was made by a winnipeg free press columnist who criticized authorities in manitoba for not disclosing more locationbased information about community transmission of the virus in normal times their refusal is understandable for legal and ethical reasons but everyone will agree these are not normal times 46 at the same time he rejected notions of making public the personal information of those infected because the latter could create a counter effect by dissuading people from getting tested and might generally lead to public shaming and stigmatization another columnist in the vancouver sun argued that the burden of social distancing is not being shouldered equally by all canadians and reflected on the possibility and legality of sanctions individuals who are in breach of isolation orders can be criminally penalized given the nature of this unprecedented national crisis such measures are unlikely to violate the charter of rights and freedoms 47 another columnist speculated about the possibility of hotlines or volunteer watchdogs to become generally accepted by people frustrated by selfisolation indefinite school closures and juggling workfamily at home 48 the columnist then concluded that citizens reporting their neighbours is not too harsh a call to make people should face consequences for breaking distancing directives similarly a columnist in the globe and mail referred to the idea of asking individuals to act as vigilantes and report their neighbours but concluded that such a measure would erode trust in government and public health its hard to imagine a better way to poison the wereallinthistogether sense that governments are trying to cultivate than a 1800 line where people snitch on their neighbour hosting a poker game the task of getting large numbers to suddenly change their behaviour relies on social conscience and peer pressure 49 the globe and mail also criticized in an editorial on may 14 th the lack of rigorous tracking of travellers stating that trusting that people will actually selfisolate for two weeks once in canada makes no sense the editorial claimed that there is no testing no tracking and no obligation for travellers to monitor their health and provide updates to public health authorities overseas travelers landing in a canadian airport can even get on a connecting domestic flight before selfisolating 50 the issue of individual responsibility however was reframed by some columnists who argued that lack of compliance with public health guidelines is the result of city and provincial governments not facilitating physical distancing and safe access to outdoor spaces for example a columnist complained on april 3 rd that the city of toronto was not considering the idea of closing traffic lanes to make more space for pedestrians to follow the 2meter distance rule city staff demonstrated their trademark total lack of imagination in their rejection of an idea to close off two lanes of torontos yonge street 51 selley also referred to the crowded condition in which some people live in toronto and the risk this poses to mental health during the pandemic imagine being cooped up 23 hours a day with your kids in a stifling shoebox to keep people in such circumstances indoors by force to denounce them even for taking a walk to shut down schoolyards where kids could ride their bikes and scooters in at least relative safety is to risk mental and physical health outcomes that should certainly be weighed against the risks of covid19 itself in a different column on march 26 th selley shifted the blame from travellers returning home to the government claiming that selfisolation guidelines and regulations have not been clearly communicated to canadians returning from abroad one sheet of paper tells people to selfisolate but defines it as not having visitors especially older adults or those with medical conditions that misbegotten adverb especially does nothing except weaken the advice nothing on the handout suggests anything as alarming as dont even stock up on groceries or refill your prescriptions before you lock yourself inside 52 in the winnipeg free press a columnist also referred to unclear public health and official communication stating that it has been a source of confusion and stress about what exactly social distancing meansand more importantly how to do it right 53 furthermore while most writers expressed the need to act faster to stop the spread of covid19 there was no agreement regarding what should be done this leads to the questioning of core canadian values such as privacy versus surveillance law enforcement versus peer pressure and snitching versus trust discussion and conclusion the covid19 pandemic is an unprecedented health crisis that prompted a rapid public health response in canada premised on a series of changes in individual behaviour and cultural practices in this paper we argue that the normalization of infection prevention behaviours that the covid19 pandemic triggered in canada led to a moral panic over the threat that people who do not comply with public health guidelines pose to the rest of society this cultural shift led to the framing of compliance with public health guidelines as a desirable moral behaviour positioning the role of individual responsibility at the centre of the pandemic response if everyone makes sacrifices then the collective can get through this crisis but if only some fulfil their duty then the collective is at physical and moral risk transgressors were stigmatized through the use of various labels such as covidiots careless irresponsible and embarrassing conversely those who comply with prevention guidelines are considered selfless civicminded and good citizens the identification of folk devils and their stigmatization is characteristic of moral panics 245 the initial focus in the newspaper coverage was on snowbirds and young people on spring break but as the virus spread in the community transgressors became anyone not wearing face masks washing their hands covering their cough and keeping two meters of physical distance this heightened concern over groups of people not keeping physical distance isolating and wearing a mask led to the expression of anger frustration and fear in the opinion pieces some writers confessed feeling apprehensive when people who do not keep distance around them at the grocery store or the park while others expressed anger over the risk that these transgressors pose to others these representations can lead to increased fear and feeling of risk as well as intensified hostility against those who fail to comply with covid19prevention guidelines this inability to identify one welldefined group of deviants increases the feeling of risk around others an effect also found in the stigmatization of vaccinehesitant parents as antivaxxers or science deniers cf 10 additionally shaming and ridiculing those who do not follow preventive measures for covid19 could leadas in the debate around vaccinationto oversimplifying the reasons for these transgressions but while vaccinations are not mandatory in canada health crises like a public health emergency of international concern 54 can warrant the legal suspension of civil liberties consequently pheic level events require more careful treatment by public health authorities and government leaders our results show consensus in canadian opinion discourse regarding the health risk that those who do not comply with public health guidelines pose to the rest of society given that presymptomatic and asymptomatic individuals could be spreading the virus however opinions were divided regarding potential solutions and responsibility the message of prevention in canada at the beginning of the pandemic was mostly premised on a system of trust in which each canadian was called to perform their moral duty and comply with public health guidelines despite a large segment of the population complying some did not abide by the new normal within our dataset we found a variety of opinions regarding how to increase compliance with public health guidelines these ranged from conservative voices arguing in favor of strong surveillance and the surrendering of privacy rights to those who believe that blame should not be laid on individuals but on governments for not facilitating compliance thus proposing a shared responsibility among government and citizens this polarization is characteristic of opinion discourse 17 which is exacerbated by lack of previous experience and prevalent scientific uncertainty that come with the emergence of novel risks eventually the federal government and some provincial governments resorted to fines as a way to enforce compliance with infection control guidelines however enforcement of these punitive measures was inconsistent yet while the fundamental public control measures were basically clearselfisolate when sick or returning from travel wear a facemask and keep your distancethere was a myriad of confusing and conflicting guidance making it difficult for canadians to stay on point after the initial national lockdown in marchapril provinces with lower rates of covid19 began to relax restrictions in efforts to reopen the economy provincial leaders encouraged citizens to continue following public health guidance while emphasizing individual and public health responsibilities for appropriate testing and contact tracing efforts to contain the spread of covid19 as bars restaurants and the local economy reopened however provincial and federal health authorities were slow to mandate the use of masks in public or indoor spaces notwithstanding larger national chains and smaller local businesses posted signs requiring that customers wear masks on entry 5556 and mask use became a requirement to access municipal offices and services such as public transit quite early in the pandemic thereby contributing to its normalization despite this private and public sector staff often minimum wage employees had little power to challenge a customer entering a business without a facemask or remind customers to distance while in the establishment compounding these issues were the challenges that provinces faced in ensuring public health and system capacity to follow through on its end of the responsibility scale for example many people in their effort to do the right thing faced long lines at testing sites and several days to know the result 57 likewise due to rising case rates public health became overwhelmed in its capacity to follow through on contact tracing efforts when a covid positive result was known such that in some jurisdictions contract tracing was all but abandoned 58 despite the efforts to foster the desirable civicminded moral behaviour of individuals through public health guidance communication messaging created considerable gray zones selfisolation messaging was rarely as clear as to go straight home and not make any stops along the way returning travellers were further confused by seemingly redundant and often unclear federal and provincial requirements for selfisolation further encouraging households to stick to their bubble and minimize their number of contacts was regularly contradicted by provincial level messaging encouraging its residents to go out and support the local economy as part of restart efforts eventually many of the recommended public health guidance messaging which cajoled and appealed to canadians to be their bestselves had to be abandoned in favour of stricter lockdown measures with heavy fines levied for individuals and businesses that broke the rules because case rates were rising exponentially and intensivecare treatment beds in hospitals were greatly exceeding capacity seasonal holiday celebrations of november and december 2020 were dampened by messages to not celebrate with people outside their immediate household leave their homes only for essentials and to not engage in any unnecessary travel in particular vacation travel however when it came to light that several provincial and federal government officials flouted stayathome recommendations by traveling to various national and international destinations over the holiday season 59 public outrage was high while some provincial premiers reversed earlier decisions to not sanction these individuals 6061 others did not it left some editorial writers wondering why citizens were being asked to view these transgressions with compassion and kindness particularly given that nongovernmental idiots who choose to defy guidance are blamed and shamed 62 in this paper we have shown how canadian news coverage of the covid19 pandemic contributed to the creation of a moral panic around use of facemasks safe physical distancing quarantine and isolation our results highlight the importance of clear public health communication to facilitate compliance with infection prevention norms and the need for governments to provide the material conditions to promote infection prevention behaviour and reduce the discrimination of certain groups and hostile reactions towards them these are crucial aspects to consider as the covid19 vaccine program is starting in canada and those who cannot or choose not to be immunized could be the target of public condemnation and stigmatization we advance three recommendations for news coverage and risk communication of covid19 first clear public health communication addressing issues causing confusion would help increase compliance with infection prevention guidelines these moments of confusion were expressed in both columns and letters to the editor where contributors often also voiced frustration over lack of consistency in public health guidance communication efforts should highlight available community supports and resources to facilitate compliance with public health directives and lend support to initiatives such as paid sick leave that would allow people to comply with public health restrictions second the vilification in news coverage of those who violate public health guidelines can lead to the stigmatization of some groups including those who cannot comply with certain guidelines for example wearing a face mask or getting vaccinated due to underlying medical conditions similarly those who get infected with covid19 could also be vilified despite having complied with all the guidelines by providing a more nuanced account of violations and compliance with preventive measures journalists and editors can open up the discussion addressing public concerns and social and structural barriers instead of further polarizing superficial discussions over public compliance with guidelines finally opening up the discussion of compliance with public health directives to consider it not only a moral duty but also as a legal one would help normalize the fact that exceptional circumstances such as a pheic level event can trigger the legal suspension of some civil liberties journalists and editors could then frame legal restrictions as an acceptable course of action stripping them of moral judgement instead of proposing them as punishment for immoral behaviour nonetheless covid19 has unearthed a series of issues related to surveillance civil liberties community over individual level actions and responsibilities that warrant larger social discourse attention to better prepare us for the next pandemic this would promote genuine engagement for what kinds of measures are appropriate relative to the threat being faced so that we do not again find ourselves facing difficult decisions during the next unprecedented crisis details regarding the minimal data set are included in the methods of the paper data curation gabriela capurro formal analysis gabriela capurro

moral panics are moments of intense and widespread public concern about a specific group whose behaviour is deemed a moral threat to the collective we examined public health guidelines in the first months of the covid19 pandemic in canadian newspaper editorials columns and letters to the editor to evaluate how perceived threats to public interests were expressed and amplified through claimsmaking processes normalization of infection control behaviours has led to a moral panic about lack of compliance with preventive measures which is expressed in opinion discourse following public health guidelines was construed as a moral imperative and a civic duty while those who failed to comply with these guidelines were stigmatized shamed as covidiots and discursively constructed as a threat to public health and moral order unlike other moral panics in which there is social consensus about what needs to be done canadian commentators presented a variety of possible solutions opening a debate around infection surveillance privacy trust and punishment public health communication messaging needs to be clear to both facilitate compliance and provide the material conditions necessary to promote infection prevention behaviour and reduce the stigmatization of certain groups and hostile reactions towards them

introduction distance education has a relatively long history before the spread of covid19 the ways of communication have evolved rapidly especially in the second decade of the twentieth century during the industrial and technological revolution distance education combines many types of educational modes of learning using technology it refers to teaching and learning where teachers and students are distant from each other rather than in the classroom in morocco the ministry of education embarked on the integration of information communication technology in education at the beginning of the second decade of the twentieth century there was an adoption of massar and microsoft outlook emails in primary and secondary education and massive open online courses modular objectoriented dynamic learning environment and academic emails in postsecondary education however no serious attempts were made to activate these learning platforms until the outbreak of covid19 on the second day of march 2020 and the official adoption of distance education during the quarantine period starting from the mid of march to ensure educational continuity such abrupt adoption of distance caused a lot of confusion among students teachers and administrators alike hence their attitudes towards this new approach of education vary given the new emergency and crisismanagement circumstances overall this research is divided into a review of literature methodology findings and discussion review of literature covid19 has impacted greatly research on the national and international scale researchers and decisionmakers started relying on official media outlet information to identify gaps for research decisions makers started following models of other countries that are strongly hit with covid19 the number of cases and mortality rates recorded in some european countries along with the panic caused by media has impacted all aspects of life greatly especially education the different concepts types of distance education procedures and previous studies will be discussed in this section definitions of key terms the developments of technology have resulted in the emergence of new terms on education in this regard we hear of information communication technology integration in education elearning online environment among others attitudes are an important variable in using such platforms according to davies hewer ict refers to all technological tools that are currently available or will be available ict specifically refers to computerbased technologies such as desktops laptops tablets smartphones and software and internetbased technologies including email websites and social networking sites for english teaching and learning ict can be a learning resource like videos and portable document formats management of learning like moocs and moodle tv channels and radio distance education means learning and teaching through other ways that do not involve being in the same brick and mortar classrooms it is synonymously used with elearning and eteaching that can be synchronous or asynchronous the former means that it is online whereas the latter is offline during the crisis of covid19 another term has become viral it is emergency remote instruction however this term is teacherfronted whereas distance education is allinclusive as it comprises students teachers and educational authorities including parents as well as for attitudes they are perceptions that move the behavior of individuals it is one of the components of ksa that stands for knowledge skills and attitudes they refer to patterns of thinking and feeling attitudes are very important in studying the behavior of students and their influence on learning habits types of distance education platforms during covid19 the moroccan ministry of education along with universities have started delivering lectures lessons and orientation through the following ict tools websites many websites contain lessons addressed to all learners at all levels and all disciplines at the primary and secondary levels the websites include telmidtice moutamadriss massar and taalimma at the postsecondary level moroccan universities posted the courses mostly in pdfs on their website some universities created youtube channels where short video lectures are uploaded other universities provided their students with access to subscription courses on coursera like the case of sidi mohamed ben abdellah university there are also training programs for academy and administrative staff via etakwine which was launched on march 16 th 2020 the total number of the ones who benefited from these training sessions reach 23290 persons within eight weeks from its launch according to the ministry of education reports universities produced more than 111000 education resources posted on their websites moreover some online libraries like ebsco cairn manahil and dalloz are freely accessible to teachers and students for three months moreover a free internet connection was provided to some educational platforms for three months however youtube streaming is not free hence youtube videos were converted into stream videos to unify lecture delivery a mun website was created in partnership with france following the fun website it stands for maroc université numerique institutional emails all moroccan educational institutions have provided their students with an intuitional email which includes massar for primary and secondary school students and the first and last names of the students in addition to the acronyms of their universities followed by the extension acma at the tertiary level these institutional emails enable students to access software like microsoft teams and research websites like researchgate scopus and jstore these will enable students especially those who have to write a research paper in the licence degree master and doctoral programs to find research papers for their graduation projects software programs there are officially recommended and unofficially recommended software for studies the first recommended software is microsoft teams the latter announced by the ministry of education on march 23 rd 2020 the total number of created virtual classes reaches more than 725000 in the public sector and 108000 in the private sector both teachers and students have their accounts in microsoft teams to interact and study online through all media forms moreover moocs and moodle software are also recommended by some universities other unofficial software programs include coursera and social media apps like facebook whatsapp zoom and the like tv channels the moroccan ministry of education and universities started broadcasting university courses on some media channels namely arryadia and attakafia channels the lessons are daily broadcast from 830 to 2330 for sixth ninth and baccalaureate grades the tamazight channel was later added broadcasting from 830 to 1230 for primary school grades layooune channel was broadcasting lessons from 830 to 1900 university lessons especially targeted to students of the licence degree are broadcast on arryadia roundtables on covid19 were also broadcast moreover the moroccan ministry of education and the british council signed a partnership to broadcast some tv shows and radio programs in english such as world on street on arryadia channel and obla air on the atlantic radio website repetition of lessons is done during the weekends and official holidays the timing of lessons is shared on the facebook page of the minister of education dr saaid amzazi which has 711528 followers till october 2020 the total number of videotaped lessons until the mid of may 2020 reaches 3127 lessons radio some universities like ibn zohr and sidi mohamed ben abdellah university broadcast their lectures via local radio channels this is because most students who are enrolled in universities are originally from the region of the university however there are some students and teachers who live in different regions which makes impossible the process of recording lessons at university for teachers or listening to radio channels during the quarantine the procedures for distance education during the quarantine the first case of covid19 was reported on the second of march 2020 in the mid of march morocco suspended facetoface education and adopted distance education instead moroccan universities academies and directories started recording lessons and uploading materials to their websites the moroccan framework of education and training law recommends distance education according to the framework the government should take all necessary and appropriate measures to enable institutions of education training and scientific research in the public and private sectors to develop the resources and platforms of teaching learning and research similarly article 33 recommends the creation of laboratories for the innovation and production of digital resources as well as the training of specialists in this field the same article recommends the gradual integration of distance education with the view of generalizing it distance education complements facetoface learning article 31 of the moroccan constitution 2011 stipulates that the state the public establishments and the territorial collectivities work for the mobilization of all the means available to facilitate the equal access of the citizens to conditions that permit their enjoyment of the right to a modern accessible education of quality the national charter for education and training suggests distance education it was followed by the emergency plan of 20092012 and the strategic vision of 20152030 hence all moroccan legislative documents recommend distance education in one way or another all these reforms attempt to put the learner at the hub of the education process however distance education mode as implemented during covid19 is mainly teacherfronted students have to sit down in front of their laptops or phone screens to watch videos or read portable document files uploaded to the aforementioned educational platforms moreover lack of equipment internet connection and student involvement can be cited as the main obstacles for distance education while distance education may be difficult for primary and secondary school students university students are considered autonomous learners hence distance education for university students is more likely to succeed despite the relative supposed success of distance education at the university level students are not supposed to be evaluated online the moroccan ministry of education scientific research and vocational training did not recommend distance assessment until september where cases have increased in some areas universities started an online assessment for limitedaccess institutes however the perpetuation of the virus has obliged many moroccan universities to postpone exams to another date as they were initially scheduled in september 2020 unlike the baccalaureate exam which took place at schools in july 2020 assessment in higher education during covid19 pushed universities to adopt many policies for openaccess universities they started creating proximity centers for students to sit for the postponed spring term exams moulay ismail univerity in meknes was the first one to notify its students to choose the examination centers through a platform specifically made for this for limitedaccess institutes of higher education and some branches distance education was recommended students in the faculties affiliated with hassan ii university have to fill out a google form to choose whether they can sit for online exams or facetoface exams the university of mohamed the fifth in rabat issued notices warning students who are infected with covid19 with strong threats in case they sit for the exams without reporting these cases safety and education are the two main concerns of educational authorities moroccan universities can benefit from the baccalaureate experience in terms of exams for the latter stadiums universities and schools were rendered as places for exams moreover social distancing and the use of facemasks and disinfectants were used during the exam temperature is measured before the entrance to the exam room for both teachers and students secondyear baccalaureate exams took place on july 3 rd and 4 th for the pole of literature human sciences and islamic education and from 6 th to 8 th july for the pole of scientific technical and professional baccalaureate the lessons subject to examination are limited mainly to facetoface education delivered lessons this indicates the failure of distance education since the lessons delivered therein were not scheduled in the exams the catchup sessions of the exams were conducted from 22 nd to 25 th of july 2020 students infected with covid19 took their exams at hospitals the rate of success in the ordinary session is less than the previous year of 2019 which reached 6555 which amounts to 196664 it may be attributed in part to the effect of covid19 in brief the procedures adopted are determined by the status of covid19 spread in morocco facetoface education and assessment have been proven to be more practical than online and distance education for formal education delivered by the ministry of national education vocational training and scientific research previous empirical studies on attitudes towards ict there are not many studies on students attitudes towards ict or distance education in the arab world and morocco bataineh atoum alsmadi and shikhali investigated obstacles and effectiveness of distance education during the beginning of the pandemic by randomly selecting a sample of 10000 students in public and private universities the authors used questionnaires and semistructured interviews the study revealed that the majority of the jordanian university students are dissatisfied with distance education due to many obstacles such as internet speed technological difficulties and online content design in turkey isik karakis and güler investigated postgraduate students attitudes towards webbased distance learning taking the case of gazi university the study surveyed 64 participants using a fivepoint likert scale only six of the participants are females the results were analyzed by a ttest to determine the attitudes of males and females towards distance education females showed more positive attitudes towards distance education compared to males the pearson productmoment correlation coefficient was used to test the degree of a linear relationship between working years and webbased distance learning in the future moreover oneway analysis of variance was used between the purpose of the internet usage and their recommendation of distance education to students students who use the internet for research recommend webbased learning more than students who use the internet for communication in morocco draissi and young vi polytechnic university contributed to the digital plan to respond to distance education needs morocco entered in a moroccan digital university with france via an edx powered server and english sessions with the british council in morocco research methodology the current section will delve into the methodology followed in the current study it will be about the research design questions sample as well as procedure of data collection and analysis finally research ethics will be disclosed research design triangulation is the research design adopted in the current study it combines quantitative and qualitative data quantitative data will give frequencies on the use of ict for learning during covid19 whereas qualitative data will explore the reasons behind students positive or negative attitudes towards distance education it imbibes from the pragmatic philosophy and avoids the dichotomy created by empiricism on the one hand and interpretivism on the other hand research objectives questions and hypotheses the research objectives of the current study are numerous the first objective is to verify whether students use the suggested distance education platforms second the research aims to investigate students attitudes towards distance education in morocco third the study has an objective to explore the suggestions and opinions of students in relation to distance education during covid19 in morocco the study has one hypothesis moroccan english departments at moulay ismail university have negative attitudes towards distance education because of the complaints posted on social media and memos the mock distance education in terms of organization and support accordingly the study aims to answer the following research questions what platforms do students use for distance education during covid19 in morocco what are the attitudes of moroccan english department students towards distance education at moulay ismail university what do students recommend for better distance education in english departments population and sampling two types of sampling procedures were followed in the current study the first type is convenience sampling as the researcher shared the google form link in english department groups on whatsapp and facebook facetoface data collection is not possible during the covid19 state of emergency in morocco for the focus group snowball sampling was used in that the researcher asked students to invite their colleagues to participate in a whatsapp focus group in brief the two sampling procedures fall within nonprobability sampling the demographic variables of the sample are summarized in figure 1 as can be seen the majority of participants are females the dominant age category of 67 respondents is between 21 to 23 most students are junior that is they are in the third grade of the moroccan licence degree what is meant by the senior level is graduate students or students who study in a professional license degree covid19 postponed the implementation of the bachelor program instead of the licence master and doctoral programs the majority of respondents live in urban areas the data generated from the study should be understood in light of these demographics data collection procedure both the questionnaire and the focus group interviews are the data collection instruments used in the current study first a questionnaire was designed pilottested and shared on social media platforms multiple times for students to complete students were kindly asked to fill in the survey promising them that no personal information will be used and the data will be kept confidential according to the regulations of research for the focus group the researcher asked some of the students to invite others to complete 12 participants in a focus group on whatsapp the researcher and participants agreed on a time to start the discussion which too at the convenience of the participants data analysis procedure the survey questions were coded and entered into spss version 23 the completed survey was imported from google forms in excel format the graphs were generated using excel similarly students oral responses were transcribed through intelligent transcription arabic words were translated into english whenever encountered research ethics the researcher collected data in compliance with research ethics in force worldwide and in morocco the researcher started with an introduction of the self and the research respondents and participants were informed of the objectives of the study they took part in the study with their will no coercive method or fraudulent method was used in collecting or analyzing the data the data were collected and analyzed anonymously according to the purpose for which it was collected research findings this section will analyze the data of the questionnaire and the focus group quantitative data will be presented in the form of charts whereas qualitative data will be presented in the form of statements or word clouds qualitative data will complete quantitative data the analysis will be divided into three main sections equipment for distance education this section will shed light on the materials needed for distance education without connection and gadgets we cannot talk about distance education figure 2 shows how often students have an internet connection the majority of students reported that they always have access to an internet connection just two students who reported that they rarely have access to the connection however connections in morocco may not allow one to watch videos on youtube as internet connection companies give limited bundles based on nonsubscription offers the type of the connection determines its quality the majority of students have a wifi connection forty students reported that they use a mobile connection compared to one respondent who uses them both wifi connection is proven to have more quality than a mobile phone connection alone the former allows unlimited access to video streaming this will allow students to participate in live sessions and watch youtube videos mobile phones are the most frequently used gadgets by students accordingly teachers and administrators should consider this to provide compatible lessons attitudes towards distance education some measures of central tendency and dispersion of the fivepoint likert scale items are summarized in table 2 the fivepoint likert scale is considered an interval scale the mean is very significant from 1 to 18 it means strongly disagree from 181 to 260 it means disagree from 261 to 340 it means neutral from 341 to 420 it means agree from 421 to 5 it means strongly agree in the first statement the mean is 308 hence it means that the majority of participants are neutral as to whether they need technical assistance or not the mean of the second statement is 239 accordingly the majority of students do not prefer ict to facetoface classrooms the third statement about satisfaction with teachers performance the majority of students are not satisfied with their teachers online performance some students are neutral the majority of students reported neutrality with being distracted when they learn online as is seen in the mean of 30 access and use of distance education platforms figure 5 shows the most frequent platforms student have access to as can be seen whatsapp dictionary and google are most frequently used by students this is followed by portable document files and word documents other platforms like moodle and moocs in which the ministry of higher education invested much money are less frequently used by students surprisingly the majority of students reported that they do not have access to their academic emails these emails are indispensable in having access to online platforms like moodle and moocs without having these emails students cannot see the lessons posted on these platforms it is high time access be granted to students or the lessons be posted on social media accessible to everyone some students share the pdf documents taken from the platforms on whatsapp groups positive and negative attitudes towards distance education students in the focus group were asked the following questions 1 what is your attitude toward ict during covid19 note 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly agree 115 positive attitudes students reported many positive attitudes distance education is necessary during covid19 because there is no choice it is the only way to ensure education continuity and protect health respondent 1 said my attitude towards ict is that it is necessary in these circumstances to protect people moreover distance education is good for students who live far from the universities respondent 10 said none if anything i suffer more with facetoface classes than online classes i live exactly 91 kilometers away from my university and taking public transportation is not the best not to mention that it is a waste of both money and energy when sometimes professors fail to warn us of their absence employees and parttime students reported positive attitudes towards distance education because they can study in their free time without having to attend besides distance education will guarantee the safety of teachers students and their parents negative attitudes there are many negative attitudes toward distance education in morocco the reasons revolve mainly on the lack of materials and teacher involvement respondent 3 said i do not agree because they have to clarify lessons whether with recording videos or video calls the majority of students reported that their negative attitudes are because of a lack of support and lack of free platforms one student reported having difficulties by saying because we dont get enough information and we find many difficulties to understand the lessons we get from our professors the use of distance education is unplanned one student said in fact i think that our university is not qualified much better to be in the top dealing with some kind of these circumstances as now for lack of involvement another student said because some professors didnt care about their students or provide the lessons that are required to prepare for in general lack of materials involvement and organizations are the reasons behind holding negative attitudes towards distance education recommendations of students students recommended many changes in distance education as is currently delivered respondent 4 refereeing to teachers said they should do a lot of explaining of lessons and make videos this is a call for teachers to coordinate their efforts and deliver online lectures rather than just sharing materials there is an issue of internet access especially for students living in rural areas one respondent said many students live in rural areas and they dont have any wifi or internet some others have problems with websites they couldnt create accounts this is an implicit demand for improving the internet connection sector in morocco hence one student recommended the following steps to improve distance education in morocco give and supply free internet to the majority of students teachers need to provide and grant more explanations with massive examples for a better understanding however supply much time for the preparation for the exams by lessening and limiting the lessons pedagogically speaking one respondent suggested working on old exams by each teacher this is a recurrent pedagogical demand of students moroccan university students look passionately for validation of their modules by getting 10 out of 20 or beyond this average teachers have different methodologies hence students keep asking about whether a teacher so and so gives good grades or no they prepare for the exams by working on previous exams another respondent suggested organizing the material on online platforms moreover many students recommended that teachers should explain their lectures using videos and voice recordings because uploading documents alone is not enough the respondent said some teachers should take into consideration that we are no longer studying in classes because they give students lessons and leave them fighting with themselves trying to understand many recommendations were made to improve distance education in morocco especially providing the means and advising teachers to put more efforts in distance education which is still in its infancy in morocco at least during the first six months of covid19 discussion the moroccan educational system collapsed due to covid19 education was suspended starting from the mid of march upon discovering the first covid19 case coming from europe the abrupt adoption of distance education has a negative impact on students attitudes towards learning due to the lack of preparation students teachers and universities were not ready to adopt distance education despite many regulations and former recommendations most students have just mobile phones they use social media more than governmentsponsored platforms these findings fit with the study by mishra gupta and shree who investigated online teaching and learning in higher education during the lockdown period of the pandemic in india teachers and students use free platforms for education such as facebook whatsapp and google classrooms instead of limited access platforms such as teams attitudes of students vary on many variables parttime students have positive attitudes towards distance education as it allows them to study and work at the same time moreover some students live far away from the faculties they cannot attend courses hence distance education is suitable for them besides some students come from disadvantaged situations they cannot afford the rent to attend courses at university again distance education is good for them with or without covid19 this finding fits with badunyarkos study who talks about the concern with resource shortage and the need for extra work to implement distance education the attitudes of faculty members are summarized as follows • a belief that students taking distance courses will not learn as much as those in regular universities • the fear that distance education courses cannot be used to meet the entrance requirements of institutions of higher learning • the belief that the use of distance education courses will adversely affect the accreditation of the degrees and • the belief that distance education courses are poorly prepared by unqualified persons these findings are still applicable nowadays during the crisis of covid19 the limitations of the current study are mainly attributed to the small sample size accordingly generalizations cannot be drawn however the statistics given by the moroccan ministry of education on the percentages of parents and students who chose facetoface education for the 20202021 school year constitute the big majority approaching 85 accordingly this proves that most students have negative attitudes toward distance education being at university with friends is not like being alone at home studying education is more of a social and humanistic process than a strictly pedagogical one as for the recommendations there should be research more on the situation of each student each level and each institute university life of english department students should be investigated especially everything that relates to campus and dormitories the latter can give insights into the adopted type of distance education furthermore universities should have partnerships with laptops mobile phones and internet connection companies to provide special offers to students and teachers teachers should prepare lessons and deliver them in different formats universities should organized lessons in an accessible way and the government should provide free access to educational platforms it is highly recommended that distance education should take the needs of individuals with visual impairments written material will not be suitable for this category of people besides distance education should be personalized to these students who are used to high school life unlike freshman students who are in the second semester who already have some experience with university life methodology and assessment the newcomers to university need more orientation and support from the administrators and teachers as they may not even see their faces therefore universities should market more their services such as their websites academic email and elearning platforms even junior and senior students do not have access to their institutional emails let alone freshmen this issue of marketing can be seen even in that some university teachers do not use this institutional email and urkund given by the institute of scientific research in morocco hence a lot of investments and funds have been squandered in vain as few students and teachers do not know of these platforms let alone use them the minister of national education reported that 80 of students have chosen facetoface education rather than distance education this proves the low popularity accorded to distance education from preprimary schools to high schools moroccan universities launched new platforms for organizing students for exams and administrative documents this platform is called escol which refers to student affairs student support or student services some universities have distributed students to examination centers according to the address they first provided on the day of enrollment however some students complain on social media as they have changed those addresses conclusion all in all the objective of the current study has been to investigate the attitudes of moroccan english department students towards distance education in morocco accordingly the study has employed a mixedmethod research design by triangulating a survey with 117 respondents and a focus group with 12 participants in addition to a review of the main decisions taken by education authorities as well as previous research articles on the same issues in morocco and abroad the conceptual framework consists of defining ict and distance education attitudes are one of the components of ksa that stands for knowledge skills and attitudes along with motivation attitude is a determining factor in moving individuals to adopt certain behaviors distance education refers to teaching and learning moreover the statements and reports of the ministry of education as well as institutes of higher education were also reviewed the procedures of examination of the baccalaureate level reported as it was a successful experience last but not least studies on the attitudes of students towards distance education and distance education during covid19 were reviewed a mixedmethod design is adopted in the current study both the questionnaires and a focus group were adopted a questionnaire in google forms was shared on facebook and whatsapp groups for students to complete using convenience sampling a snowball sampling for the focus group was adopted 117 respondents completed the online survey and 12 participants participated in the focus group the results showed that students hold positive and negative attitudes towards distance education the former is because of workrelated issues in reallife education the latter is because of the lack of involvement of students and teachers lack of connection and lack of organizations new changes that coincided with the end of the current study was the implementation of distance assessment by limited access institutes and institutions where there are high rates of covid19 infections university hassan ii was the first one to implement distance assessment in open access institutes students were given exams in the form of research topics that involve the use of research skills rather than knowledge alone students in the undergraduate program of the english department in ain chok faculty of arts and humanities were given one hour to one hour and thirty minutes to finish the exam type or scan it then send it to the email given by their professors a warning of plagiarism was reported on the exam papers however teachers did not use the email address that measures plagiarism affiliated with urkund and sponsored by the moroccan institute of scientific and technic information it is highly recommended that more marketing of such platforms should be done for university teachers in morocco during and after covid19 besides students recommend more serious works for distance education to be successful in morocco moroccan facetoface education was resumed in september for primary and secondary education whereas tertiary education was resumed in the mid of october parents and students had to choose which mode of education they prefer by signing a form for that the majority preferred facetoface education despite the risks

the current study aims to investigate students attitudes towards the use of distance education during covid19 in morocco the first cases of covid19 starting from the first weeks of march 2020 has obliged educational authorities to suspend facetoface education immediately distance education was declared the alternative means to complete the academic year moroccan tv channels started broadcasting lessons for different levels at different times moreover teachers and students started using social media and university platforms to share lessons however not all students agree with distance education in the adopted format accordingly the current study investigates the attitudes of moroccan english department students at moulay ismail university a mixedmethod design was adopted by triangulating data from fivepoint likert scale questionnaires and a focus group the results showed that students generally prefer facetoface education rather than distance education however parttime students reported positive attitudes towards distance education it is recommended that both distance education and facetoface education should be planned by teachers coordinators and administrators

will be implemented and how it will be implemented as part of canadas nap on vaw remains an open question there have been several consultations with experts over the years on what actions should be included in the proposed nap on vaw most recently the federal governments women and gender equality ministry funded womens shelters canada to develop a roadmap for developing and implementing canadas nap on vaw based on a list of 646 initial recommendations collected from prior reports policy documents and other sources 13 the recommendations were organized into four thematic pillars with each assigned to one working group of vaw advocates service providers leaders and researchers to evaluate edit and prioritize the final report includes 100 wideranging recommendations across the four pillars of enabling environment and social infrastructure prevention promotion of responsive legal and justice systems and support for survivors and their families the report also addressed the need for an intersectional feminist monitoring and evaluation framework for the nap and the implications of statutory differences in definitions of ipv across canadian jurisdictions notably the authors recommended ongoing engagement with vaw survivors sector experts and advocates in the continued development and evaluation of canadas nap we sought to build on this foundational work in the current study we conducted the first to our knowledge formal and peerreviewed qualitative analysis of the perspectives of leaders service providers and survivors on what should be considered in the design and implementation of canadas nap on vaw in doing so we aimed to increase the transparency and rigour of our conclusions as well as the depth of information underpinning our recommendations due to resource constraints past consultations have tended to focus on participants recommendations for the nap without giving space to share lived experiences with vaw service access or sectoral work more broadly these experiences may offer further insight into important factors to consider in vaw policy we used data from a study of the vaw sector in canadas largest city toronto during the covid19 pandemic to critically develop nuance and prioritize recommendations for canadas nap on vaw the covid19 pandemic has changed the landscape of vawexacerbating existing challenges but also creating new opportunities for transformative policy and practicemaking it an important time to reconsider priorities and identify innovations methods ethics approval the unity health toronto research ethics board and the dalhousie university research ethics board approved this study data collection and analysis qualitative data were collected from april to september 2021 as part of a communitybased mixedmethods study on the processes experiences and outcomes of adapting vaw programming during the covid19 pandemic in collaboration with 42 vaw organizations across the greater toronto area 11 the studys coleads and three peer researchers conducted interviews typically in pairs eligible participants were either direct support or leadership staff working on a vaw service in the greater toronto area since 11 march 2020 or adult women who had accessed at least one vaw service in the greater toronto area since 11 march 2020 we deemed any services and programs designed to support vaw survivors as relevant to the study to broaden the scope of our analysis and conclusions participants provided informed consent by email prior to interviews we used interpretation services whenever participants were not comfortable speaking in english we provided participants with a 40 honorarium following their interviews introduction genderbased violence against women or violence against women is actual or threatened physical psychological economic or sexual violence that is disproportionately perpetrated against women or inflicted because the victim is a woman 12 the most common form of vaw is intimate partner violence 3 in canada 44 or 62 million women aged 15 years or older are estimated to have experienced ipv in their lifetime 4 vaw including ipv is one of the key determinants of injury and disease among women and at worst can result in death 5 6 7 the covid19 pandemic including its attendant restrictions and socioeconomic impacts has led to increases in the incidence and severity of vaw and created and exacerbated barriers to accessing and delivering supportive services 8 9 10 11 for over three decades canadian advocates have been calling for a national action plan to address vaw 1213 in line with canadas international human rights obligations 14 the intended goal of naps is to create the necessary political legislative funding and research infrastructure to support sustained coordinated action between all levels of government civil society and other relevant stakeholders to more effectively prevent vaw at the time of writing this manuscript in canada only a strategy to prevent and address genderbased violence has been implemented which solely involves federal departments 12 at the same time provinces and territories have their own diverse and at times inconsistent laws and policies around vaw which need to be addressed in an effective canadian nap 15 in 2022 the federal government affirmed in its budget an investment of cad 600 million over five years to advance a nap to end genderbased violence and with the endorsement of provincial and territorial ministers released a highlevel framework of opportunities for action while an important first step this document has been critiqued for only presenting an optional set of actions for provinces and territories to consider as opposed to commitments without any directives for federal or national bodies 16 as a result what aiming to sample a diverse cross section in terms of personal factors and types of services accessed our goal in purposively sampling staff and survivor participants was to capture experiences across different and intersecting forms of marginalization and the diversity of vaw practice and programming with staff support we ensured that survivors were in a physically and mentally safe space to participate 1718 we provided survivor participants with a list of vaw mental health resources following their interviews interviews were conducted and recorded over zoom and transcribed verbatim using trint at least two research assistants checked each transcript for accuracy and removed identifying information interviewers took field notes and were debriefed following each interview we used a reflexive thematic analysis methodology which recognizes and embraces the subjectivity of researchers encourages the use of flexible coding practices and emphasizes iterative and indepth engagement with the data 19 our interviews were semistructured staff and survivor interview guides are available online 11 in this analysis we have focussed on data on gaps in policy and practice as well as data collected in response to the following questions canada is currently investing cad 600 million over five years to prevent genderbased violence under the national action plan to end genderbased violence this includes funds to enhance the capacity of vaw organizations indigenous women organizations and a crisis hotline • what do you think would be helpful to include in this plan • what immediate changes should be made in canada to better respond to vaw • what longterm changes should be made to prevent vaw from happening in the first place four researchers collaborated on data analysis three of whom were also interviewers the analysis team first coded the same two interview transcripts and met to discuss initial codes aiming to incorporate diverse perspectives on priorities and relevant features of the data each analyst was then assigned a subset of the dataset for inductive coding analysts met regularly to discuss the coding process once all data were initially coded each analyst double coded a portion of the dataset to identify opportunities to add or refine codes and integrate perspectives two researchers then read through each code to develop an initial summary of the most salient data for recommendations for the nap we generated recommendations based on patterns of ideas identified within the data and developed a thematic framework to summarize the relationships between these patterns to further refine and situate our framework of recommendations we referenced available reports on the nap and theoretical and empirical literature on preventing vaw our analysis was informed by a critical feminist lens aiming to identify the ways in which participants experiences and thoughts demonstrate how societal structures disadvantage women at the intersection of different social identities and ways the nap can address this 20 21 22 the analysis team shared outputs regularly with the broader research team an advisory group of vaw leaders and vaw stakeholders for feedback through meetings and knowledge translation events we have selected quotations to support our analysis and included anonymized participant identification numbers to locate and demonstrate the scope of the data used results and discussion invest in vaw services and increase accessibility of crisis supports the accessibility of crisis supports for women experiencing violence was a common concern shared by both staff and survivor participants many survivor participants recommended investment in increasing public awareness of available vaw crisis supports central to survivors recommendations for increasing public awareness was the idea that women will be more likely to seek help if they realize their own experiences constitute violence for instance survivor c78s comments demonstrate several ideas for raising public awareness especially for women living with abusers this participant draws the connection that public information can be a first step to breaking the cycle of control of abusers denormalizing vaw for survivors and empowering them to seek support these ideas are borne out by existing evidence the lack of awareness of ipv including what constitutes violence and the lack of available resources have been found to be among the greatest barriers to survivors seeking help 23 the importance of denormalizing vaw through publicfacing campaigns was echoed by staff participants for instance leader p5 makes the point that public information on vaw will not only support survivors reaching out to services on their own but can also help community members groups and agencies to understand vaw and connect survivors to available services indeed evaluative research suggests that information campaigns should be longterm and involve engagement with multiple stakeholders aiming to shift public discourse and societal norms around gender and violence 24 to avoid unintended harms campaigns should use inclusive definitions of ipv and avoid traumatizing or stigmatizing language or imagery 2526 information campaigns on their own however are not enough 24 staff participants described innovations implemented c only asked of survivor participants d rows for each variable do not add up to 100 as all survivor participants accessed multiple types of vaw services during the pandemic e communityspecific organizations included languagebased and culturally specific organizations f only direct support staff participants were asked to indicate their programmatic specialization as in most cases leadership were responsible for directing managing or supervising an entire vaw service or organization specializations do not add up to 100 as one participant worked on both transitional housing support and counselling the more people that understand violence against womenwhether thats the layperson the local church group right or if thats a community agency somewhere rightthe more people that understand violence against women the more we can get the supports to those women that are hard for me to reach leader p109 like i was talking about the continuum of services for our community its just like some things need to be done with a translator … theres a big gap for services specific to my community already but if you add to that that most of the services were not done persontoperson no more it had to go by virtual … we did some referrals of almost a year ago at some time that we still do not have responses … the referrals are already long but it takes a lot more time survivor c73 i dont know how much times my kids had to hear about my story and i felt pretty shitty about myself to be honest i wish my kids didnt to have to hear as much they had to hear but i had no other choice survivor c80 so when i wanted to reach out to canadian community always i worried if i could deliver my message exactly or not … not everybody has … english perfectly also for culture i cannot understand other peoples culture how can they understand my culture c benefits of flexible funding in providing wraparound supports leader p137 thats probably the biggest help because clients dont have to be eating garbage before we can help them and they could be you know too much money for that but not enough money for this we can provide clothing we can provide money for summer activities we can provide computers we can provide winter coats we can provide upgrading so some very concrete support we can provide d gaps in traumainformed and specialized mental health supports leader p110 in terms of traumaspecific services like trauma treatment i would love to have to provide that service but that requires a particular skillset that we dont have here … i cant afford to pay for staff that would be coming with those skillsets direct support staff p103 have real therapy offered to people at a reasonable rateyou dont have to be rich to afford real therapy or have a benefit plan to afford it because most of our clients dont survivor c76 the stress through the beginning of the pandemic was extremely hard for me … it made it worse too for my eating disorder because i just couldnt do anything … i wish that there was more access for people with mental health conditions prior to the pandemic abbreviation vaw violence against women during the pandemic to broaden the accessibility of crisis supports or made recommendations to make crisis supports more accessible in the future these included a national crisis line to coordinate contact information for provincial supports virtual chat lines and strengthening referral pathways between crisis lines and other vaw organizations to provide immediate and ongoing support to those in highrisk situations or nonvaw shelters strengthening referral pathways in particular has been a major implementation challenge for vaw services exacerbated by the pandemic many staff participants highlighted the difficulties of connecting clients to services through vaw referral mechanisms these difficulties included for instance getting survivors into housing or legal supportas wait times severely increased due to a lack of stock or closed courts respectivelyas well as uncertainty over which services were open and available staff participants highlighted the need to increase investment into a systematic and centralized process for referrals to mitigate these challenges in future emergencies in addition many vaw organizations refer out to community services or programs to meet the varying needs of survivors as part of their normal practice when those services shut down or reduced their capacity during the pandemic some vaw organizations did not have the capacity to offer survivors wraparound supports inhouse leader p109 provides one example of how challenges with referrals were even more difficult for communityspecific services for which the already limited pool of potential service providers became even more restricted due to the pandemic and the switch to virtual services this loss was felt deeply by survivors consistent with p109s comments survivor participants commonly described being negatively impacted by insufficient programming for children interpretation and culturally specific services ensuring that vaw organizations can provide their own wraparound supports to consistently meet survivors varying needs even during a pandemic will require increased funding to expand vaw workforces training and infrastructure staff participants who spoke positively about funding during the pandemic often highlighted the benefits of funders allowing flexibility for organizations to use their monies as they saw fit to respond to pandemic conditions for instance as leader p137 illustrates flexible funding empowered staff to better meet the needs of survivors during an otherwise disempowering time however vaw organizations need enough funds to benefit from flexible conditions across staff participants this was more often the case for multiservice vaw organizations with larger pools of charitable and private donations to draw upon highlighting the inadequacy of public vaw funding a key area that participants highlighted as requiring increased funding to vaw organizations was traumainformed and specialized mental health supports participants recognized that survivors trauma has been compounded by the pandemic with more survivors reporting more severe violence highrisk situations and covid19related stress all of which have been found in other emerging research 8 effectively addressing the ongoing and exacerbated mental health burden among vaw survivors requires increasing vaw funding portfolios to develop the necessary expertise in the vaw workforce to deliver mental health support as both staff and survivor participants lamented without greater and critically sustained investment access to specialized mental health care will remain inequitable as is the case for access to mental health services more broadly 27 enhance structural supports for vaw participants stories and recommendations highlighted the importance of developing the necessary infrastructure and funding streams within the nap to support the full housing continuum specifically for vaw survivorsfrom emergency shelter to longterm supportive housing 28 these limitations predated but were exacerbated by the pandemic with the additional challenges in referral pathways and reduced availability of shelter and affordable housing staff and survivor participants acknowledged the critical role that emergency vaw shelters play in supporting women fleeing violence and the frustration of not always being able to gain access two participants had to access city homelessness shelters instead of or prior to vaw shelters in these cases there was a stark contrast drawn in the adequacy of the supports for vaw survivors for instance survivor c73 described fearing for herself and her children at the city shelter driven by the intersecting presence of men and alcohol use a precursor for violence experienced by many survivors 29 this was amplified by the retraumatizing experience of being exposed to potential violence in the shelter and dealing with her own history of alcohol misuse without any social or psychological support these comments are in line with other staff and survivor participants accounts that demonstrated the ways in which housing and homelessness policy and practice largely guided by the experiences of men have been insufficient for vaw survivors 9 it was clear from participants accounts that more investment is needed into vaw shelters as one solutionboth in terms of strengthening referral pathways but also in terms of increasing funding and resourcing to support capacity staffing and training to collaborate with other systems in the provision of vaw care however participants recognized that there must also be greater focus on longerterm housing solutions for vaw survivors 28 for instance as direct support staff p140 suggests greater investment in transitional housing for vaw survivors as a mediumterm solution in the housing continuum is an important way to establish a sense of home for survivors and their families while awaiting independent housing the ultimate goal 30 participants juxtaposed these longerterm housing options with shelter which being shortterm and shared does not provide that same enduring sense of stability and independence while shelter has lifesaving benefits for many survivors who access it participants also acknowledged that it is not the right option for everyone hence the need to invest in the full vawhousing continuum 9 for instance as direct support staff p23 demonstrates many women experience hidden homelessness without being able or feeling safe enough to access shelter and without adequate alternatives 31 this was reflected in the stories of survivor participants for instance survivor c74 who returned to an abusive situation after shelter c75 who faced discrimination in the housing market as a single pregnant woman on disability support and had to accept housing with significant water damage and c72 and c76 who were forced to endure harassment and abuse from male neighbours without recourse or the means to move participants highlighted the structural barriers that have limited safe and affordable housing for vaw survivors and driven womens risk of experiencing hidden homelessness for instance leader p110s comments spoke to the broader issue of canadian housing policy and residential tenancy laws not reflecting the lived realities of vaw survivors 93233 direct support staff p23 like i know the shelters reduced their capacity so its really hard to get women into shelter and also like many women dont feel safe going there in the first place so we just need something more stable like a shelter is only temporary we need more affordable housing in the city its just not right people stay in relationships and then go through this violence and hardship because of the housing issues and poverty c genderbased inequities in social and economic resources and the determining role of canadian law and policy leader p110 violence looks differently depending on your context your… people so we decided what violence looks like at the provincial level we decided that yeah in a relationship usually there is a man and a woman and they have two kids and a dog or a cat and that both of them contribute equally to the relationship in terms of finances they are codependent and that the both of their names are going to be in this nice lease … who did we write that policy for not for the clients we serve because many of them do not have their names on the leases and many of them dont have the equitable relationship with their partners many of them… its insane its like youre trying to fit our clients in this mould that someone in the policy office thought of based on maybe on their own contacts and their own frame of reference of what a relationship is like survivor c76 so theres tons and tons and tons of housing programming for men but where are the mass quantities for women survivor c72 upstairs there was this man that was so unhelpful he kept unfortunately kept trying to come on to me every time i would come home and stuff … having trauma surrounding men and having ptsd and depression i wouldthere was days that i just didnt want to leave the house because between my ex knowing my codes and then the landlord of that place being a male and then that guy that lived upstairs who wasnt the landlord but he was a leader p136 but after theyre willing to seek help if their primary needs are not taken care of rightthey dont have money they dont have food shelter they dont have access to their kidsthey would not leave so thats not something that we as an agency can help thats a systemic issue right there has to be wraparound supports for food shelter access to safe education without you know their dads picking up their kids from school right thats something systemic that is only empowered by policy and public dollars written proof of cohabitation with an abuser during a given time period or for newcomers sponsorship or lacking the finances credit history or assets to secure their own independent housing thus as p110 highlights the social inequities between vaw survivors and their abusers are in some cases widened by the very policies seeking to support them 32 this notion mapped onto participants broader expression of injustice at the inequitable distribution of social and economic resources in society based on gender and other intersecting factors this included housing supports and discrimination in the housing market as well as the intersecting barriers for newcomer women eg develop coordinated systems to strengthen the response to vaw intersecting with the need to strengthen structural supports to respond to vaw participants stories illustrated the importance of better coordinating vaw services with other systems with which survivors frequently interactespecially the health and justice systems participants described ways in which each of these systems has not been set up to account for intersections with the specific needs of vaw survivors for instance survivor c76 described being in and out of hospital over the last decade and struggling to receive the emotional social and economic support needed for recoverycircumstances only exacerbated by the covid19 pandemic c76 further pointed out that social assistance has been available to seniors requiring support in their daytoday lives and accessing services this contrasts with vaw survivors who are also often experiencing social isolation and physical and mental health symptoms and may benefit from similar levels of support this service gap especially impacts survivors experiencing economic marginalization although more limited in number in our sample staff participants heavily involved in health systems work reinforced these points for instance leader p68 whose work is funded by the ontario ministry of health provided further context around the health care system which has been operating siloed from the vaw sector among others and thus not strategically addressing the diversity of vaw survivors needs p115 a direct service provider in the health care system offered additional insight raising the point that the solution for better health care outcomes for vaw survivors is not necessarily the provision of vaw training to health care providers who may lack the capacity to provide intensive vawspecific care within their regular practice 35 instead the recommendation is to grow the workforce of vaw staff and advocates within the health care systeman approach that has shown promise internationally 36 and necessitates the strategic vawhealth care systems collaboration referred to by p68 this type of coordinated advocatebased approach would not just support specific needs of vaw survivors navigating the health care system but would strengthen the identification and referral of atrisk patients 37 issues exemplified by the experiences of survivor participants who accessed the health care system prior to accessing vaw services for instance throughout survivor c77s pregnancy her abusive partner who was sponsoring her visitors visa accompanied her for every appointment a common tactic in controlling and coercive abuse 38 despite the psychological distress she was exhibiting and the clear power imbalance in the relationship her doctor never asked her partner to leave the room to safely discuss the potential of ipv safety planning or available vaw services survivor c81 attended the hospital for injuries inflicted by her partner and over the course of at least three visits was not provided the necessary interpretation services to discuss the abuse she was experiencing in both cases neither c77 nor c81 had had prior contact with vaw services and best practices for safe identification and referral should have been but were not implemented 39 participants were further marginalized by the system as newcomerslacking permanent resident status or comfort speaking in english these examples demonstrate that in the implementation of any coordinated systems approach vaw advocates must also be trained and resourced to respond to the intersections between vaw and other forms of marginalization 37 challenges in the justice system for vaw survivors and staff in many ways mirrored those experienced in the health care systemincluding for instance survivors not being appropriately connected to vaw supports following contact with law enforcement as with the health care system participants recommended vaw training across the justice system as a response with certain specialized vaw staff based in the justice system recommending more of a coordinated advocatebased approach ideally such an approach ensures that survivors in crisis receive support from staff with specialized training in vaw and the capacity to respond appropriately 40 however by virtue of vaw survivors interactions with the justice system typically involving others there were also more specific ways to address vaw that participants outlined for instance direct support staff p139 raised two important challenges for vaw survivors interacting with the justice system discussed by participants child protection and mandatory charging regarding child protection staff survivor c77 c77 my doctor knew actually all the time when i visit doctor my partner he was going inside with me … he was always going with me and my doctor a little she had like she got the sense that im in stress so she asked me some questions that do you have any friends or family here i said no and she knew that im on visitor visas so i dont have health card so every time he was going and paying so the fees of the doctor interviewer did the doctor ever turn around and say to him or your partner or whoever was with you i need to speak to the patient alone or unfortunately i need to ask you to leave the room c77 no she never asked that but i think she got that sense and she was asking me do you have any stress do you have any stress i said yeah im having stress because i cant eat anything im tired this is… and he was sitting there so how i couldbecause at that time i was not having intention that i will leave this person or i can complain about him because i was pregnant i was not thinking to leave him so i was just silent survivor c81 interviewer did any doctor or any nurse or anybody in the hospital ask you how did the injuries from your partner happen to you or has or did anybody ask you is anybody hurting you c81 no they dont ask you because they speak english and they dont use translators and they just want to check you out and just get it done and thats it interviewer can i ask how many times the last year have you been to the hospital c81 three or four times continued on the following page and survivor participants spoke to p139s point about the need to include vaw survivors in the conversation and decisionmaking around child protection recognizing the potential harms of family separation 4142 and provide appropriate supports to survivors throughout the process survivor c75s story serves as one example of this specifically c75 was not considered in the child protection processincluding examining the root of her trauma and providing appropriate treatmentand as a result her mental health and substance use issues worsened this removed the opportunity to keep mother and child together and reduced the likelihood of future family reunification which in many cases has important benefits for both mother and child 41 participants similarly articulated the importance of direct support workers being trained to identify and provide support for womens experiences of violence in responding to domestic violence calls which legally require charging while p139 highlights the marginalization of survivors who do not speak english and are not provided with appropriate interpretation support direct support staff p23 more broadly demonstrates the systematic gaps in this process p23 illustrates the need for stronger coordination between the vaw and justice systems including more traumainformed supports for survivors involved in the justice system and stronger referral mechanisms at pointofcontact these comments along with p139s and c75s speak to a larger observation around the weaponization of the justice system against vaw survivorswhere survivors are criminalized or traumatized from child apprehension in addition participants described situations in which vaw survivors were manipulated and disempowered by abusive partners or professionals in high conflict cases taken together these accounts demonstrate how societal gender norms will continue to pervade the justice system if left uncheckedthat is without mandatory training and coordinated intersectoral action including vawand traumainformed advocacydisadvantaging vaw survivors and allowing their continued exploitation by abus ers especially men who use violence 4344 implement and evaluate primary prevention strategies for vaw either more training for officers or a change to allow kind of more mental health workers social workers to be deployed with frontline … so that … clients know that there is more emotional support available for them right at the time that things happen direct support staff p139 child protection … its not only about the kid i know that is importanti know that is what they are there to do but theres so many things involved that the family the mother has to be included and understand not that iwe dont have to understand abuse or neglect its not about it its about that … its not black and white and sometimes they are very very radical like so and the police as well the police you know the violenceso so many times women they dont speak the language and theyre the ones that are charged that are put in jail because there is no mark but there is a mark on the man but they were defending themselves so you know i think education if they could provide more training for those and to have more opportunity for women survivor c75 the whole reason why i started my substance abuse is because i was going through physical abuse and i had to hide it for months like years i was hiding it and then ithats how i coped i wanted to forget i wanted to numb the pain i wanted all of that and for them to help me deal with my problem they took my kids away but that doesnt really help the problem you take my kids away and so thats going to make me drink more because now im depressed you know what i mean and so it started out as trauma but then they just keep building on top of that trauma and then its kind of like well you just have to stop drinking but theyre building that trauma so how do they expect you to just stop when they keep building on top of what youve already gone through direct support staff p23 with mandatory charges … it backfires and uh yeah it just creates this really the hardship for women the system needs to change they need to consider womens experiences going through the system to be able to support and to prevent this from happening again … its up to the police to decide … they will separate people they will mandate like the par partner assault response program but at the same time i feel like the supports are not really being provided like its oh well you have your charge now you have to deal with that on top of everything that youve experienced like i think police training needs to happen really thats how they work with people thats problematic i hear it from many clients its very very traumatic to go through something like that … if the police would say okay call here like you know they will help youthat would make a difference and not leave you kind of hanging and waiting … after this covid ends we know that more programs need to be put in place … we need to really work more collaboratively in this like you know uh situation and to learn from this kind of situation and improve our services because wei feel like many people are being left behind in this covid crisis abbreviation vaw violence against women table 4 subthemes with example data under theme 3 develop coordinated systems to strengthen the response to vaw inherent in p92s comments is a principle that participants widely articulated the responsibility of preventing vaw should not fall to women alone but rather belongs to all of societya rejection of the notion that women need to learn how to avoid risky situations 45 46 47 staff participants highlighted the importance of directing educational and more broadly supportive interventions to boys and men comments like p140s make explicit the need to include boys and men in vaw prevention efforts as the most common perpetrators of vaw 45 they also however highlight the current tension for vaw organizationsmandated to support women experiencing violence and chronically underfundedin expanding their programmatic targets there is thus a need for increased funding dedicated to the design and delivery of educational and supportive interventions to boys and menperhaps in some cases by vaw organizations and in others with their collaborationbut without limiting the funding pool for womencentred supports both p92s and p140s comments further speak to the emphasis that participants placed on interventions that stop the cycle of violence for younger generations including and beyond educational interventions this is congruent with the idea that strengthening the structural response to vaw will also have implications for primary prevention by equitably improving the social and economic supports and resources available to women whose children may otherwise be at higher risk for experiencing or perpetrating violence later in life 4649 in other words policies that target the societal distribution of resources and social norms are critical to all levels of vaw prevention this idea was reflected in the data with participants discussing the importance of promoting gender and intersectional equity through policy and systems change in terms of both responding to vaw and preventing it in the first instance these multilayered benefits are well captured in survivor c74s comments c74 illustrates the insidious consequences of genderbased and intersectional economic disparities in societyupheld by political systems that benefit from maintaining the status quowhich impact womens capacity to leave violent relationships and increase the likelihood of intergenerational cycles of vaw 2147 c74 makes the point shared by other participants that preventing vaw must move beyond hypothetical discussion into transformative policy action this will require legitimate shifts in the distribution of power resources and prestige in society enshrined in law and policy that promote the economic independence of all women attending to intersecting structural barriers uncomfortable for the hegemonic classes who will inevitably lose power through redistributive policies 2145 finally c74 echoes a point well illustrated by our study the often neglected value of meaningfully including the perspectives of vaw survivors in policy planning summary of recommendations from this study table 6 summarizes the recommendations for canadas nap on vaw based on our study findings and situates these recommendations in reference to existing literature including the most recent nap analyses 91350 strengths and limitations this study offers the unique contribution of developing prioritizing and nuancing recommendations for the nap based on a rigorous analysis of the perspectives and experiences of survivors and staff accessing and delivering vaw services respectively in toronto canadas largest and most diverse city during the covid19 pandemic we relied on strong partnerships with vaw sector actors and women with lived experience of violence as research team members advisors and knowledge users as a result our dataset came from staff and survivors from a diversity of vaw programming across residential and nonresidential services and we maintained active engagement with our vaw stakeholders throughout analysis and dissemination using integrated knowledge translation our sample was high in informational power for our research questions providing rich and detailed data on participants experiences that allowed us to generate nuanced recommendations with indepth justifications 51 we were committed to capturing the stories of staff and survivors with a diversity direct support staff p37 sometimes theyre more talk than action i guess whatever they say they have to put the action first too not just talking about it abbreviation vaw violence against women a see also table 3c 1350 information campaigns should avoid traumatizing or stigmatizing language or imagery involve multiple stakeholders in development and implementation and be implemented within a multipronged strategy that aims to increase the availability and accessibility of supportive services 24 25 26 b strengthen referral mechanisms to vaw programming develop a systematic and centralized process for referrals to vaw supports including more accessible entry points for survivors and closer coordination between crisis lines and vaw organizations strengthening referral processes should include designating contact points who are responsible for keeping up to date on service availability and maintaining transparency and accountability throughout the referral process this work necessitates more indepth consultations with staff and survivors across the vaw and other intersecting sectors to determine priority steps for improvement and the implementation of a monitoring and evaluation system to ensure how well adaptations are working for the diversity of survivors in need while prior nap consultations have reviewed the importance of increased availability of vaw crisis supports including crisis lines and integrated service delivery 1350 our study revealed important insights regarding the need for a more systematic centralized and transparent referral system c increase the number of vaw organizations with the capacity to provide inhouse wraparound supports to clients extending the call for the development of onestop multiagency hubs 50 our study demonstrated the need for greater investment in the vaw sector to increase vaw workforces training and infrastructure to expand the delivery of inhouse wraparound supports even amid emergency conditions while not all vaw organizations may realistically have the capacity to offer multiple services to clients our findings highlight the difficulties in providing holistic support to clients in the face of staff shortages and the shutdown of inperson community services during the pandemic our results in particular emphasize the importance of accounting for the needs of communityspecific vaw organizations and services with dedicated funding to strengthen capacity for inhouse programming and referral supports this action within the nap should be supported by directed consultations with a diversity of these organizations and survivors with consideration of intersecting social factors d provide flexible funding mechanisms to vaw organizations funders should allow more flexibility for vaw organizations to use their monies as they see fit to respond to client demand and needs especially in the midst of emergency conditionsa new recommendation from our study that builds on the need for increased sustainable funding to vaw services recommended in prior nap reports 1350 and reflects the evolving service context of the covid19 pandemic flexible funding would be benefitted by strengthening the monitoring and evaluation systems of vaw organizations including improving client feedback and engagement processes to ensure that organizations can maximize the likelihood that any adaptations meet the diverse needs of their clients e increase traumainformed and specialized mental health supports in the vaw sector increase sustainable funding streams that support vaw organizations in developing and maintaining the necessary expertise to deliver specialized traumainformed mental health care to survivors consistent with prior nap recommendations 13 enhance structural supports for vaw f increase investment into the full housing continuum for vaw survivors building on prior recommendations for the nap to expand the full vawhousing continuum 91350 our study highlighted the need for increased investment into • vaw shelters including strengthening referral pathways and increasing funding and resourcing to support capacity staffing and training to collaborate with other systems in the provision of vaw care • secondstage housing for vaw survivors to provide mediumterm housing solutions with psychological legal economic employment and housing supports and • safe accessible and affordable housing for vaw survivors with wraparound supports including attending to survivors safety needs in the neighbourhood and in the home as well as greater collaboration between the vaw sector and private landlords to prevent discrimination towards vaw survivors while the 2022 federal budget proposes that 25 of the cad 15 billion earmarked for building new affordable housing units over the next two years go to womenfocussed projects it is critical that funding eligibility is inclusive of vaw organizations and projects involving housing considerations and wraparound services for vaw survivors are supported 9 extending prior nap recommendations 91350 our study illustrated priority areas for policy reform to strengthen the structural supports for vaw survivors including continued on the following page • revising residential tenancy laws to provide greater flexibility for survivors to be added to tenancies and the removal of partners who use violence • revising eligibility criteria for housing benefits to remove requirements of cohabitation with an abuser during a given timeperiod or for newcomers sponsorship • creating opportunities for lowbarrier independent housing that allows women who lack the necessary finances credit history or assets to secure their own independent housing • increasing the basic need and shelter allowance in the provision of social assistance • increasing funding for legal aid to support vaw survivors • improving the accessibility and affordability of child care options and • improving employment and educational opportunities for women including training for professional certificates résumé guidance and interview coaching for vaw survivors develop coordinated systems to strengthen the response to vaw h strengthen healthvaw systems coordination and collaboration prior nap consultations have led to recommendations for vaw training for health care providers 1350 based on our findings and existing evidence on intervention effectiveness 3536 this is necessary but not sufficient we also recommend the development and sustainment of a coordinated system of vaw advocates based in the health system to support the specific needs of vaw survivors navigating the health care system and strengthen the identification and referral of atrisk patients vaw advocates across sectors must also be trained and resourced to respond to the intersections between vaw and other forms of marginalization i strengthen justicevaw systems coordination and collaboration paralleling the significant focus on justice system reform in women shelters canadas nap implementation guide 13 based on the current analysis we recommend vaw training across the justice system and embedding designated vaw advocates in the family and criminal justice systems to • strengthen traumainformed and antiracist decisionmaking that is responsive to the intersectional needs of vaw survivors • ensure appropriate referral mechanisms are engaged for all vaw survivors and • prevent continued patterns of abuse against survivors within the justice system in addition across all interactions with the justice system survivors who do not speak english should be provided with appropriate interpretation support implement and evaluate primary prevention strategies for vaw j improve educational curricula beginning in early years in line with previous nap consultations 1350 we recommend the development implementation and evaluation of ageappropriate curricula for schoolaged children to prevent vaw in collaboration with provincial education systems our findings highlight the importance of covering healthy relationships and gender expression and what constitutes violence k engage boys and men in vaw prevention the women shelters canada nap implementation guide contains extensive recommendations around directing vaw preventive efforts towards boys and men 13 our analysis reinforces the importance of increased funding dedicated to the design and delivery of educational and supportive interventions to boys and menperhaps in some cases by vaw organizations and in others with their collaborationwith the important caveat of not limiting the funding pool for womencentred supports 48 l implement redistributive and gendertransformative policies b strengthening the structural response to vaw will also have implications for primary prevention by equitably improving the social and economic supports and resources available to women whose children may otherwise be at higher risk for experiencing or perpetrating violence later in life the perspectives of a diversity of vaw survivors and experts should be meaningfully included in policy analysis and planning table 6 summary of our priority recommendations for canadas nap on vaw of personal and social identities and especially those experiencing different forms of marginalization for instance 70 of the survivors we interviewed identified as racialized persons compared to the only other pandemic study of vaw services in canada to interview vaw survivors to date which included only white participants 10 nonetheless most of our sample identified as heterosexual ciswomen and most survivor participants were economically marginalized we also found that communityspecific organizations and racialized frontline staff tended to face more barriers to participating in this study this speaks at least in part to the structural disadvantages that disproportionately impact them in light of these limitations there are nuanced experiences and perspectives within different communities that warrant further study in addition our study provides an indepth snapshot of torontobased perspectives as canadas largest and most diverse city with expansive health and social services this is a critical context for informing the nap especially in terms of our recommendations focussed on crosssystems collaboration and wraparound supports for survivors that account for intersecting social factors however other municipalities and jurisdictions will have unique needs that should be studied and addressed in the nap one important area for future research and policy is the further development and implementation of the nap on missing and murdered indigenous women and girls which should be led by indigenous communities conclusion while the federal government has made the initial commitment to fund a nap on vaw and suggested a highlevel framework now is the time to enact the recommendations derived from our study and from previous nap reports this must include the development and implementation of a clearly defined plan as well as an ongoing feminist intersectional and traumainformed monitoring and evaluation system to maximize the likelihood for sustainable effective prevention conflicts of interest priya shastri and elizabeth tremblay are employed by the toronto region violence against women coordinating committee the vawcc is funded by the ontario ministry of children community and social services which is a primary funder of many vaw organizations in the greater toronto area maria huijbregts is employed by family service toronto which receives funding from mccss 1 the article refers to canadas proposed national action plan to end genderbased violence the editors feel it is worth noting that federal provincial and territorial government endorsement of the nap was announced on november 9 2022 1 after this manuscript was accepted for publication authors contributions and statement in addition the following statement within the articles introduction has been slightly modified from the january 18 to date in canada only a strategy to prevent and address genderbased violence has been implemented is replaced by at the time of writing this manuscript in canada only a strategy to prevent and address genderbased violence has been implemented

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introduction recent empirical research in sports coaching has started to explore the political complex realities of the working lives of coaches within sporting organisations 1 2 3 4 early findings have highlighted that coaches have to deal with contradictory goals and conflicting personal agendas which are often driven by the structural vulnerabilities associated with the working life of a coach 1 2 3 to date much of the work in this area has been theoretically informed by a symbolic interactionist micropolitical perspective 56 which has been used as a sensemaking approach to highlight some of the ways in which sports coaches interpret the situation they find themselves in and how this interpretation influences their future actions 7 central to the micropolitical perspective is an understanding that the actions of members of organisations are largely driven by selfinterests 5 6 7 8 these interests might be similar or shared which may lead to increased cooperation or even to conflict between individuals within organisations 12 where members might use sources of power and influence in order to further their own interests 7 whilst professional football is characterised by high levels of staff turnover uncertainty vulnerability and insecure employment 9 10 11 there is a dearth of useful empirical research from which to understand the process of organisational change and how change is experienced in the daytoday working lives of coaches within this environment 12 indeed much of the academic work within organisational change literature in sport focuses upon process models and macrolevel rationalistic approaches which lack empirical evidence of the essential embedded sociocultural interactions upon which such organisational change is premised 12 importantly to further our understanding of the contested social complexities of sports coaching additional empirical work within this area is required to build a stronger theoretical basis upon which to better prepare coaching practitioners for the realities of employment 1 2 3 4 to address this paucity contextually sensitive and detailed ideographic case study methodological approaches have been suggested as a useful means of illuminating the individual and idiosyncratic complexity of the working lives of sports coaches 1 2 3 4 in particular researchers have further suggested that nested case studies are well placed to increase our understanding of the relational micropolitical complexities of the working lives of coaches 4 nested case studies maintain the integrity of the case as compared with the focus of different and contrasting cases in multiple case designs 13 moreover nested case studies allow for an interpretation of the entangled relationships within each specific case within the wider case 13 consequently such a methodological approach may assist in furthering our empirical understanding of the influence of selfinterests on the interrelational complexities of cooperative and noncooperative actions and strategies between coaches within a single sports organisation 214 therefore the purpose of the present study is to build upon our current understanding of the micropolitical nature of sports coaching environments through a nested interpretive case study exploration of the experiences of a coach during the process of organisational change in professional football as part of a larger research project building towards a nested understanding of the process of organisational change within alder fc four interrelated research questions have guided this study rq1 how did the participant coach experience the change process and what changes were evident in the working environment for the participant coach rq2 how did others act towards the participant coach and how did the participant coach act towards others during the change process rq3 in what sense did the participant coach come to understand the micropolitical realities of organisational change rq4 what impact did the change process have on the working conditions and subsequent employment opportunities for the participant coach methodology philosophical underpinning and research aim an interpretive case study research design was rigorously developed informed by an ideographic relational interpretive research methodology that examined the individual case 413 15 16 17 18 19 20 the research project was underpinned by a relativist ontology that recognised that there is no reality independent of perception and reality is multiple created and mind dependent 4 15 16 17 18 19 20 epistemologically our approach was informed by constructionism in that knowledge is constructed through social interactions and that the social world is subjective in nature 415161920 such an approach recognises that reality is socially constructed and that the sociology of knowledge must analyse the process in which it occurs 415161920 the participants narrative has been presented in the manner in which he articulated his experiences to both the primary and secondary researchers through the process of narrative coconstruction 415161920 an explanation of the validity of such an approach has been provided by polkinghorne 15 who stated that storied evidence is gathered not to determine if events actually happened but about the meaning experienced by people whether or not the events are actually described the truths sought by narrative researchers are narrative truths not historical truths the interactionistinterpretive methodology utilised sought to investigate the participants motives actions and interests and the meaning that the participant attributed to both his own behaviours and those of others within the professional football environment during a period of organisational change 413 17 18 developing such a research design allows for a deeper exploration of phenomena about which little is known such as the experiences of employees within professional football clubs during periods of organisational change 2 3 4 the aim of the study was to develop a contextually sensitive and rich descriptive narrative that detailed the interrelated nature of the lived experiences of the participant specifically the narrative focused on how the participant interacted in the settings with key characters during a plotline of critical incidents in his employment at a professional football club during a period of organisational change 413 15 16 17 18 19 20 research design the present case study forms part of a larger multiple participant nested project at a professional football club called alder fc with academy coaches richard george john james and ian and the principal author luke in this particular study the findings and rich empirical insights from james are presented data collection took place from a retrospective perspective to explore how james made sense of the behaviours of other key actors and himself and consequently the effects these behaviours had on the process of organisational change within the academy following an iterative reading of the data and micropolitical theorising this study focused upon the coachs interpretations of the actions and behaviours of staff within the club during the process of change and the subsequent impact of the change process upon his actions strategies and professional interests 41516 the case and context alder fc is a professional football club competing in football league one and following assessment by the english premier league will be working at an academy category 3 level within the elite player performance plan at the point of data collection the principal author luke was employed as a parttime academy coach at alder fc working with the u16 squad during this period as an employee at alder fc the author experienced various instances of organisational change at different levels of the football club and witnessed a number of colleagues leaving the club as a result of organisational change alder fc was selected as a local knowledge case derived from the principal authors position within the academy at the beginning of and during the ongoing process of organisational change 13 the local knowledge case is a benefit to this case study research in that the principal authors intimate knowledge enhances his ability to read the people who inhabit the arena 13 additionally this also allows for a richness and depth of data that would be unavailable to you otherwise prior to data collection institutional ethical approval was granted by the sport outdoor and exercise science ethics committee at the university of derby with the correct protocol and research guidelines followed the participant the participant was selected as part of a purposeful sampling process as he was considered to be a rich source of data in relation to the phenomena under investigation significantly james had recently experienced a process of managerial and organisational change within alder fc 14 following an initial approach to the participant and discussion around the purpose of the research james agreed to take part in the study and voluntary informed consent was obtained at the beginning of the data collection process james had been coaching for a period of 10 years and was head of foundation phase at alder fc james holds the uefa b licence as well as the english fa youth award at the time of the change process the club in question was competing in football league one in his role as head of foundation phase james oversaw the technical games programme and coaching curriculum for the u8s u9s u10s u11s and u12s age groups he was also responsible for 10 parttime academy coaches academy recruitment scouts a parttime sport scientist and a parttime physiotherapist by the time data collection and analysis were completed james had left alder fc to work for another english professional football club data collection data were collected by the principal author luke who at the time was employed as the head coach of the u16 team the data consist of ethnographic field notes and observations from informal meetings and formal academy staff team meetings in addition there were indepth interviews with three coworkers regarding the period of organisational change and four indepth semistructured interpretive interviews with james which were conducted in a quiet and private setting at his convenience 14 21 22 23 24 the interview data with james resulted in around five hours of audiorecorded conversation in total 1421 prior to the start of the first interview james was made aware of the nature of the data collection process the aim of the research project and how the research would be disseminated and issues surrounding the confidentiality of peers or colleagues within the data was discussed 1422 james was also made aware of his right to withdraw at any point during the study and to withdraw permission to publish the final analysis of his narrative throughout the interviewing process the primary researcher became an active listener and encouraged james to discuss his experiences at his own comfort level and discretion 14 22 23 24 the focus of the interview topics was guided by the four interrelated research questions which were designed to explore james experiences of the micropolitics of organisational change 1 2 3 4 25 26 27 28 29 30 31 specifically questions focused upon the impact of change upon james working relationships with other coaches and his own behaviours at the football club 1 2 3 4 25 26 27 28 each of the interviews was audiorecorded transcribed verbatim by the primary researcher and analysed through a process of iterative analysis to inform subsequent interviews 1342123 narrative data analysis narrative analysis was chosen as an approach to take us outside of stories themselves to the occasions and practical actions associated with the story construction and storytelling specifically narrativity can contribute to our knowledge of individual and group experience and is often juxtaposed with the typically flat thin contributions of positivistic methods gubrium and holstein 19 pp 245246 the rationale for moving towards narrative methods and the narrative turn by scholars within the field of social science can be seen as a consequence of their dissatisfaction with and lack of confidence in postpositivism and what can be called neorealism specifically postpositivist approaches by their ontological and epistemological nature tend to attempt to control for and remove temporal emotional personal political cultural contextual and situated lived experiences of participants from the research process 20 however such relational and complex empirical insights are required for the generation of social theory capable of adequately understanding the interactions of actors within the social world and further developing disciplinary fields in the light of the above data were analysed using narrative thematic analysis in inductive and deductive approaches 42324 narrative themes were identified in james data through a systematic coding process 1342123 specific attention was given to data that could be distinguished as crucial in understanding james relationships and actions at the club during key moments during the period of managerial and organisational change upon completion of each interview theoretical memos were used to make connections to the theoretical framework to make sense of james experiences 25 26 27 28 theoretical framework this paper explores how the work of kelchtermans 25 kelchtermans and ballet 26 and kelchtermans 27 might be used as an analytical frame to better understand the role of professional selfinterests as a mediator of micropolitical action during the process of organisational change in professional football this framework is premised upon kelchtermans 27 subjective educational theory as the personal system of knowledge and beliefs about education that teachers use when performing their job specifically questions such as how should i deal with this particular situation and why should i do it that way are addressed key to answering these questions is the teachers ability to judge and interpret certain situations prior to the decision making process of which action to take as kelchtermans 27 states this ability to read judge and then act is essential for competent teaching building on the work of blasé 6 kelchtermans and ballet 26 highlighted that understanding professional interests is central to micropolitical theory professional interests arise from the characteristics that teachers attribute to their beliefs around effective teaching and the desired conditions for teachers to carry out their tasks effectively professional interests can be distinguished into five separate categories that may also be evident simultaneously 27 moreover the actions strategies and tactics that make up a portfolio of micropolitical literacy will also inform the theoretical framework of this study the first category of professional interests is that of selfinterests kelchtermans and ballet 26 note that when selfesteem or task perception is threatened selfinterests tend to emerge specifically selfinterests protect integrity and identity to elaborate further kelchtermans and ballet 26 identify the importance of looking for selfaffirmation coping with vulnerability and coping with visibility within the category of selfinterests here the judgment of significant others plays an important role in searching for selfaffirmation when coping with vulnerability coaches may feel their social recognition is threatened particularly within professional relationships 28 coping with visibility also places a burden within organisational settings as blasé 29 explained the professional context can be described as working in a fishbowl where significant others observe and evaluate daytoday working practices material interests relate to the accessibility to materials funds or specific infrastructure within the coaching context this may be access to facilities and other coaching equipment that can influence the coaching practice kelchtermans 28 has highlighted the importance of understanding the symbolic meaning attached to material issues within the organisational context if we are to comprehend lived organisational experiences organisational interests relate to the roles positions procedures and formal tasks within the organisation primarily retaining a job and choosing among job offers are central organisational interests for employees kelchtermans and ballet 26 explain that the longer the time of uncertainty about a job the more selfesteem becomes threatened leading to a doubt about professional competencies culturalideological interests revolve around the explicit norms ideals or values acknowledged within a professional football club for example and form the makeup of the organisational culture as altrichter and salzgeber 30 suggested these interests also embody the interactions and procedures that define the culture finally socialprofessional interests refer to the quality of interpersonal relationships with key stakeholders within the organisational setting indeed the work of kelchtermans and ballet 26 highlighted the importance of these relationships in allowing for discussions that positively or negatively affect working conditions theoretically the present paper focuses upon the actions strategies and tactics that inform the micropolitical action and literacy of stakeholders within alder fc blasé 29 described a continuum of political strategies that consist of reactive and proactive endeavours reactive strategies are utilised in an attempt to maintain the situation and protect against external influences proactive strategies are aimed at improving the situation and working conditions within the organisation it is important to understand that micropolitical action be recognised as cyclical in nature rather than distinct points on a continuum 27 in reality micropolitical activity becomes evident in a range of forms talking pleading arguing gossiping flattering being silent avoiding taking sides accepting extra duties changing the material working conditions and the use of humour 6 blasé 6 further noted that a simple inventory or list summing up all micropolitical strategies and actions is not relevant and probably not even possible because almost any action can become micropolitically meaningful in a particular context results and discussion the following section will present a narrative analysis of james story with a particular focus upon his actions strategies and professional interests during the process of organisational change each section will provide an insight into the highlighted themes along with a discussion of the data in relation to previous literature the data indicated that the change process prompted james to reflect upon his own professional interests in developing micropolitical literacy to maintain fulltime employment during a period of organisational change 25 26 27 28 the findings revealed the micropolitical strategies employed by james to ensure the academy coaches within his department were onside additionally james highlighted the relief he felt when he realised he had passed his test and was accepted by the 1st team manager as part of his academy staff to move the club forward during this period james also reflected on his experience of choosing sides and backing the winning horse when it came to working with other fulltime staff that he thought might eventually be sacked by the 1st team manager upon retaining his employment james discussed the importance of managing upwards and his relationship with the 1st team manager finally the move to a new and improved training ground brought about a change in culture and daytoday working practices as part of the change process new chairman board of directors and 1st team manager after a year of employment at alder fc as head of foundation phase james experienced largescale organisational change on both football and organisational levels as james stated when the new chairman and board of directors came in there was a lot of change around the club all of the press releases were about developing and evaluating the academy when the 1st team manager came in initially you got the impression that there were going to be big changes with the staff so that was a bit of a testing period you are a little bit guarded in terms of what you spoke about such periods of uncertainty brought about micropolitical action and strategy from james in an attempt to negotiate an environment where colleagues became guarded similar to the work of kelchtermans and ballet 26 who describe the importance of becoming micropolitically active to protect against vulnerability james stated that you wanted to show what you can do and keep your job but on the other hand you dont want to be seen as if youre sucking up to him 1st team manager furthermore james elaborated on the rationale behind his actions i suppose i was trying to be a bit tactical and play it the right way you wanted to side with the right people but not get on the wrong side of people by sucking up or making others look bad to make yourself look better a few times the 1 st team manager would get you on your own and youre thinking this is my opportunity to show myself in a good light hes trying to work out who he wants to get rid of or keep youre also thinking whats everyone thinking whilst im with him on my own what are they thinking im saying to him obviously when you go back everyone is asking whats he said what did you discuss everyone is a bit cagey … at the end of the day youre trying to protect your job and your livelihood indeed such micropolitical action has previously been reported as important to maintain employment in order to protect professional selfinterests within the culture of football 1 2 3 4 james decision to become guarded resonates with the suggestion that the continuum of both proactive and reactive micropolitical action strategies and tactics takes different forms in reality 6 getting people onside as head of the foundation phase within the academy james was responsible for six parttime coaches who worked with the age groups within that phase james discussed his continued approach to engaging with micropolitical action strategy and tactics in an attempt to protect his job and livelihood and stated i suppose i was trying to be around their the coaches sessions more be constructive and make them feel a part of the team ive been there myself and i didnt want them to be a cog in the wheel james reflected upon his reasoning behind this approach i was new to managing staff so i was learning as i went along i found that involving people and making people feel a part of the change got them to buy into you a little and made them feel welcome and you wanted them to be there and be a part of it and in turn you were trying to get the coaches onside so that if people ask questions about you like whats he like as a boss whats james like whats he like as a coach then they will probably be more inclined to say that youre alright and that they dont have any issues with you as kelchtermans and ballet 26 explained selfinterests tend to be at the heart of micropolitical action the strategy of getting coaches onside meant that james engaged in proactive action aimed at changing the situation and changing the conditions blasé 6 describes how such proactive actions can take the form of pleading and flattering however it must be noted that any action can become micropolitically meaningful in a particular context passing the test subsequently after the organisational and managerial change within the club james discussed moments where staff were put on the spot and put under pressure and that was your test and you may or may not pass i know exactly what mine was and i was lucky enough to pass it at the time james recalled the moment he became aware of his test he the academy manager rang me up later that evening … ive got some bad news for you … what … 1st team manager is going to take a team he wants to play your team tomorrow night at training hes rang me up now and said i need to arrange it he wants to see you working with a team how you set a team up what youre like so that night im sat on the laptop looking for other jobs my first thing was that if he wants to put me under this test then he must not be having me so im gonna be going kelchtermans and ballet 26 have highlighted how prolonged uncertainty regarding employment can lead to selfdoubt regarding professional competency as james states the uncertainty brought about by his test had a negative influence on his professional competency and social status and recognition upon reflection james gave this explanation ive probably never been in that situation before where youve been in employment but then put on the spot you become a bit vulnerable in trying to prove your ability the fact that you have to go through that process puts a bit of doubt in your mind you start to think what has he seen to make him think this to make him think that he needs to put me under this pressure james went on to explain his feelings at that point and the day leading up to his test i was pretty defensive really i wanted to just be left to it i was comfortable with what i was going to do richard academy manager went right alright whatever it was as if he was thinking right go and hang yourself on the night academy training session if somebody from above eg the 1st team manager or academy manager comes to watch your team if they stand away from you i think that is a visible thing that they want to detach themselves from you or they want to say something that they dont want you to hear which was striking on that night with richard standing away from me the better we did the more he drifted back towards me i think he was being a little bit tactical and thought these are going to get beat here so ill stand away but when they start doing well ill attach myself physical space between social actors can also be seen to represent support through close proximity or a lack of closeness through both physical and social distance indeed blasés 6 emphasis on the importance of coping with visibility provided an interpretation of james story with professional activities reflecting living in a fishbowl 29 specifically coaches become subjected to observations by colleagues parents and other stakeholders within professional football clubs and at academy training sessions 25 in an attempt to cope with such visibility james developed a range of strategies actions and tactics to proactively manipulate the situation in his favour and change his working conditions 2627 james further explained it was a case of listen were here to win tonight i need you to play well and win for me i had quite a good relationship with them all and looking back now it probably wasnt the right thing do but it probably saved my job i was a lot more vocal more tense than usual indeed james team won the game with his players producing a convincing performance subsequently james found out that he had passed his test in his words it was the day after i got called out and probably had a 45minute chat with the 1st team manager and we went through everything and we started talking about the game and he was quite complimentary he told me his plans and where he saw me within that that gave me a bit of confidence to then say right lets get on with my job and start doing what im supposed to be doing rather than panicking about whether im going to be here or not following his discussion with the 1st team manager after his test james became less concerned about his job prospects and competence as a coach leading to a sense of decreased vulnerability this was highlighted as james described the assurance and relief he felt after the conversation with the 1st team manager james went on to state that it also proved that your initial thoughts about the reason behind the test being to see how good you were were right back the winning horse upon passing his test james witnessed the experiences of other staff within the academy that did not pass their own tests as he explained there were four of us fulltime academy staff at the time and it was split two and two there was me and richard who ended up staying and mike and jim who ended up leaving james highlighted the difficulties around the interpersonal relationships with his colleagues within the academy during this period of change we james and richard sort of passed the test and got some assurance that we were going to be part of the team and it became clear that they mike and jim werent going to be obviously we were in the same office so it was a bit tense there was one afternoon where richard and me got invited to go down and play 5aside with the 1st team manager and all the staff and the chairman but they didnt ask mike and jim so there were alarm bells ringing for them but youre thinking we have to go with the flow a little bit and look after ourselves in terms of keeping our job again the choice made by james to take part in the 5aside game represents the actions strategies and tactics 12327 he employed with the rationale of doing what he had to do to keep his job james went on to elaborate this point it was horrible really these are your work mates who you work with every day you build relationships with them it got to a point where you had to back the winning horse and go with that one we had discussions about it in the office at the time and jim just said thats football thats the way it is just do what you have to do similar actions and strategies have been highlighted elsewhere as micropolitical actions that sports coaches have used in an attempt to maintain and advance their employment particularly within the culture of football 1234 james further explained the rationale behind his tactic of backing the winning horse in the following manner i think for richard and me we probably realised each others strengths and realised that we were better together than apart if that makes sense he struggled with certain things and id help him because it suited me better for example the eppp audit was coming up and getting everything sorted for that lent itself to my skills really the other two jim and mike were like these two are teaming up together it wasnt like that but obviously you can see why in relation to the professional interests outlined by kelchtermans and ballet 26 james decision to back the winning horse positively affected his socialprofessional interests specifically kelchtermans and ballet 26 found that several respondents told how they silently endured negative situations because the risk of troubled relationships with colleagues was not outweighed by the potential gains of improved working conditions in the context of james story his decision to sacrifice elements of his personal relationship with mike and jim was outweighed by his desire to maintain his position within the club james decision to take such action was vindicated as he explained mike and jim lost their jobs and then george jims replacement as youth team manager came in george had come in and he was chosen by the manager so youre thinking i probably need to be in with this person and make sure i make a good impression on this person because hes got the managers ear so there was that period where you were trying to form a positive relationship with george ive been lucky with george in that hes been bringing his lad down to train with the team that ive been mostly involved with in my department so hes seen me work first hand and it seems to have made a good impression on him james strategy of forming a positive working relationship with someone who has the managers ear demonstrates the social nature of professional interests kelchtermans and ballet 26 state socialprofessional interests often appear to weigh more heavily in decisions than other interests indeed the analytical power of the greater understanding the importance of professional selfinterests has significantly improved our understanding of the motivations that underpin the actions and strategies of football coaches in dynamic and complex environments to secure and advance their employment 1 2 3 4 you want to be a part of it after changes within the staff at the football club were made changes to procedures and formal tasks began to take place affecting james organisational interests 26 specifically as james discussed the technical board meetings that happened prior to the change would just consist of the academy manager and youth team manager going off with the 1st team manager and they would come back and you werent told anything whereas now were all involved james outlined the positive effect that the above changes to procedures and tasks had not only on james organisational interests but also on the manner in which he now perceived his role its having that responsibility and being a part of something and that youre needed i suppose the feeling around the place at the time was that you wanted to be a part of it and a lot of the stuff needed doing required me to be at these meetings and that was good you got more ownership i suppose you feel a part of something and youre about it a little bit more and you want to do a good job because its a reflection on yourself in how well youre doing your job you felt a part of something that was moving forward so to be able to contribute to it was really good previous work has highlighted that value of discussing the interrelated nature of professional interests simultaneously as opposed to in isolation 26 this is evident as the changes to the organisational interests indicated above positively affected james selfinterests and in particular their selfesteem and task perception furthermore james highlighted the change in culturalideological interests and the norms values and ideals within the football club james explained the 1st team manager and the chairman are very demanding of everybody so i dont think anybody would be allowed to become comfortable or complacent because you get found out straight away because there is that much scrutiny placed on the academy when we go to the football league meetings people are amazed at how much attention we get from above when you first come into it you have ideas about it all being about development but going through that initial period of change and seeing what a football environment is like at that time and you sort of go from being a playercentred coach to a coachcentred coach because i want my teams to do well because that reflects on me so people will then be going whos the coach im not trying to come across as selfish or say that it is all about me but you do realise and learn about the environment then you have got to be like that if you want to get on indeed such a sense of organisational socialisation is increasingly apparent within the sports coaching literature the micropolitical frameworks utilised here and elsewhere have started to further explain the motivations actions and strategies of sports coaches working politically to survive and thrive within highly competitive and complex coaching contexts 1 2 3 4 that is the often espoused task perception of working within a professional football academy to develop individual players may be sacrificed for compliance to align with culturalideological interests in an attempt to cope with employment vulnerability 28 managing the gaffer james explained that central to maintaining and further promoting his position within the academy was the relationship that he developed with the 1st team manager through a range of micropolitical actions james gave this example the above example highlights the development of james micropolitical repertoire in reading the 1st team manager and james perceptions of the 1st team managers behaviours and actions furthermore james conveyed other instances that have aided the development of his micropolitical literacy its there have also been occasions where ive been honest in meetings after he has criticised the academy and ive defended us you can tell that others in the room are agreeing with you but not saying anything there has been a time where i think i have been punished for what ive said there was one particular time where i booked games against milton pseudonym on the saturday for my teams and everyone was well aware of it but there was a daft event going on at the training ground and he made me stay to look after the event and lock up where there were loads of others he could have asked it was one of them but the way it was at the time after that meeting it was a little bit like im the boss dont question my authority or this is what happens the fact that there was other people in the meeting … if its onetoone between the two of you its like hell be happy to take your opinion but if its in front of people he cant be seen to be shot down by someone like me so its about understanding the hierarchy and what they want in certain situations james discussions here demonstrate the knowledge aspect of micropolitical literacy in that james began to interpret and understand the micropolitical character of the situation and what the 1st team manager wanted in different circumstances 31 subsequently james developed an instrumental and operational repertoire of actions and strategies to proactively or reactively tell the gaffer what he wants to hear or give the 1st team manager his honest opinion finally james reflected on the experiential aspect of his micropolitical repertoire and the degree of satisfaction he felt about his repertoire by stating that i have developed the confidence over time though i wouldnt have said it in those initial periods the new training ground finally james discussed the improved material interests brought about the managerial and organisational changes and subsequently the move to the new training ground james stated being here has brought a higher level of professionalism i suppose for one i think alder fc from the outside is an attractive place to work and people see alders academy as one that is improving all the time its attractive for people who want to be in football to come and work beforehand everyones opinion of alder fc was that were the lowest of the low the teams arent very good and the facilities arent the best now i think were held in quite high regard with people when people visit they expect a certain level of professionalism and we have to match that kelchtermans and ballet 26 identified that it is important to understand material issues from their symbolic meaning in the organisational context the move to the new training ground and the improvement of material aspects of the football club have influenced the change in culturalideological interests brought about by the higher level of professionalism the use of visibility as a political strategy to advertise professional competence ensured that james met the new levels of professionalism 28 specifically james highlighted that it provided me with the opportunity to step up and take things on and contribute more than i had before so the more responsibility and people saying james can you do this for us or james any chance you could help me with this was good for me at that point james reflected on the improvement in material aspects of the organisation and how this affected his selfinterests in terms of his selfesteem and identity 26 27 28 as a coach working within professional football and his future prospects it was always … probably before all the change alder fc was always a steppingstone … do what you need to do but youre always looking to move on and do something else but then you suddenly started thinking well actually this place is going somewhere i wanna be a part of it so that was the main difference you were thinking im really gonna apply myself here and do a good job and be a part of something moving upwards conclusion in an attempt to address the aim of this paper and the subsequent research questions posed to examine organisational change within professional youth football this study provided novel and rich empirical insights into how the participant coach negotiated the relational social complexities of the change process specifically the participant highlighted how others acted towards him and how he then acted towards others during the change process during this period jamess central concern was his professional selfinterests which drove his motivations actions and strategies in the workplace importantly for the first time this research project has provided rich empirical and theoretically informed insights into the importance of understanding professional selfinterests and the specific actions strategies and tactics utilised during the process of organisational change in professional football for example james engaged in additional social activities with new senior members of staff such as 5aside football games and informal conversations ensured his own staff were onside and created a social distance from existing staff who he perceived as being viewed in an unfavourable light whilst we are not suggesting that these strategies were the only courses of action available to james or the best courses of action the findings of this work highlight how james used these approaches to successfully manoeuvre himself in a way that protected his professional selfinterests such findings add to the existing work 1 2 3 4 that has started to provide much needed rich empirical insight into the social complexities and micropolitical realities of semiprofessional and professional football coaching environments characterised by structural vulnerability with coaches and key stakeholders working in conflict with contradictory personal agendas specifically the present study furthers our empirical and theoretical understanding of the effects of professional interests upon the actions and strategies of a professional football coach during a period of organisational change 25 26 27 28 in further support of previous findings within the field 1 2 3 we propose that the ability to develop micropolitical literacy and a repertoire of micropolitical actions strategies and tactics would benefit coaches working within professional football during such periods of instability and change specifically coaches should consider and be able to answer the following four interrelated questions who are the key individuals and groups that influence your practice environment resources employment reward retention and progression how do these individuals and groups view your competence capability and role performance what are the best ways of positively influencing these key individuals and groups to align with your professional selfinterests to reduce vulnerability and increase progression in the coaching workplace and from an ethical perspective what are the consequences of the actions strategies and tactics that you have chosen to employ within your context 32 once coaches are better able to clearly analyse understand and articulate the coaching workplace their own actions strategies and tactics may be developed to align with their career goals furthermore in an attempt to develop micropolitical literacy gibson and groom 4 suggested that such findings may be developed into a problembased learning approach to support the education of practitioners and assist them in dealing with the complexity of organisational change and organisational life in sport

employment within professional football is characterised by high levels of staff turnover uncertainty vulnerability and insecurity this paper aims to investigate the experiences of james head of foundation phase within an english professional youth academy during a period of organisational change data were collected through field notes informal observations and meetings formal academy team meetings coworker interviews and four semistructured indepth participant interviews which were subjected to an iterative process of inductive and deductive analysis theorising regarding the influence of professional selfinterests upon the actions and strategies of the social actors was utilised to make sense of james narrative the findings highlighted how james strategically managed his relationships with others to further his own professional selfinterests finally following the findings of this study we propose that the ability to develop micropolitical literacy and a repertoire of micropolitical actions and strategies would benefit coaches working within professional football during such periods of instability and change

introduction this paper reflects on issues relating to recruiting and engaging senior people as users in a codesign project in the senior interaction project a public care unit two universities nine private companies and senior citizens collaborate to design concepts that can strengthen social interaction among seniors in a specific urban environment the overall objective is to develop and explore welfare technologies and service models that support experiences and social interaction among seniors and thus contributing to greater selfreliance and social wellbeing the project suggests a move away from service models focusing on a relation between the individual citizen and the service provider towards concepts based on a broader content and social perspective offering opportunities for peertopeer communication closely connected to ongoing everyday activities focus is on initiating and maintaining locally based networks by offering services to groups of seniors for instance in relation to the meal exercise and mobility and cultural experiences these areas seems to have a great potential of binding people together in a neighborhood and thus contribute to the feeling of belonging and being confident in the local environment a long term design laboratorium the senior interaction project uses the design laboratory as a methodological platform for organizing and guiding innovation with design laboratory we refer to open collaborations between many stakeholders sharing a mutual interest in design research in a particular field the open collaborations means that what is to be designed is not predefined in the outset but something which is codesigned by the participants experimented with and rehearsed as the process goes along the authorship of the results is therefore also shared among the participants the design laboratory sets up a learning organization which right from the start simultaneously explore both the what to design and how to innovate thus the approach is different from more traditional approaches that separate research ideation and concept development from design and implementation the core activities in the design laboratory is series of codesign events where all stakeholders participate in activities that focus on mutual experimentation and learning each event usually lasts a half to a full day and is organized to produce tangible outputs in order to succeed it is important to find out who to recruit as participants in the design laboratory and how to organize activities so they create engagement shared experiences new knowledge and are found relevant for all parties involved the senior interaction project began in the late 2009 and is running for three years it is set up as a longterm design laboratory divided into the following three phases in a first phase seniors are recruited to the project and invited to take part in a series of three workshops the first round of workshops is ended by a number of possible use scenarios for communication technologies that provides a possible infrastructure for an enhanced community building in the second phase the scenarios forms the basis for prototyping in the senior participants everyday environments the last phase include living labs where seniors in their own homes and local environment try out new service models and welfare technologies recruiting users for the design lab in codesign processes designers and future users are carrying out central part of the design activities together as designers we may have an initial idea of who these future users are but users are never just out there people have to be recruited and mobilized to enact the roles of future users and to take on the membership in the group of users that the design project enables if a design project is well defined and already promoted by strong stakeholders codesign approaches may address the participation of those affected but otherwise not included in the design activity this was the case in early participatory approaches to systems design where for example office workers were enrolled in designing new administrative systems even though the term user was here also often contested as it tends to assume that a particular role for those participating is already in place there was also a powerful rhetorical claim in asking for user participation as codesign approaches gain ground and become not only a complement to but also the defining methodology for design projects the definition of relevant participants becomes in itself a controversial issue that must be negotiated in the codesign process as the senior interaction project was initially negotiated with the institutional partners we decided to apply a broad and loose definition of the group of seniors that should be recruited to the project we found it important to include seniors who were not in any way in touch with public or private services to the elderly as well as seniors with both little and extensive contact with these services in terms of age this definition was tentatively translated into 55 the point in attempting to recruit so broadly was both to ensure to have participants who could take on the long term perspective of the project to innovatively rethink services and infrastructure addressing a strengthening of senior networks around everyday activities and just as important to establish a realistic life time perspective on senior culture that inevitably include different degrees of dependency on external services as the copenhagen municipality was the lead partner of the project we further decided to recruit seniors from a particular part of the city both to ensure that the professional staff from the municipality could be properly briefed and included in the project activities and to prepare the ground for subsequent living lab activities to be rooted in already existing local networks very soon as we moved on to establish contacts with possible participants the initial definition of seniors proved to be highly controversial when applying a codesign approach addressing senior citizens this creates a number of issues related to identity selfimage and stigmatization when these senior citizens are to consider themselves potential codesigners britt östlund also addresses this issue of stereotyping elderly and their ability to handle new technologies when do people consider themselves elderly old as senior citizens or similar labels used to categorize people in the late part of their life and what do identification with such labels entail when approaching people in the specific urban environment who we envisioned to be the future users we realized that almost nobody among the group of people between 55 and 75 years old identified themselves as elderly or senior citizens rather they tend to refer to the others or even to their own parents this was particularly striking in an early conversation with a potential participant whom we had been pointed to because of her active involvement with local community work among seniors she is herself 75 years old retired from work and so severely drabbed by arthritis that special arrangements had to be made for setting up the conversation we had a lively dialogue addressing the vivid activities of the social clubs that our informant was part of organizing about her personal interest in traveling and of her general discomfort with researchers and research students that want to do studies of little interest to her and her peers as the conversation moved on to one of the core concepts of our project communication technology that can grow in importance as the person using it is growing older a remarkable shift occurred our informant now spoke passionately about her recently deceased mother and how important it had been to her to have well known people around her while she lived in a local elderly home surprisingly it was not immediately attractive for our informant to consider herself a possible user of the technologies that we were envisioning these experiences are in line with riche and mackay who write that recruiting proved more difficult than anticipated in part because people do not appreciate being stigmatized as elderly and because they did not see a direct benefit for themselves the interview above and other early interviews made us realize that we need to find new ways of not only inviting participants into our project but also to reconsider the way we think of address and refer to them as future users of the technologies that we are going to codesign communities of practice instead of focusing on recruiting individuals for the project an alternative approach might be to use everyday practices as frame and starting point the concept of communities of practice was originally developed in field of work to capture the skills and competencies enacted by people engaged in a professional practice lave and wenger coined the concept of communities of practice they write in using the term community we do not imply some primordial culturesharing entity we assume that members have different interests make diverse contributions to activity and hold varied viewpoints in our view participation at multiple levels is entailed in membership in a community of practice nor does the term community imply necessarily copresence a welldefined identifiable group or socially visible boundaries it does imply participation in an activity system about which participants share understandings what they are doing and what that means in their lives and for their communities originally the notion of communities of practice was used in the understanding of situated learning processes in organizations but it has also become quite influential in participatory design as a way of understanding relations between different groups of users in a specific context according to lesser and storck a community of practice is a group whose members regularly engage in sharing and learning based on their common interests one might think of a community of practice as a group of people playing in a field defined by the domain of skills and techniques over which the members of the group interact being in the field provides members with a sense of identity both in the individual sense and in a contextual sense that is how the individual relates to the community as a whole when expanding this concept to include everyday practices outside work one could talk about communities of everyday practice where senior citizens similarly are skillfully enacting everyday practices as seniors gradually as they get older they enact what we would call situated elderliness with situated elderliness we refer to practices that include activities that for some reason or another has become more challenging or perhaps even impossible to carry out by himself or herself an example could be not being able to pull up ones socks or stockings another example is when a bank decides that all transactions have to be carried out over the internet a consequence of changing the banks practices suddenly creates a large group of senior people considered old as they are not able to handle their bank transactions themselves due to lack of experience using the internet in these situations in a contextual sense they practice situated elderliness but simultaneously they might be able to handle all other situations in their everyday life inviting communities of everyday practice in relation to recruiting senior people for the senior interaction project we visited social clubs elderly homes and community centres in the local environment to these initial meetings we brought socalled workbooks containing evocative collages of pictures and text on the themes of the project as a way to both inform them about the project and invite the participants tell stories about their everyday practices and by this hopefully making them interested in participating in the workshops the meetings were all lively and the seniors were eager to contribute stories about themselves and particularly the everyday they have together at the club or center more than 20 seniors accepted the invitation to the first workshop but though there was a positive interest in the themes of the project the dialogue at the meetings had a pronounced emphasis on the participants accounting for who they were and why they were there when we brought up the issue of building on local networks the people we talked to came up with stories about how they were actually not from here as they had either just recently moved to the neighborhood or had come to the club from an other part of town when we presented our interpretation of senior life as marked by changes that includes often difficult losses of beloved friends and relatives we got stories about how mourning and complaining were really not part of what you could share when together with others when we touched on the possibility to create extended networks between those serviced by the municipal home care service we got stories about how home care service was really not part of what they felt were needed in their life and as one man in the meeting came to admit that he had help from home care the others acknowledged that this was off course different for him as he was a man these reactions may seem as contradictions to what we brought to the meetings and in many ways they are but as we interpret what we heard we find that the reactions are as much about not being boxed in as elderly as they are about rejecting the relevance of the themes that we brought up in the meetings an observation was also that when meeting with the seniors in for instance a community center they tended first and foremost to provide stories about what they did at the centre in our codesign process we therefore consider these communities of everyday practice our potential future users and the participants of these communities our collaborating codesigners creating landscapes of everyday communities during the second workshop the first activity were to have all the senior participants create a landscape of the various everyday communities of practice that they were part of clipark with images and stylized silhouettes of human beings were provided to cut from arrange and glue to the cardboard there were also a number of flags with text that could be used to name the various communities if they wished to do that examples of the text on the flags were communities across age help each other in the local environment fun playing games and having competitions something steady to meet around the themes on the flags were based on the stories from the initial meetings and the first workshop an example of the resulting landscape can be seen in figure 2 when looking at the resulting landscape collages they are of course different as they represent various senior people some had for instance very many communities of practices that they were part of others had fewer still there seem to be the tendency that each community of practice was distinct in the sense that the people in the various communities did not mix very often there were for instance the other seniors that they exercised with another group that they played bingo with being with the family was another community of practice etc what seemed to establish the various communities of practices were the activities that were shared they also seemed most confident in describing the community of practice related to other participants in the workshop it was easiest to talk about the everyday contexts that were shared within the context of the center for their part less focus was on for example their children and grandchildren this might be the seniors way of interpreting what we were after and perhaps negotiating their roles as potential future users discussion when the senior interaction coproject started we did not know that recruiting seniors already in the initial steps should prove to be so complicated our project wants to expose a vivid senior culture spanning the 55 year old just getting to the point of considering that she is in the second part of life and the 93 year old at an elderly care home realizing that life is coming to an end we may have started out naively assuming that our codesigners are already there ready to embark on our project journey but constructing who are to be considered as future users is part of the effort during the initial visits to social clubs elderly homes and community centers we are not seem to be much more the statements than yes we are our project seems to depend on a particular definition of being a senior that were much too simplified and stereotype rather than using biological age institutional categories or similar formal ways to group the users that we imagine as the future users we suggest therefore to talk about situated elderliness we acknowledge that the rationale of our project is to address and assist citizens in coping with the particular circumstances of for example reduced mobility and potential social isolation associated with becoming elderly by associating such elderliness not to all encompassing life circumstances but to certain everyday contexts we can turn our attention towards the communities of practice that defines these contexts when reflecting on our process of recruiting and engaging senior participants as potential users in the project it seems that what we actually did was inviting groups of people sharing some kind of everyday practices to the workshops

communities of everyday practice and situated elderliness as an approach to codesign for senior interaction in ozchi 2010 proceedings pp 400403 copyright and moral rights for the publications made accessible in the public portal are retained by the authors andor other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights • users may download and print one copy of any publication from the public portal for the purpose of private study or research • you may not further distribute the material or use it for any profitmaking activity or commercial gain • you may freely distribute the url identifying the publication in the public portal take down policy if you believe that this document breaches copyright please contact us providing details and we will remove access to the work immediately and investigate your claim

introduction climate change is leading to an increased frequency and intensity of extreme weather events like floods 12 the occurrence of such phenomena poses significant hazards to both human life and property as a result these catastrophes tend to inflict greater harm on households communities and nations primarily due to factors such as uneven distribution of hazards exposure and vulnerability 3 worldwide climate change is contributing to a rise in flood occurrences and intensity 4 warming temperatures are responsible for more extreme weather phenomena such as intense rainfall and snowfall leading to flooding 56 additionally rising sea levels caused by melting glaciers and ice are exacerbating coastal flooding 6 7 8 deforestation contributes to climate change by releasing stored carbon intensifying greenhouse gases and global warming this alteration in climate patterns increases the likelihood of heavy rainfall and floods moreover deforested regions are more susceptible to flooding due to the diminished vegetations capacity to absorb water and stabilize soil 9 10 11 the global population residing in urban areas is continuously expanding 12 leading to urban sprawl and soil sealing 13 the interplay of extreme weather and climate change impacts rainfall patterns in water catchment regions 14 consequently leading to higher flow rates and faster runoff generation 1415 the combination of urbanization growth and expected climate shifts will lead to heightened extreme weather events resulting in more frequent and severe urban flooding occurrences these inundations may arise from either river floods or rainfallrelated floods furthermore there is a global trend of an increasing elderly population residing in urban areas 16 the term flood refers to the transient inundation of land that is conventionally nonsubmerged 14 though alterations in precipitation within a drainage basin are the predominant catalyst for river flooding 9 17 18 19 other factors such as swift snow thaw in mountainous regions 2021 and dam malfunctions may also contribute to this phenomenon 2223 storm surges 24 and tsunamis 24 are two coastal phenomena that may lead to inundation flooding resulting from river and coastal events is typically an outcome of natural occurrences and the severity and frequency of such events are connected to specific areas the sheer force of water 25 associated with these events may often result in significant damage moreover in addition to the physical harm inflicted by water its force can act as a powerful agent of erosion 26 this can lead to the degradation of materials situated beneath the foundations of buildings ultimately resulting in their collapse 26 subsequent to the recession of a flood the aftermath may exacerbate owing to several factors such as power and water shortages coupled with the dissemination of ailments such as cholera leptospirosis and typhoid fever 2728 these circumstances can lead to additional economic and personal losses in the affected region 29 although these floods result from natural factors the majority of the damage is attributed to human habitation in floodprone regions 30 31 32 people often reside in these areas due to the limited availability of alternative locations for construction within a municipality the presence of modern engineering infrastructure can create a false sense of security as it does not entirely eliminate the risk of flooding 33 consequently recent shifts in land use are primarily driven by population growth and economic development in floodprone regions rendering societies more vulnerable to such occurrences 3435 hence rainfall plays a vital role in assessing climate change particularly concerning floods to classify a flood event essential elements like flood severity duration and inundation area are examined 36 these factors act as key indicators for understanding and characterizing floods utilizing quantitative assessments of flood risks and models is crucial in making informed decisions to prevent disastrous flood incidents 37 according to the ipcc fifth assessment report vulnerability is a consequence of the interaction between two fundamental components sensitivity and capacity 38 therefore social vulnerability is a multifaceted concept that can be defined and used in various ways and is often related to other concepts like resilience risk exposure sensitivity and coping capacity 39 40 41 social vulnerability is a complex issue that affects many people around the world it refers to the susceptibility of certain groups of people to harm and negative outcomes due to their social economic and political positions in society this vulnerability can be influenced by various factors including poverty unemployment discrimination limited access to healthcare education and other essential resources as well as age gender race and ethnicity in this essay we will explore the concept of social vulnerability in more detail and examine its impact on individuals and communities the impact of social vulnerability can be seen in many different areas of life for example socially vulnerable individuals may have limited access to education and job opportunities which can make it difficult for them to achieve economic stability and financial security additionally poverty is a primary cause of social vulnerability 42 people who live in poverty often lack the resources and support necessary to protect themselves from harm they may live in unsafe housing lack access to healthcare and struggle to provide basic necessities for themselves and their families as a result they may be more vulnerable to environmental hazards such as natural disasters or pollution as well as health risks such as infectious diseases or chronic conditions 1043 furthermore they may experience higher rates of illness and disease as well as increased exposure to environmental hazards due to their living conditions and lack of access to healthcare additionally socially vulnerable individuals may be at higher risk of experiencing violence or abuse as well as social exclusion and stigmatization in recent years social vulnerability indices have become a popular method for measuring and mapping human vulnerability to hazards 32 43 44 45 there are a multitude of social vulnerability indicators utilized for natural hazards including but not limited to the social vulnerability index for disaster management 46 the social determinants of vulnerability framework 47 and the social vulnerability index 48 although design and context impose limitations quantitative indicators offer significant advantages for reducing vulnerability quantifying social vulnerability can facilitate the identification of the most vulnerable regions and the critical drivers of social vulnerability quantitative indicators present significant advantages in reducing vulnerability despite the limitations imposed by design and context 35 the objective of this research focuses on exploring the interconnection between social vulnerability contexts flood hazard incidence disaster phases and the levels of development at the national scale the interconnection between the national level of development and the social vulnerability context in malaysia is complex elevated national development has the potential to enhance infrastructure and resources thereby augmenting community resilience nevertheless social vulnerability may still prevail in certain communities due to regional discrepancies to tackle this issue it is essential to implement targeted interventions ensure equitable resource allocation and foster community engagement regardless of overall national development the purpose of this analysis is to enhance understanding with regard to the identification development and validation of factors that contribute to social susceptibility to floods to achieve this objective a comprehensive prisma metaanalysis of qualitative case studies focusing on flood disasters was conducted prisma is an advantageous instrument that offers a transparent means of reporting and the latest guidance for incorporating advances in methodologies pertaining to the identification selection appraisal and synthesis of studies moreover prisma provides a systematic approach to data extraction and synthesis allowing researchers to compare and combine data from various studies this facilitates a more comprehensive and meaningful analysis of social vulnerability to floods resulting in more robust findings overall prisma is an invaluable tool for conducting rigorous systematic reviews and metaanalyses on social vulnerability to floods it ensures transparency guides literature searches sets criteria and facilitates data synthesis thereby contributing to highquality research in this area materials and methods search and literature database the present article employs the prisma approach for a methodical assessment this approach has mainly been used by healthcare professionals for the formulation of systematic reviews and metaanalyses however specialists in environmental management have also adopted prisma for conducting systematic reviews below is a simplified overview of the primary components and methodology behind the prisma approach the prisma guideline comprises a set of precise measures that researchers must follow it begins by formulating a research question and establishing criteria for study selection or exclusion researchers then identify relevant information sources and create a comprehensive search strategy to retrieve studies the procedure involves evaluating titles and abstracts analyzing fulltext articles and applying inclusionexclusion criteria to select studies aligned with the research query systematic data extraction and quality evaluation of the chosen studies are conducted summarizing findings interpreting outcomes and drawing evidencebased conclusions are pivotal steps in the prisma process the flowchart layout of prisma visually represents the study selection process providing a clear overview of the progression evaluation of the chosen studies are conducted summarizing findings interpreting out comes and drawing evidencebased conclusions are pivotal steps in the prisma process the flowchart layout of prisma visually represents the study selection process provid ing a clear overview of the progression a comprehensive literature search was conducted in order to identify relevant stud ies pertaining to the assessment of social vulnerability covering a time period of 12 years from january 2010 to january 2022 to perform this search a number of online databases were utilized including springer link science direct jstor and web of science in or der to narrow down the results specific search terms such as social vulnerability to floods flood flooding social vulnerability index hazard assessment tool index risk sovi and svi were employed as inclusion criteria for the literature selection these terms were used both individually and in combination as inclu sion criteria for the literature to be considered for this review it is essential to note tha this study only includes peerreviewed articles in the english language that discuss the development of a social vulnerability assessment tool or index screening process the screening phase is the second step of the systematic review process during this phase it is essential to gather all of the articles related to the research topic and eliminate any irrelevant data simultaneously table 1 outlines the parameters for inclusion and non inclusion that must be followed in order to identify relevant articles in order to identify relevant articles a total of 281 articles were examined using a series of inclusion and non inclusion parameters these parameters were designed to consider factors such as the na ture of the literature language timeline countries and territories as well as the field o study for the literature type criterion this study narrowed its focus to journal research articles while excluding papers that mimic review articles book chapters and conference proceedings in terms of language only english publications were considered while arti cles not written in english were not considered the publication criteria stipulated the period between 2010 and 2022 exclusively while the geographical criterion was limited to asean the middle east and european countries lastly this study selected articles ex clusively from environmental studies and sustainability social studies and agricultura a comprehensive literature search was conducted in order to identify relevant studies pertaining to the assessment of social vulnerability covering a time period of 12 years from january 2010 to january 2022 to perform this search a number of online databases were utilized including springer link science direct jstor and web of science in order to narrow down the results specific search terms such as social vulnerability to floods flood flooding social vulnerability index hazard assessment tool index risk sovi and svi were employed as inclusion criteria for the literature selection these terms were used both individually and in combination as inclusion criteria for the literature to be considered for this review it is essential to note that this study only includes peerreviewed articles in the english language that discuss the development of a social vulnerability assessment tool or index screening process the screening phase is the second step of the systematic review process during this phase it is essential to gather all of the articles related to the research topic and eliminate any irrelevant data simultaneously table 1 outlines the parameters for inclusion and noninclusion that must be followed in order to identify relevant articles in order to identify relevant articles a total of 281 articles were examined using a series of inclusion and noninclusion parameters these parameters were designed to consider factors such as the nature of the literature language timeline countries and territories as well as the field of study for the literature type criterion this study narrowed its focus to journal research articles while excluding papers that mimic review articles book chapters and conference proceedings in terms of language only english publications were considered while articles not written in english were not considered the publication criteria stipulated the period between 2010 and 2022 exclusively while the geographical criterion was limited to asean the middle east and european countries lastly this study selected articles exclusively from environmental studies and sustainability social studies and agricultural science from the inclusion and noninclusion criteria 249 articles were eliminated in total inclusive and noninclusive inclusive and noninclusive for the third phase of inclusion 232 articles were used in total each paper with a title abstract and content is crucial and requires a thorough examination to ensure that it meets the inclusion criteria and objective review requirements a total of 221 articles did not meet the criteria and were excluded therefore the selected articles for analysis are primarily focused on social vulnerability and empirical research this selection was made because the objective of this study is to determine the indicators utilized to evaluate social vulnerability in the malaysian flood context the importance of this study is based on understanding the actions related to social vulnerability especially in integrating climate change and risk reduction into the governance and arrangement of both urban and rural sectors more specifically this method highlights the significance of public education in raising awareness about potential flooding more accurately while flood frequency can vary across countries due to diverse climate conditions this study aims to include asean the middle east and european countries to bridge the research gap in developing social vulnerability indicators by doing so the research can offer valuable insights into how to better address flood risks and enhance community preparedness in a broader geographical context after completing the assessment and analysis of the remaining articles the researcher initiated the data extraction process the first stage involved a comprehensive evaluation of the abstract of each article which was followed by a thorough examination of the entire text to identify the relevant themes and subthemes related to the research objectives subsequently in order to establish a typology for each article the themes and subthemes were systematically arranged results based on the results shown in table 2 a total of 11 articles were chosen for this study and the authors of these articles include those of 4 25 26 27 28 29 30 31 32 33 50 furthermore the chosen articles were published within the years spanning from 2014 to 2021 the primary aim of this study is to identify patterns in research pertaining to social indicators that are consistently examined and deliberated upon for the purpose of constructing a social vulnerability index for a specific region or community with respect to the countries represented in this study two of the studies originated from australia and canada while the others were conducted in italy the philippines the netherlands the united states china taiwan and indonesia this compilation encompasses the names of the authors the countries where the studies were conducted the titles of the articles and the objectives of the scholars investigations author country year title objective 4 indonesia 2020 assessment of social vulnerability to floods on java indonesia to determine the local government units with the highest vulnerability and analyze their spatial allocation through cluster analysis 50 united states 2021 flood exposure and social vulnerability in the united states to explore the geographic dimensions of social susceptibility to inland flood exposure in the contiguous united states employing the use of flood hazard maps 44 taiwan 2020 a gisbased approach for assessing social vulnerability to flood and debris flow hazards to supply a collection of reliable indicators that may be utilized to examine social vulnerability as a means of enabling decision makers to develop a plan for mitigating environmental hazards to identify indicators of social vulnerability at the level of municipal districts in the netherlands and construct a simple social vulnerability index 51 philippines 2015 assessing social vulnerability to flooding in metro manila using principal component analysis the researchers aim to identify the most important factors contributing to social vulnerability to flooding and create a social vulnerability index 52 italy 2017 assessment of social vulnerability to floods in the floodplain of northern italy to apply the social vulnerability index to the floodplain of northern italy using census data to identify social differences and vulnerabilities in the area 53 australia 2021 geophysical and social vulnerability to floods at municipal scale under climate change the case of an innercity suburb of sydney to propose a novel approach and susceptibility index for flooding that integrates advanced hydrologic and hydraulic modeling with metrics relating to the built environment and socioeconomic factors source author analysis 2022 indicators used to measure social vulnerability in a flood the indicators of social vulnerability to floods were most frequently related to demographic characteristics particularly in the stages of disaster response and recovery the indicators most frequently detected after these were those related to socioeconomic status primarily noted during the response phase the correlation between demographic as well as socioeconomic factors and their impact on susceptibility to inundations highlights the significance of characteristics like ethnicity gender age and income in determining a societys resilience response and recovery from floodrelated disruptions in addition other significant factors include health education risk perception migration disability and disabled persons floods can significantly impact both the physical and psychological health of individuals and communities 58 additionally exposure to contaminated floodwaters can lead to waterborne diseases posing a severe health risk while disrupted access to medical assistance during floods can delay treatment for injuries and medical conditions amplifying health concerns 1059 moreover the psychological toll of the upheaval caused by floods including displacement and loss can lead to heightened stress and emotional distress addressing the health impact of floods requires proactive disaster preparedness and response measures such as early warning systems evacuation plans and improved infrastructure public awareness and education on flood risks and safety measures are essential to empower individuals and communities to protect themselves during such events 5860 by understanding and effectively responding to the health consequences of floods communities can enhance their resilience and safeguard their wellbeing in the face of these challenging natural disasters meanwhile education plays a significant role in shaping how individuals comprehend and react to floodrelated information as well as resources 6162 education in this context pertains to the level of formal schooling and knowledge acquired by individuals people with higher levels of education are more likely to comprehend flood warnings issued by authorities enabling them to take appropriate and timely actions during flood events 63 they can also access recovery resources more effectively utilizing problemsolving skills and resource management capabilities 64 on the other hand individuals with limited formal education may face challenges in comprehending flood warnings and finding recovery resources potentially making them more vulnerable to the impacts of floods 5065 enhancing education and promoting floodrelated awareness can improve preparedness and response among communities reducing the adverse consequences of floods on vulnerable populations moreover risk perception refers to how individuals and communities perceive the likelihood and severity of potential hazards such as floods 66 it involves peoples subjective judgments and beliefs about the risks that they face which can be influenced by various factors including past experiences cultural beliefs and access to information 6768 individuals with high risk perception are more likely to take precautionary measures and engage in preparedness actions to reduce their vulnerability to floods 1069 they are more likely to pay attention to warnings plan for evacuation and implement strategies to safeguard themselves and their properties during flood events understanding risk perception is crucial for disaster management and community resilience as it can help authorities tailor communication strategies improve preparedness programs and foster a better understanding of how individuals respond to flood risks 70 on the other hand migration refers to the movement of people from one location to another often driven by various factors like economic opportunities environmental changes or seeking better living conditions in the context of flood vulnerability migration can have both positive and negative impacts 21 people may migrate away from floodprone areas to avoid the risks associated with floods reducing their vulnerability however migration can also lead to increased vulnerability if people relocate to areas with a higher flood risk or inadequate infrastructure or if they become displaced during extreme flood events 21 the term disability denotes physical or mental impairments that hinder an individuals daily functioning and this can be further exacerbated by flood events disabled persons are individuals with disabilities who may encounter additional difficulties in terms of preparing for and responding to flood events overall these factors highlight the complex and multifaceted nature of social vulnerability to floods as well as the need for a comprehensive understanding of the drivers and impacts of vulnerability in order to effectively address and mitigate flood risks table 3 provides an inclusive list of 14 indicators that can be used to determine the level of social vulnerability in the event of a flood these indicators encompass factors such as age group gender property ownership physical infrastructure economic status household composition academic background employment status profession urbanization level disability migration status healthcare availability and population demographics population population growth rate 495152 sources adopted from 71 demographic characteristics in contemporary research demographic characteristics serve as frequent indicators of social vulnerability nevertheless there is often an inconsistency in the academic literature in terms of the exact effect of individual demographic variables on socially vulnerable populations for example there are studies that highlight that children are a particularly susceptible demographic in the population however they may also act as a driving force for promoting resilience by means of fostering community networks through their education or aiding in household recovery endeavors 347273 it is commonly assumed that the elderly and women are the most vulnerable however research on fatalities related to floods reveals that young 49 and middleaged men are also at risk due to their inclination towards risky behavior 52 rescue activities and health impairments caused by drug or alcohol consumption 449 a review of standard demographic factors is necessary due to these discrepancies a detailed classification of the frequency of citations on demographic factors that impact social vulnerability to floods is presented in table 3 the demographic features that are most commonly found in the literature encompass age gender race recent immigrants and singleparent households 25 26 27 28 29 30 31 32 33 in the literature age is widely recognized as the primary demographic factor that influences social vulnerability mainly due to its pervasive prevalence and consequential impact the age variable includes the ratio of inhabitants classified into four age groups those aged 65 and above aged 4 and below individuals aged 514 and residents aged 1519 4 25 26 27 28 29 30 31 32 33 50 from these findings a negative outcome has been shown for elderly people indicating an increased susceptibility to vulnerability reducing social vulnerability with regard to age can be accomplished by utilizing prior experience with disasters and taking proactive measures in the mitigation phase however studies suggest that the elderly and young are more susceptible to disasters due to their dependence and physical condition with limited linear connections between age and vulnerability identified 44951 this indicates that individuals who fall into the categories of very young or very old may require additional assistance and support during disasters due to their agerelated limitations disabled populations including those living in institutions those with limited abilities to care for themselves individuals with longterm or chronic illnesses requiring continuous care and residents of nursing homes have frequently been identified as the main driver of social vulnerability according to research patients in nursing homes and hospitals face significant challenges when it comes to evacuation and seeking shelter in situ 5154 furthermore in severe situations family members of patients may hinder the evacuation of those who require selfcare the presence of limited mobility dependence on care and reliance on medication as well as other services poses significant challenges to the process of evacuation in contrast when services are disrupted the recovery process may be impeded due to the increasing difficulty in providing care for special needs populations 54 furthermore recognizing the complex relationship between gender identity and flood susceptibility is essential as women are disproportionately responsible for taking care of their families 44 genderbased vulnerability was evident in both developed and developing nations stemming from differences in resource accessibility opportunities power rights informal sector employment and income 26 the only choice available to women is often informal sectors with low wages which leads to limited opportunities for economic expansion and lower pay than men 27 the impact of gender on susceptibility to floods is not a simple phenomenon to understand women are recognized for their superior coping mechanisms greater commitment to obtaining knowledge related to risk and stronger social bonds which account for this 33 the analysis of individual cases has demonstrated the difficulty in generalizing the vulnerability of women in society furthermore it is important to consider the overall complexity and diversity of individual cases when analyzing the vulnerability of women in society even in developing nations with high levels of inequality social vulnerability cannot be predicted solely by gender womens daily living conditions are affected by their socioeconomic status household structures and geographic locations making it an unreliable indicator 4 the evidence from several studies conducted in this specific context suggests that gender is not a determining factor in the level of social vulnerability experienced during flooding events 5557 the factors of race class ethnicity and immigration status serve as supplementary drivers of social vulnerability to floods cultural and linguistic obstacles can impact the selection of residential areas in highrisk zones predisaster mitigation measures and the availability of postdisaster resources for recovery 72 73 74 socioeconomic status the elements that determine socioeconomic status are commonly utilized as primary features in measuring social vulnerability in different geographic locations in social vulnerability studies several common indicators of socioeconomic status are measured such as household composition poverty profession academic background economic and employment status and property ownership at the individual level social vulnerability may arise from a variety of factors including resource constraints power dynamics poverty and marginalization these factors can limit access to resources influence coping behaviors and induce stress 8 similarly at the community level social vulnerability is determined by factors such as income distribution resource accessibility and economic asset variety 46 within this specific context income and poverty are the foremost factors that significantly impact social vulnerability the primary reason for this is that income is intricately connected with other forms of capital that could potentially act as alternative indicators for social vulnerability to floods to assess social vulnerability to floods various indicators can be used such as access to education affluence occupational category overcrowding in residences home or car ownership and unemployment 19 education is an important factor in the correlation between income and other forms of capital individuals who are educated have a greater advantage in all areas of life compared to those who have not received education or have only received minimal education moreover it can lead to betterpaying jobs and ultimately result in higher incomes 31 as a result this may lead to an increase in asset ownership though at a higher cost for wealthier households specifically in regard to flood damage however flood damage expenses make up a smaller fraction of the total income and capital of wealthier households 32 on the contrary a lower level of education is correlated with poverty unemployment overcrowding marginalization and income inequality lowincome groups tend to experience more severe negative effects from detrimental flood incidents and recovering from a moderately damaging event may take years for individuals who lack adequate financial resources as indicated by 27 moreover individuals with a higher level of education are less likely to be vulnerable to any form of hazard according to 19 someone who has sufficient education and knowledge about a certain issue will have a more thorough understanding of the nature of a hazard and its potential effects on them health health is a primary indicator of social vulnerability to flooding furthermore flooding causes adverse consequences on fatality rates and bodily as well as psychological health in particular the most significant impact of floods on human health is the fatalities resulting from drowning thus variables such as medical services health issues and proximity to healthcare facilities are crucial components in evaluating social vulnerability 4495154 deaths resulting from floodrelated illness can be influenced by various factors such as age gender medication disruptions and public water consumption 49 meanwhile the impact of flooding on psychological wellbeing may vary depending on individual factors such as anxiety and stress levels age gender preexisting health conditions and recovery duration 4 additionally floods can also have a significant impact on mental health which can be prolonged due to conflicts with insurance companies and homeowners as well as the disruption of various public commercial and health services 430 despite establishing the key determinants of vulnerability to health issues caused by floods current research does not come to a consensus on the demographic and societal aspects linked to health outcomes from floods in addition the influence of flood circumstances in worsening health concerns and mortality is still inconclusive coping capacity analyses of social vulnerability often focus on identifying social characteristics that increase susceptibility to negative impacts however it is important to recognize that social vulnerability also includes individuals ability to manage the impacts of hazards in the short term and adapt to them in the long term 7576 coping capacity refers to the capacity of individuals and communities to effectively manage the adverse effects of hazards especially natural disasters like floods coping strategies are successful when they allow individuals to access or allocate resources to meet immediate needs without putting assets and income sources at risk these resources can be both individual such as personal skills and knowledge and social such as support networks and community organizations successful coping strategies involve accessing or allocating these resources in a way that allows people to overcome immediate challenges while also maintaining their longterm assets and livelihoods this means that people need to be able to balance their shortterm needs with their longterm goals the concept of coping capacity is important because it helps us understand why some individuals and communities are better able to recover from disasters or crises than others the specific strategies adopted vary depending on social physical and geographic contexts in the literature the evaluation of coping capacity involves examining not only proactive measures taken before flooding such as preventive and adaptive actions but also reactive strategies implemented immediately after an event 77 this means that coping capacity can be understood as both proactive measures taken before a disaster occurs and reactive measures taken in response to a disaster coping capacity refers to the ability of individuals and communities to deal with and recover from the impacts of disasters preventative measures are actions taken before a disaster occurs to reduce the impact of a disaster in the case of floods preventative measures include accumulating food and medicine supplies saving finances arranging construction materials and obtaining insurance coverage 7879 these measures can help individuals and communities prepare for a flood and reduce the damage caused by a flood however the use of preventative strategies is constrained by income and land tenure this means that individuals and communities with limited financial resources or insecure land tenure may not be able to take these preventative measures instead the majority of preflood actions focus on elevating structures and their contents in order to protect residences from flooding structural mitigation refers to physical changes made to buildings to reduce the impact of a disaster in the case of floods this may involve elevating the building or its contents to prevent damage from floodwaters 80 while these structural mitigation measures can be moderately effective in reducing damage they may not be accessible to all individuals and communities this highlights the importance of addressing social and economic inequalities in disaster risk reduction efforts risk perception the evaluation of risk perception centers on comprehending the manner in which perception influences conduct and mitigates susceptibility in the context of floodrelated calamities numerous case studies have frequently noted the influence of risk perception on societal vulnerability previous research endeavors have delved into diverse aspects of flood perception encompassing flood awareness antecedent experiences trust appraisal of flood risk as well as demographic characteristics 25 however the findings regarding perception and vulnerability were often contradictory in nature the issue of flood awareness and knowledge has frequently been the subject of investigation with the underlying belief that awareness serves as a crucial prerequisite for preparedness 81 emotions such as fear uncertainty and concern are important intermediaries in the relationship between cognizance and safeguarding measures 7682 indeed several studies have reported a correlation between a lack of awareness regarding floods and a limited uptake of measures aimed at flood protection and preparedness 6583 generally measures are implemented by considering elevating homes acquiring flood insurance accumulating supplies relocating building contents to higher floors and carrying out evacuations although government dissemination of official flood information can increase awareness it may not be enough to reduce societal susceptibility land tenure property social vulnerabilities across land tenure categories differ during a disaster indicating that individuals belonging to a specific tenure category may be vulnerable in one phase of a disaster but not in another before a flood occurs homeowners tend to become more aware of flood hazards 84 understand alerts better 25 and quickly take steps to prevent damage 85 and are less likely to seek emergency shelter 86 meanwhile flood insurance was mainly considered a factor for reducing the impact of floods in studies conducted in developed countries 54 nevertheless the connection between tenure and flood insurance is not straightforward in the aftermath of the flooding tenants experienced a greater number of healthrelated consequences and stress compared to property owners during the flood event 8 furthermore they continued to rely on property owners during the recovery and reconstruction processes in response to flooding property owners were also more inclined to engage in structural enhancements to mitigate future floodrelated losses 27 there are multiple factors that contribute to the stronger attachment that homeowners tend to have to their homes compared to renters these factors include emotional attachment market conditions and control over maintenance and repairs disaster management plans disaster management plans are designed to address the unique challenges posed by different types of disasters 70 each disaster requires a tailored approach for an effective mitigation and response accordingly higherrisk areas receive greater attention and allocation of state resources to ensure comprehensive protection 4687 in the context of flood management the flood vulnerability matrix serves as a valuable tool to guide suitable actions these actions may involve the maintenance of existing reservoirs and the construction of new water storage dams ranging from smallto largescale structures 70 these reservoirs play a crucial role in regulating water flow especially during flood events by strategically managing water release downstream areas can be safeguarded from excessive flooding to further mitigate flood risks it is essential to adopt measures that reduce runoff and divert floodwaters into designated reservoirs 36 these reservoirs should be strategically located at a safe distance from populated regions to minimize potential damage and protect human lives 85 special attention should also be given to city drainage systems ensuring the efficient channeling of excess water away from urban areas 88 a proactive approach involves diverting runoff water to potential flood pocket zones which can act as natural storage areas helping protect cities and communities from the brunt of flood impacts by employing a combination of infrastructure development strategic planning and proper drainage management disaster management plans can enhance flood resilience and minimize the devastating consequences of flooding events on vulnerable populations 83 discussion several studies have utilized both case study and indicator development techniques to analyze social vulnerability in the context of floods in general the selection of variables analyses of indicators weighting mechanisms and aggregation techniques are often based on implicit factors or justified by the principles of simplicity or prior study decisions there are numerous cases where no justification is provided improving contextual integration can significantly enhance the effectiveness of social vulnerability indices in representing observed conditions the results of this study show several deficiencies in understanding pertaining to the formulation of social vulnerability indices to identify indicators of social vulnerability it is essential to consider the time period during which these indicators are applicable in addition it is essential to enhance the ability to quantify the factors that have a significant impact on vulnerability furthermore a comprehensive understanding of social vulnerability requires an appreciation of how various indicators interact with one another temporal context one interesting finding from the metaanalysis is that social vulnerability determinants show a lot of variation during different stages of a disaster which highlights the fact that social vulnerability is a dynamic state that can change over time 304789 the results from demographic and health studies offer important insights both young and elderly people were found to be more vulnerable to floods because they lacked knowledge and preparedness 34 among those affected during floods men and middleaged individuals showed higher vulnerability due to risky behaviors and involvement in emergency operations 4560 additionally children and elderly individuals were more vulnerable as they had limited swimming abilities and difficulty finding safe places during floods 6086 in the aftermath of a flood females singleparent households and the elderly experienced heightened vulnerability primarily stemming from limited access to resources and difficulties in upholding their longterm care and services 4760 measurability although indicators are valuable tools for policy formulation and public communication it is crucial to understand that there are certain boundaries that need to be considered 9091 when social vulnerability indicators are employed without proper consideration of practical factors such as cost data availability and measurability misguided decision making can occur with these factors taking precedence over validity 92 improving measurability is important especially when it comes to social capital risk perception and the psychosocial dimensions of health these things can be challenging to measure because they often depend on the situation and require different scales than other indicators indicators for these aspects are usually not available in publicly accessible databases such as national censuses conversely they require the implementation of qualitative methodologies specific surveys and participatory strategies to overcome these limitations scorecards have been widely adopted as a popular survey instrument especially for researchers studying urban resilience however more research is necessary to enhance the integration of research outcomes derived from the application of these methods specifically the value of participatory approaches in generating meaningful quantitative data is often disregarded and should be afforded greater attention 93 each of the mentioned indicators can be measured through specific metrics for instance in northeast india the indicator of income levels can be used to determine socioeconomic status 94 while in pakistan the indicator of educational attainment can be used to evaluate education level 63 similarly proximity to floodprone areas can be used to measure proximity among other metrics measurable data offer a clear comprehension of the vulnerabilities that exist in various communities and regions thereby enabling a comprehensive and systematic evaluation of social vulnerability for instance when evaluating the accessibility of healthcare facilities during river floods in bangladesh researchers have the ability to gather data on various factors such as the number of healthcare facilities available their exact locations and the population that they cater to by measuring this particular indicator it becomes possible to comprehend the level of accessibility to healthcare services during floods and also to pinpoint areas that may have insufficient access 95 similarly in the case of examining the impact of education levels on vulnerability during urban floods in jakarta experts can gather information on literacy rates school enrolment figures and educational achievements within the affected communities 4 these data facilitate an assessment of how education can influence an individuals ability to comprehend flood warnings and respond appropriately the ability to measure is also restricted by a limited comprehension of the fundamental processes of social vulnerability in certain studies protective factors included being a child 4762 elderly 4596 a woman 9798 and a minority group 50 the impact on social vulnerability displayed considerable ambiguity and nuance especially in relation to risk perception the results of previous studies on risk perception are too contradictory to draw general conclusions for selecting indicators 99100 therefore there is a need for the development and testing of new geospatial indicators of social capital social capital encompasses social networks shared cultural norms and interpersonal trust that facilitate cooperation and coordination among individuals and groups 51 these indicators can help in understanding the social context of flood risk and inform decision making additionally there is a need to search for suitable existing proxy measures that can be used as indicators proxy measures are indirect measures that are used to estimate a variable of interest when direct measures are not available or feasible generally measurability challenges are important in developing social vulnerability indicators and being aware of the limitations researchers should be cautious when making claims about the accuracy of these indicators especially when important factors that are difficult to measure are not included this means that researchers should carefully examine what information is missing and how it may affect the accuracy of the indicators indicator relationship additional studies are required to gain a deeper understanding of how social vulnerability drivers interact particularly across varying geographical and temporal scales the case studies offer fascinating examples highlighting the interdependence between population composition economic status property ownership social relationships 64 ethnicity and social status age financial status 101 and social isolation moreover the analysis of flood insurance underscores the complex relationship between social vulnerability drivers and their effects at an individual level a significant correlation has been observed between the purchase of insurance policies and income home ownership and mitigation behavior age and gender are key factors in determining vulnerability to various hazards the unique circumstances of children elderly individuals and women often render them more vulnerable children may be deficient in awareness and coping skills whereas the elderly may have reduced mobility and resilience meanwhile women particularly in conservative societies may encounter cultural and societal barriers that impede their ability to respond to disasters effectively additionally vulnerability is significantly influenced by property ownership and economic status those with restricted access to resources and financial means are more vulnerable during disasters property ownership affects the ability to relocate or access safe shelter while economic status impacts access to healthcare food and other essential resources the other significant indicators are the state of infrastructure and household composition adequate infrastructure such as wellmaintained roads bridges and emergency services can mitigate vulnerabilities and enable better disaster responses supportive household structures with strong social networks and capable caregivers enhance resilience and coping mechanisms during adversity the determinants of livelihood resilience are influenced by various factors including educational background employment status and profession individuals who possess higher levels of education are endowed with better access to information resources and opportunities thereby enhancing their ability to adapt to diverse circumstances and challenges furthermore stable employment guarantees a reliable source of income and financial security enabling individuals to cope with adversities more effectively vulnerability is significantly impacted by urbanization and migration patterns in rapidly developing areas with dense populations there exists an increased exposure to risks such as environmental hazards and limited access to basic services the concentration of people in urban centers can strain resources thus making it more challenging to provide adequate support and assistance during times of disasters in regard to indicator aggregation many social vulnerability indicators still use additive techniques according to this methodology every element contributing to susceptibility is assumed to operate independently and any inadequacy in one aspect of social vulnerability can be counterbalanced by an excess in another aspect 102 the metaanalysis reveals the limitations of relying on individual indicators to understand social vulnerability to floods and emphasizes the need for modeling and mapping approaches that consider the interactions between drivers the flood social vulnerability illustrated in figure 3 is based on a statistical analysis utilizing pearsons correlation analysis an investigation was conducted to scrutinize the relationship between the drivers that were identified in each of our individual studies the aforementioned correlation elevates the level of interaction between drivers thereby revealing the specific drivers that are positively or negatively correlated however it is essential to realize that the existence of the aforementioned factors during the practical investigation does not necessarily indicate a causal correlation between them instead they have a tendency to concur or manifest simultaneously moreover in most instances empirical studies primarily devote attention to the dominant relationships conclusions in this study we undertook a comprehensive analysis of the components of flood and social vulnerability firstly we searched key databases and identified a total of 281 articles subsequently we employed prisma guidelines to filter the articles based on inclusion and exclusion criteria resulting in a final selection of 11 pertinent articles using information gathered from these studies we collated a list of fifteen variables that are commonly utilized as indicators in the context of malaysia not all places or locations bear the same brunt of floods thus the extent of social vulnerability would vary and the methods used to measure them would differ as well even if people face the same calamity or catastrophe it does not imply that every individual undergoes identical phases of devastation recuperation appraisal etc as their counterparts certain individuals are at a significantly greater risk of social vulnerability and this is subject to the indicators utilized in the context of malaysia and its climatic conditions there are seven crucial indicators that have been identified with regard to flood occurrences these indicators include education age migration special needs populations health accessibility demographic characteristics and socioeconomic status these indicators are significant in measuring the social vulnerability index of highrisk communities in the face of flood hazards the measurements obtained from these indicators would prove useful to authorities as com conclusions in this study we undertook a comprehensive analysis of the components of flood and social vulnerability firstly we searched key databases and identified a total of 281 articles subsequently we employed prisma guidelines to filter the articles based on inclusion and exclusion criteria resulting in a final selection of 11 pertinent articles using information gathered from these studies we collated a list of fifteen variables that are commonly utilized as indicators in the context of malaysia not all places or locations bear the same brunt of floods thus the extent of social vulnerability would vary and the methods used to measure them would differ as well even if people face the same calamity or catastrophe it does not imply that every individual undergoes identical phases of devastation recuperation appraisal etc as their counterparts certain individuals are at a significantly greater risk of social vulnerability and this is subject to the indicators utilized in the context of malaysia and its climatic conditions there are seven crucial indicators that have been identified with regard to flood occurrences these indicators include education age migration special needs populations health accessibility demographic characteristics and socioeconomic status these indicators are significant in measuring the social vulnerability index of highrisk communities in the face of flood hazards the measurements obtained from these indicators would prove useful to authorities as complementary data to their geological mapping of disaster risk management specifically with regard to the location of flood events this study is of significant importance as it enables a better understanding of the social vulnerability index in the context of floods in malaysia data availability statement not applicable

flood disasters a natural hazard throughout human history have caused significant damage to human safety and infrastructure this paper presents a systematic study using databases from springer link science direct jstor and web of science the study employs the prisma report analysis method to examine 11 flood disaster case studies between 2010 and 2022 the findings reveal that demographic characteristics socioeconomic status and access to healthcare crucially determine social vulnerability to adverse flood events notably risk perception and coping capacity also received substantial attention in the case studies unfortunately many indicators of social vulnerability fail to adequately consider the influence of these factors the effects of factors that make communities vulnerable vary across disaster stages and countries this emphasizes the importance of considering specific situations and locations when understanding the origins and consequences of vulnerability the article concludes by offering recommendations to customize quantitative indicators of social vulnerability to flood contexts covering aspects such as temporal context measurability and indicator relationships

introduction several decades ago thomas kuhn first articulated the now widely accepted idea that scientific disciplines are based on paradigms that entail assumptions regarding the nature of some class of empirical phenomena and the types of explanations required to elucidate it according to kuhn normal science involves conducting research on the important questions raised by a fields paradigm and its theoretical derivatives although the social sciences encompass a wide variety of disciplines and subfields they all tend to share a general paradigm sometimes labeled the standard social scientific model this paradigm views human behavior as a product of socialization and culture with biology exerting little influence indeed social scientists have a long history of being suspicious of biological explanations of human behavior and we often view ourselves as in a battle with those who would impose an unproven and socially dangerous biological determinism these fears have some basis in reality given the many examples of human abuses perpetrated in the last century based at least in part on flawed scientific research linking biology to various deviant behaviors importantly however recent paradigmatic shifts in the life sciences largely obviate these longstanding concerns in his discussion of scientific progress kuhn noted that research sometimes generates anomalies that challenge a fields existing paradigm as these anomalies continue to accrue a scientific revolution takes place with the result being a new paradigm that provides a fundamentally different view of the field this new vision rests on an alternative set of assumptions points to new types of theories and suggests a fresh set of problems to be investigated many would argue that this is what has occurred in two branches of the life sciences genetics with its movement away from genetic determinism to an emphasis on epigenetics and neuroscience with its movement from a fixed to a neuroplastic view of the brain importantly these new paradigms recognize indeed they place a premium upon the role of the environment hence these new developments provide a unique opportunity for rapprochement and fruitful collaboration between the life and social sciences we develop this argument by briefly describing the paradigmatic shifts that have taken place in genetics and neuroscience for each of these fields we begin by describing the old paradigm turn to consideration of the anomalies that challenged its legitimacy and then present the alternative environmentally friendly paradigm that has emerged during the new millennium the remainder of the paper focuses upon the challenges and opportunities for social scientists especially those involved in developmental work proffered by these paradigmatic shifts indeed we will argue that coming to grips with these changes in the life sciences has the potential to foment a paradigmatic shift in the social sciences the epigenetic revolution in genetics the old genecentric model in the early 1950s watson and crick discovered that genes are composed of sequences of 4 nucleotide bases and that these dna strands represent a code for forming the bodys protein molecules their discovery ushered in the paradigm of genetic determinism the belief that genes control all of our traitsphysical behavioral and emotional genes produce rna which controls the production of proteins which control the functioning of cells and ultimately behavior this idea became the dominant dogma of molecular biology and it gave rise to much hyperbole over the decades regarding the power of genes this hyperbolic presentation was supported by behavioral genetic studies suggesting that virtually every aspect of human behavior from disease to political ideology was determined in large measure by a persons genes all that was left to be done was to sequence the human genome this would enable scientists to identify the specific genes that make people vulnerable to physical and emotional illnesses learning difficulties obesity aggression and all sorts of other undesirable traits and behaviors anomalies that challenged the genecentric model the human genome project was launched in 1990 by the national institutes of health the goal was to identify the basis of human traits both positive and negative and to foster development of new medical applications around the world based upon the assumption that genes control an organisms traits researchers expected to find a strong correlation between the complexity of an organism and the number of genes that it possesses with over 100000 proteins in the human body and with a blueprint needed to make each protein the assumption was that the human genome consisted of at least 100000 genes surprisingly however shortly after the turn of the century the hgp reported that humans with over 50000 trillion cells have only about 23000 genes just slightly more than the barely visible roundworm further recent research has revised the number of proteins utilized by the human body from 100000 to upwards of 2 million clearly the one geneone protein assumption is incorrect most genes appear to be capable of producing a multitude of protein products another major challenge to the genecentric paradigm involved the missing genes problem sequencing of the human genome was completed in 2002 and scientists immediately began to do genomewide association studies to identify the genes associated with various diseases and disorders well over a decade of such research has failed to find significant associations between specific genetic variants and virtually any human traits illnesses or behaviors this failure has raised serious doubts about the validity of behavioral genetics studies reporting strong heritability for most phenotypes it appears that the high heritabilities found in these studies were due in large measure to methodological deficiencies associated with the twin study method and to a faulty conceptual model that incorrectly assumed that genes exert main effects that are independent of the effects of the environment finally contrary to the genecentric model evidence suggests that only about 2 of the human genome codes for proteins while most of the remaining nonprotein coding dna is involved in regulatory processes that determine which protein coding segments of a gene will be expressed and the types of proteins that will be produced such findings have fostered a paradigmatic shift that places less emphasis upon inherited dna differences between people and more importance upon identifying the epigenetic factors that control or regulate dna expression the new epigenetic model the new genetic paradigm views genes as a combination of dna segments that together constitute an expressible unit through complex promoters and alternative splicing the various dna segments that comprise any particular gene can contribute to the production of a variety of rna sequences and proteins and what determines how a gene expresses itself as biologist h frederick nijhout has noted a gene cannot turn itself on or off rather when a gene product is needed a signal from its environment not an emergent property of the gene itself activates expression in other words the environment controls gene expression the environment includes the external world in which the organism is located or develops as well as its biochemical internal world of hormones metabolism and the like in contrast to the old view of the deterministic gene the new paradigm places the environment center stage environmental circumstances foster gene expression which through several additional mechanisms results in behavior although most gene regulation is a response to the immediate demands of the environment in recent years researchers have devoted much attention to a type of gene regulation that takes place over much longer intervals epigenetics focuses on changes in gene expression that last for months years or even a lifetime epigenetic regulation entails biochemical mechanisms that influence the genome to express particular genes genes are regulated through epigenetic mechanisms such as methylation which inhibits gene expression and acetylation which encourages gene expression while epigenetic processes such as methylation and acetylation are responsive to developmental and physiological cues they are also influenced by environmental conditions importantly for our purposes there is rapidly accumulating evidence regarding the role of epigenetic factors in neural development studies have shown for example that epigenetic modification of particular genes influences perception emotion memory cognition learning and neural plasticity from an evolutionary perspective epigenetic changes appear to be a fundamental process whereby a fixed genome can respond to changing environmental challenges and circumstances epigenetic factors appear to be an important mechanism whereby life experiences become biologically embedded and provide the physiological underpinning for cognitive emotional and behavioral traits tailored for adaptation to environmental demands as the editors of nature recently noted it has now been proven beyond doubt that although our genes are fixed their expression is highly dependent on what our environment throws at us the current challenge is to work out precisely how environment affects our biological tissues and changes us in short the old genecentric paradigm has been debunked and replaced by a new developmental model that recognizes the permeability and malleability of the genetic in response to environmental influences this new paradigm conceptualizes and studies genes as part of a broader cellular environment that is responsive to environmental input the neuroplastic revolution in neuroscience the old view of the brain prior to the new century conventional wisdom in neuroscience held that the adult mammalian brain is fixed in two respects no new neurons are created and the fundamental structure of an individuals brain is dictated by genes and largely immutable this fixed perspective viewed the brain as a complex machine it consisted of a set of parts each with a particular function if a part was damaged or worn out nothing could be done to replace it an important component of the brain was its many neural pathways evidence suggested that it was these pathways that enabled the various bodily functions such as cognition memory sensory awareness and muscle movement importantly these pathways were assumed to be fixed universal and immutable recent research has shown that in large measure these assumptions are incorrect there is strong evidence that the size and shape of the various neural pathways in our brain change depending upon what we do over the course of our lives anomalies that challenged the old view of the brain first of all research has established that the assumption that no new neurons are produced following birth is incorrect evidence suggests that neurogenesisthe manufacture of new neurons within the braintakes place well into old age particularly in areas such as the hippocampus second the assumption that when a particular part of the brain is injured or worn out it cannot be replaced is contradicted by studies showing that individuals often regain a function following brain injury because another portion of the brain is appropriated as a substitute for the injured area in such cases the brain recruits nearby healthy neurons to perform the function of the damaged ones such findings are clearly contrary to the assumption that the brain is a prewired machine where each part serves a particular function finally and this is the finding most relevant for social scientists there is now strong evidence that environmental influences can change the network of neuropathways within a persons brain several studies have reported evidence of such neuroplasticity among children mri and fmri studies have indicated for example that exposure to harsh and unpredictable childhood conditions is associated with greater volume and reactivity of the amygdala a portion of the brain that is responsible for vigilance and emotional responsiveness to threat and alteration of the prefrontal cortex the area responsible for executive control other studies have reported that among adopted children those adopted later have larger amygdala volume than those adopted earlier and that children continuously exposed to maternal depression show larger amygdala volume than those without such exposure importantly the amygdala and prefrontal cortex as well as their interconnection are implicated in emotional regulation impulsivity reactive aggression and internalizing problems moreover in addition to these findings regarding childhood there is also strong evidence that neuroplasticity continues throughout adulthood a recent study by mackey et al for example revealed that young adults enrolled in a law school admissions test course showed strengthening in networks of the brain implicated in highlevel reasoning such work challenges the view that intelligence is a set of innate immutable abilities other studies have reported the growth of areas in the brain associated with context and space among taxicab drivers and of areas associated with finger movements in virtuoso violinists indeed simply repeatedly imagining oneself playing a simple fivenote sequence on the piano has been shown to increase the space in the motor cortex devoted to the fingers further while hundreds of studies have shown that cognitive behavior therapy can effectively change the thought processes and behaviors of adults with various types of psychopathology there is strong evidence to suggest that these cognitive and behavioral changes are associated with neurological changes when assessed with mri and fmri similarly experiments have shown both mindfulness and compassionfocused meditation to be effective in reducing anxiety depression and anger while enhancing emotion regulation empathy and psychological wellbeing these changes have been linked to changes in gene expression and in brain function and structure thus there is a wealth of data indicating that the old view of the brain is incorrect the brain appears to adapt to everyday circumstances and challenges this plasticity is most apparent in childhood but continues to a lesser degree throughout life the neuroplasticity paradigm the core feature of the newly emergent neuroplastic paradigm is the recognition that repeated experiences activities and thoughts alter gene expression and in turn the wiring or structure of our brain this process involves growth in cortical space devoted to processes and functions that are used more frequently and a corresponding decrease in cortical space devoted to rarely performed processes this is a result of the competitive process constantly at work in the brain whereby frequently used networks are strengthened while those that are rarely utilized are gradually lost as a consequence the thickness space and extensiveness of the various pathways that comprise a particular persons brain are determined by the demands of his or her everyday environment thus the very structure of our brainthe relative size of different regions the strength of connections between one area and anotherreflects the lives we have led implications for the social sciences although the social sciences have tended to see nature and nurture as two competing explanations for human behavior the recent paradigmatic changes in the life sciences just described indicate that this is a false dichotomy indeed these new plasticity paradigms identify various avenues whereby environment influences including social factors become biologically embedded through processes like epigenetically induced changes in gene expression biological systems such as the sympathetic nervous system and hypothalamicpituitaryadrenal axis are calibrated and the brain sculpted in a manner that prepares the individual to function and survive given existing environmental conditions these biological systems in turn influence the way that an individual responds to subsequent situations and events importantly however new environments and experiences can change gene expression and alter biological systems in other words systems can be recalibrated and the brain can be resculpted to facilitate adaptation to subsequent changes in the environment this new plastic view of human biology vindicates social scientific claims regarding the importance of the social environment in explaining human health and behavior and provides a basis for rapprochement between the social and life sciences as the editors of nature recently noted now is a perfect time for reconciliation of the two cultures…sociologists have been studying human environments for decades…biologists are now in a position to benefit from their insights although they will need to learn the language of sociology and sociologists stand to benefit from the understanding that biology will bring to their own vindicated empirical research both camps stand to benefit from entente and increased collaboration it is an opportunity for the life sciences to better identify the manner in which the environment influences biological processes and an occasion for the social sciences to enhance the comprehensiveness and precision of their theories by making them more biologically integrated collaboration between the life and social sciences is already well underway in the area of medical research for the past few years the national institutes of health have promoted interdisciplinary work on issues related to physical and mental illness as a consequence interdisciplinary teams consisting of physicians geneticists psychologists and sociologists are examining issues such as the manner in which stress across the life course influences gene expression inflammation metabolic dysregulation biological aging and health such work is rooted in a new biopsychosocial perspective that emphasizes the interpenetration of environmental psychological and biological processes using this paradigm old disciplinary boundaries blur and begin to lose their meaning there is of course a division of labor among the team members indeed that is the purpose of bringing together such a mix of scientists at the same time however the team members must learn something about the corpus of knowledge associated with each others fields the psychologist and sociologist must learn the basics of genetics and human biology and the physician and geneticist must master rudimentary information regarding human development families and communities social scientists are absolutely essential to such teams medical researchers for example are very interested in how environmental conditions influence biological processes such as gene expression and health but they have only a crude understanding of how the environment should be conceptualized and measured thus past medical research regarding the impact of stress on biomarkers of health has been largely limited to an examination of the consequences of ses a comprehensive understanding of how various childhood and adult experiences including social relationships influence biology and health requires team members with training in the social sciences participation on such a research team is both exciting and challenging the biologically oriented scientists on our team are surprised at the theoretical and statistical complexity associated with investigating seemingly simple environmental effects such as the manner in which romantic partners influence each others health whereas the psychologists and sociologists on the team find it fascinating to venture into the world of gene regulation and biomarkers of health the end result is group discussions where all of the parties are pushed to go beyond their comfort zone and to think about problems in more nuanced and comprehensive ways although such interdisciplinary work will likely increase dramatically in the coming years it is also the case that the social sciences are interested in much more than helping the life sciences identify and assess environmental factors that might influence health the various social scientific disciplines have their own topics and concerns importantly there are many instances where the new biology might be utilized to elaborate and fine tune extant theoretical explanations much of social scientific research involves building models of the manner in which social experiences influence the way individuals think and act these models might be expanded to include epigenetic and neurological changes as well as other potentially mediating and moderating biological processes there is strong evidence indicating for example that childhood adversity fosters an insecure distrusting attachment schema further past research has shown that the neuropeptide oxytocin shapes the neural circuitry of trust empathy and intimacy in human beings this suggests that that the oxytocin system may serve as a critical biological mechanism linking adversity to attachment style consistent with this idea studies have linked childhood mistreatment to lower levels of oxytocin and a recent study revealed that methylation of the oxytocin receptor gene mediates the effect of adult stress on changes in attachment style this pattern of results suggests that calibration of the oxytocin system serves to mediate the impact of childhood adversity on attachment style but that recalibration of this system can take place in adulthood such findings not only identify the biological underpinnings for distrusting attitudes and behaviors they also make the theoretical argument linking adversity to attachment style more complete precise and compelling in our view this line of research provides an exemplar for how the new biology might be used to expand our understanding of the link between a wide variety of social experiences and human cognition and behavior for instance findings from our project indicate that factors such as exposure to discrimination family adversity neighborhood violence and incarceration are associated with increases in anger distrust and aggression in the coming months we hope to obtain better insight into these relations by identifying epigenetic changes that are associated with these cognitive emotional and behavioral changes our goal is to identify how environmental events shape biological processes that serve as the underpinning for cognitive and behavioral tendencies the fact that attitudes and behaviors become biologically embedded explains why they are often so difficult to change especially during adulthood however the new plastic view of genes and the brain suggests that some degree of change can and does take place throughout life hopefully in the coming years social science research will make important contributions to our understanding of the degree of plasticity associated with various periods of the life course conclusion for a variety of reasons the social sciences have a long history of opposition to biological explanations of human behavior in recent years however the life sciences have moved away from the biological determinism that the social sciences found so objectionable the new paradigms in genetics and neuroscience recognize the importance of the environment in regulating gene function and sculpting the brain given this new perspective the old nature versus nurture argument no longer has any meaning rather the new view is nature and nurture we have argued that this rapprochement between the life and social sciences presents opportunities for enhancing the power and comprehensiveness of our theories by making them more biologically integrated although we have emphasized paradigmatic changes regarding the environmental and biological plasticity it is certainly the case that the social sciences can benefit from other developments in the life sciences as well the discovery of mirror neurons for example aids our theorizing about concepts such as theory of mind and taking the role of the other and findings suggesting an innate concern with fairness and reciprocity provide us with a clearer understanding of human nature the bottom line is that a multitude of discoveries and theoretical developments in the life sciences require a paradigmatic revolution in the social sciences the standard social science model is no longer tenable the evidence clearly shows that both nature and nurture are necessary to explain human behavior this new reality should not be seen as in any way challenging the legitimacy or the raison detre of the social scientific enterprise the evidence not only suggests that the two fields are inextricably interlinked but importantly it indicates that they are connected in a manner that honors the priority that the social sciences place upon the environment accepting this fact and incorporating biological processes into our work will sharpen our theories and enhance their significance on the other hand waging war with a superannuated biological determinism is like tilting at windmills it makes us look foolish and irrelevant author contributions rs drafted the manuscript based upon the remarks that he presented as part of the elliott youth development lecture ek helped draft and refine the manuscript both authors have read and accepted the final version of this article

for good reason social scientists have a long history of being suspicious of biological explanations of human behavior importantly however recent paradigmatic shifts in the life sciences have largely obviated these longstanding concerns we highlight the changes that have occurred in genetics with its movement away from genetic determinism to an emphasis on epigenetics and in neuroscience with its switch from a fixed to a neuroplastic view of the brain we describe these new developments noting the way they recognize indeed place a premium upon the role of the environment the remainder of the paper focuses upon the challenges and opportunities for social scientists especially those involved in developmental work proffered by these paradigmatic shifts the evidence clearly shows that nature and nurture are inextricably interlinked importantly however it also indicates that they are connected in a manner that honors the priority that the social sciences place upon the environment we contend that incorporating biological processes into our developmental work will sharpen our theories and enhance their significance we argue that such biologically integrated models will provide a clearer and more comprehensive understanding of how nurture influences behavior across the life course

discrimination experiences and relationship qualities in twoparent african american families fathers transactions within the family may have different and possibly stronger implications for family wellbeing than those of mothers which may be due to differences in mothers versus fathers family involvement furthermore examining the links between racial discrimination and mothers and fathers family relationships has practical implications as family interventions may be more effective for african american families when sociocultural stressors are better understood grounded in research and theories of stress and gender the overarching goal of this study was to assess how racial discrimination experiences one type of contextual stressor influence the nature and quality of parentadolescent coparenting and marital relationships further to determine whether discriminationfamily relationship links were different for mothers and fathers we tested the moderating role of parent gender and we also examined parents gendered personality qualities specifically expressivity and instrumentality as potential moderators of the links between discrimination and family relationships the role of gender in stress responses our examination of differences between mothers and fathers reactions to discrimination is grounded in research on males and females responses to stress whereas males tend to exhibit an active problem focused fightorflight response in the face of stressors taylor and colleagues also proposed that females are more likely to display tendandbefriend responses that is women tend to lend and seek support in response to stressors empirical support for gender differences in stress responses comes from several studies aneshensel rutter and lachenbruch found that males were more likely to report active problemfocused responses to perceived stress whereas females reported more expressive emotional responses when they perceived more stress based on the work of neighbors and howard some empirical research has found that men were less inclined than women to seek social support in the face of psychological distress women tended to report better psychological adjustment than men in the face of reported stress which may be due to their inclinations to seek out social support specific to the current study in the context of discrimination african american adolescent boys exhibited more externalizing behaviors than girls in the face of this research however most of what we know about gendered responses to stressors has not yet been applied to african american families and no research has explored whether the stressor of racial discrimination is linked to mens and womens family relationships thus in developing our hypotheses we drew on studies of workfamily stress which document the processes through which stressful experiences at work affect the quality of family life and highlight gender differences in the links between work stressors and family relationships findings from two such studies revealed that on days when fathers reported higher stress at work they were more likely to engage in conflict or to withdraw from their families in contrast when mothers reported more work stress they engaged in more nurturing behaviors at home one reason for these differences may be the nature of family roles womens roles in the family may be more scripted and less influenced by outside experiences whereas mens roles are less scripted and therefore more susceptible to extrafamilial experiences although the role of raceethnicity in stress responses has not been a focus of substantial research affiliation in the presence of stress may be especially evident among racial ethnic groups for whom family and extended kinship networks are salient in stressful situations external resources may be scarce and family networks can provide emotional support and assistance for african americans indeed some research shows that african american women report greater use of informal support networks to cope with the stressor of discrimination as compared to women from other racial ethnic groups further findings from a study on the psychological impact of racial discrimination on african american men suggest that social support may play a role in buffering individuals from racismrelated stress however there is less empirical evidence about the circumstances that contribute to mens tendencies to seek support from family members given the salience of family relationships in some racial ethnic groups our primary goal was to understand whether and how mothers and fathers experiences of discrimination were associated with their family relationships knowledge of differences between african american mothers and fathers responses to discrimination has important implications for interventions that may reduce the negative effects of such stressors the role of gendertyped personality traits in responses to stressors gendertyped traits have been studied in terms of instrumentality a stereotypically masculine set of qualities including assertiveness and independence and expressivity a stereotypically feminine set of attributes including tendencies to display emotionality and affection although men are more instrumental and women are more expressive on average the relations between sex and gendered traits are not absolute there is variability in gendertyped characteristics within each sex thus it may be that biological sex reflects the gendered traits that may be responsible for observed differences in mens and womens responses to stressors for example tendencies to engage in conflict or withdrawal from family relationships may be an artifact of instrumental problemfocused attributes particularly in the case of a stressor such as racial discrimination which is beyond an individuals personal control attempts to manage stress using a problemfocused strategy may promote frustration which in turn spills over into conflict with or withdrawal from family members from another perspective individuals with more instrumental traits may be less inclined to seek support when faced with a stressor because this response may be incompatible with a tendency towards selfreliance or independence in contrast the tendency to affiliate with others in the face of a stressor may be a function of having more expressive traits in this study we tested whether gendertyped traits accounted for observed sex differences in stress responses research on gender and mental health suggests that individuals who are both highly expressive and instrumental may have the best mental health outcomes compared to individuals who are less expressive or instrumental in the context of relationships however an expressivity hypothesis suggests that being more expressive is a key factor in positive family relationship qualities given the potential implications of gendertyped attributes namely expressive traits for relationship qualities we were interested in whether and how mothers and fathers gendered attributes moderated associations between their discrimination experiences and relationship qualities the present study prior research has linked experiences of discrimination to individual wellbeing we extended this work by investigating the implications of discrimination for family relationships our first aim was to explore the associations between mothers and fathers reports of discrimination and their experiences of warmth and conflict in parentadolescent coparenting and marital relationships however we did not have specific expectations about the patterns of association between discrimination and relationship qualities for each type of family relationship the second aim of this study was to explore the role of gender in these associations first to assess the role of biological sex we tested the moderating effects of parent gender on discriminationfamily relationship links next to illuminate one basis for observed gender differences we tested whether gendered traits moderated racial discriminationfamily relationship linkages we tested three hypotheses consistent with research on biologically based sex differences in males and females stress responses our first hypothesis was that mothers would report more warmth in their relationships with family members but that fathers would report more conflict and less warmth in family relationships when they experienced more frequent racial discrimination to understand whether gendered traits were responsible for observed sex differences our second hypothesis was that mothers and fathers with more expressive traits would exhibit more warmth and less conflict in family relationships in the face of discrimination thirdly we hypothesized that mothers and fathers with more instrumental traits would report more conflict and less warmth in their relationships in the face of discrimination method participants the data came from mothers fathers and adolescents in 156 families that participated in the second phase of a threeyear longitudinal study of relationships in twoparent african american families given the goals of the larger investigation a study of family gender socialization we did not seek a representative sample rather we targeted families that selfidentified as black or african american and included a mother and father who were living together with at least two adolescent aged offspring recruitment took place in two urban centers in the northeast with substantial african american populations and we used two strategies to generate the sample first we hired african americans residing in targeted communities to recruit families by advertising in businesses churches and at community events approximately half of the sample was recruited in this way to recruit the rest of the sample we purchased a marketing list of names and addresses of families with offspring in grades 47 we sent letters describing the study and interested and eligible families called a toll free number or returned a postcard of the original 202 families participating in the larger study 11 mothers and fathers who were not african american were omitted 27 fathers refused to participate 6 families did not participate and 2 fathers were deployed in phase 2 of the study these families did not differ from the sample as a whole on any key variables of the 156 families in the present analyses mean ages of mothers and fathers were 4191 and 4459 respectively in terms of marital status 8462 of parents were married and all couples lived together for at least 4 years at the time of the interview mothers and fathers education was 1459 years and 1423 years respectively indicating on average parents had completed some college parents combined income was 8661490 which falls between the medians for twoearner families in the states from which data were collected together these figures are indicative of a largely working to middleclass sample most parents were employed with fathers working more hours per week on average than mothers the early adolescents in these families were on average 1143 years of age the majority of youth were biologically related to both parents and the sample was approximately equally divided by gender procedures mothers and fathers from each family were interviewed individually in their homes by a team of two interviewers almost all of whom were african american interviewers began by obtaining informed consent family members reported on relationship experiences individual characteristics and attitudes and individual wellbeing during the past year interviews generally lasted 2 hours following the completion of interviews families were sent a 200 honorarium measures racial discrimination experiences were assessed by the 11item experiences with discrimination scale developed by murry and colleagues mothers and fathers used a 4point rating scale to indicate how often they had experienced different types of discrimination during the past year cronbachs αs were 86 for mothers and 90 for fathers reported discrimination parentadolescent relationship warmth and conflict were assessed using two separate measures parents reported their warmth towards offspring using an eightitem 5point rating scale from the parent version of the childs report of parental behavior inventory cronbachs αs were 83 for fathers reports of warmth and 86 for mothers reports of warmth with adolescent offspring parents also reported the frequency of conflict with their offspring across 11 domains such as chores and social life on a 6point scale cronbachs αs were 87 for mothers and 89 for fathers reports of conflict with offspring marital satisfaction was measured using the couple relationship domains scale each parent rated satisfaction in eight domains such as household work decision making and communication on a 9point scale with responses ranging from 1 extremely dissatisfied to 9 extremely satisfied cronbachs αs were 89 for mothers and 93 for fathers marital conflict was assessed with a 5item subscale from the relationships questionnaire items such as how often do you feel angry or resentful toward your partner were rated on a 9point scale with responses ranging from 1 not at all to 9 very often cronbachs αs were 81 for mothers and 78 for fathers coparent cooperation and conflict were assessed with a measure developed by margolin gordis and john all items were rated on a 5point scale ranging from 1 not at all to 5 almost always the cooperation scale consisting of 5 items reflects the degree to which mothers and fathers support each other as parents cronbachs αs were 77 for mothers and 73 for fathers conflict specific to parenting matters was assessed with six items cronbachs αs were 81 for mothers and 79 for fathers gendertyped traits were assessed using the bem sex role inventory using a 7point scale mothers and fathers indicated how well a list of 20 instrumental stereotypically masculine adjectives and 20 expressive stereotypically feminine adjectives applied to their personalities cronbachs αs ranged from 80 to 87 background characteristicsfamily background characteristics reported by parents included family members ages genders education levels and parental employment status results means standard deviations and correlations for all variables are presented in table 1 these data suggest that family relationship quality was generally positive that is above the scales midpoints which is indicative of a wellfunctioning sample also of note expressivity and instrumentality had positive correlates for mothers and fathers suggesting that in general both types of gendered traits were related to positive relationship qualities in terms of discrimination experiences mothers and fathers ratings were well below the midpoint of the 4point rating scale indicating that on average parents had never to rarely experienced discrimination during the past year despite high correlations between coparenting and marital qualities a body of research documents that these are unique relationships in family systems therefore we retained all relationship measures in the following models in a preliminary step we examined motherfather differences in discrimination and in gendertyped traits using a series of repeated measures analyses of variance consistent with prior work fathers experienced discrimination more often than mothers f 2418 p 01 as expected mothers had more expressive traits than fathers f 6395 p 01 and fathers had more instrumental traits than mothers f 6873 p 01 parents experiences of discrimination and family relationship quality to address the nonindependence of the data we tested a series of multilevel models an mlm approach extends ordinary least squares regression by accounting for data clustering and allowed us to examine withinfamily differences in mothers and fathers experiences and family relationship outcomes for our first aim we explored the main effects of mothers and fathers discrimination experiences on warmth and conflict in parentadolescent coparenting and marital relationships our second aim was to test the moderating roles of gender and gendertyped traits in these links we tested three hypotheses in separate models to determine whether there was a difference between mothers and fathers in the links between discrimination and family relationship qualities we first tested the interaction between parent gender and discrimination to determine whether gendertyped traits moderated these interactions we tested parents expressive and instrumental attributes as moderators of discriminationrelationship quality links to control for the potential effects of unmeasured stressors and because prior work has evidenced a link between discrimination and socioeconomic status family income was included as a control variable we also tested for effects of fathers biological relatedness to offspring but this variable proved nonsignificant so is not included in the models given our directional hypotheses we interpreted hypothesized interactions using a 1tailed statistical test discrimination was positively related to four dimensions of family relationships consistent with our expectations discrimination predicted parentadolescent conflict β 17 se 08 t 209 p 05 d 34 coparenting conflict β 21 se 07 t 284 p 01 d 46 and marital conflict β 48 se 15 t 321 p 01 d 53 inconsistent with the idea that discrimination is related to negative relationship qualities findings revealed a positive link to parentadolescent warmth β 12 se 06 t 222 p 05 d 37 the moderating role of parent gender to test the first hypothesis that parent gender would moderate discrimination family relationship linkages parent gender was dummy coded three discrimination × parent gender interactions were significant for parentadolescent warmth β 22 se 10 t 199 p 05 coparenting cooperation β 32 se 15 t 209 p 05 and marital satisfaction β 65 se 31 t 208 p 05 we followed up these interactions by testing separate models for mothers and fathers followups revealed that for fathers β 23 se 07 t 308 p 01 d 50 but not mothers β 01 se 09 t 06 ns experiences of discrimination were related to more warmth with adolescents followups also showed that for mothers β 30 se 14 t 215 p 05 d 35 but not fathers β 04 se 09 t 42 ns discrimination was positively related to coparenting cooperation in the case of marital satisfaction followups revealed that the discriminationmarital satisfaction link was positive for mothers and negative for fathers but neither coefficient was significant β 26 se 29 t 90 ns and β 32 se 21 t 155 ns respectively the moderating role of gendertyped personality traits we next examined the moderating role of gendertyped personality traits in the links between discrimination and family relationship quality to followup interactions we used procedures outlined by aiken and west specifically we performed a tertile split to distinguish high versus low levels of the moderator in each model beginning with hypothesis two that expressivity would moderate discriminationrelationship quality links for mothers and fathers analyses revealed no evidence of threeway interactions so these terms were dropped three significant twoway interactions between expressivity and discrimination emerged in terms of parentadolescent conflict for parents with lower expressivity the link between discrimination and parentadolescent conflict was positive β 27 se 11 t 253 p 01 d 41 but the effect was nonsignificant for highly expressive parents β 01 se 06 t 18 ns also as expected for parents who were high in expressivity the link between discrimination and coparent cooperation was positive β 39 se 09 t 413 p 01 d 67 but nonsignificant for low expressivity parents β 02 se 10 t 19 ns also as hypothesized for parents low in expressivity the link between discrimination and marital satisfaction was negative at trend level β 35 se 21 t 168 p 10 d 28 but nonsignificant for parents high in expressivity β 28 se 19 t 144 ns we next tested hypothesis three to assess the moderating role of instrumentality analyses revealed three significant threeway interactions and two trendlevel interactions between instrumental traits experiences of discrimination and parent gender in a first step we followedup the threeway interactions by testing each discrimination × instrumentality interaction separately for mothers and fathers these analyses revealed that instrumentality moderated the effects of discrimination experiences for fathers only in the case of marital conflict interactions between discrimination and instrumentality were not significant for mothers β 16 se 34 t 46 ns or for fathers β 34 se 29 t 116 ns so we did not perform further followup for this analysis followups showed that for fathers who were more instrumental the link between discrimination experiences and fatheradolescent conflict was positive β 25 se 12 t 209 p 05 d 38 this effect was nonsignificant for low instrumental fathers β 22 se 23 t 99 ns in the absence of discrimination however having more instrumental qualities was related to less conflict in the case of fatheradolescent warmth an interaction between discrimination and instrumentality reached trend level so given our directional hypothesis we conducted a followup test this showed that for less instrumental fathers the link between discrimination and fatheradolescent warmth was positive β 47 se 15 t 318 p 01 d 51 but nonsignificant for more instrumental fathers β 14 se 08 t 129 ns as with fatheradolescent conflict in the absence of discrimination experiences more instrumental fathers had warmer adolescent relationships followups revealed similar patterns for fathers marital relationships for fathers who were less instrumental the link between discrimination and coparenting cooperation was positive β 36 se 18 t 201 p 05 d 33 but this effect was not significant for more instrumental fathers β 07 se 10 t 75 ns for fathers who never experienced discrimination however more instrumental fathers had greater coparenting cooperation for more instrumental fathers the link between discrimination and marital satisfaction was negative β 55 se 22 t 247 p 01 d 40 but nonsignificant for less instrumental fathers β 28 se 42 t 67 ns in the absence of discrimination more instrumental fathers had greater marital satisfaction in sum these findings suggest that instrumentality may be protective under nonstressful circumstances but detrimental for mens relationships when they experience stressful events exploring alternative hypotheses given the literature on androgyny and individual wellbeing we conducted analyses to explore whether androgyny played a role in the links between mothers and fathers discrimination experiences and family relationships toward this end we tested whether androgyny moderated discriminationfamily relationship links consistent with the idea that androgyny is linked to positive wellbeing analyses revealed a positive relationship between androgyny and parental warmth β 13 se 05 t 245 p 05 d 39 however we found no evidence that androgyny moderated discriminationrelationship linkages discussion a body of work has established that individuals who experience racial discrimination are at risk for poorer psychological wellbeing the present study built on this literature by examining whether racial discrimination was linked to family relationship qualities of african american mothers and fathers and whether sex or gendertyped traits moderated these links although discrimination occurred at a low frequency for the sample as a whole results were consistent with our expectations fathers reported more frequent discrimination experiences than mothers and discrimination was associated with qualities of parentadolescent coparent and marital relationships differences between mothers and fathers were evident in some discriminationrelationship quality links however these differences were qualified by parents expressive and fathers instrumental traits specifically gendertyped traits moderated the links between discrimination experiences and family relationship qualities for both parents such that more expressive mothers and fathers generally reported more positive family relationships in the context of discrimination in addition more instrumental fathers reported more negative family relationships in the face of discrimination although instrumentality was associated with positive family relationships for fathers who did not report discrimination taken together our findings imply that there may be more variability for fathers than mothers in the ways that discrimination experiences are associated with their family relationships at the most general level our findings that discrimination was linked to family relationships in a sample of middleclass wellfunctioning african american couples who reported low rates of discrimination attest to the significance of discrimination as a sociocultural stressor for african american families in the following pages we expand upon these conclusions highlighting the differences between mothers and fathers in discriminationfamily relationship associations and the distinct patterns of linkages between discrimination and dimensions of family relationships results related to our first hypothesis were somewhat consistent with our expectations about sex differences in stress responses the positive association between mothers discrimination experiences and coparent cooperation suggests that mothers may perceive more family support in the face of a stressor but this is the only tendandbefriend response that emerged for mothers in general there were fewer links between discrimination and mothers as compared to fathers family relationship qualities consistent with the idea that mothers relationships in the family may be more scripted than fathers it is possible that their extrafamilial experiences are less likely to come into play in their family relationships in contrast fathers family experiences may be more variable and links between contextual stressors and family relationships more evident for fathers results were generally consistent with our expectation that discrimination would have negative implications for their relationships but also revealed that discrimination was positively related to fatheradolescent warmth this pattern suggests that when fathers experience discrimination they may exhibit more affection and support that is tendandbefriend in relationships with their offspring this is consistent with the racial socialization literature which finds that fathers are key socializers of discrimination in african american families and parents who experience discrimination are more likely to prepare offspring for racial biases compared to parents who do not encounter discrimination importantly these experiences may foster closer bonds between fathers and youth future work may reveal if this type of response is specific to african american fathers discrimination experiences in line with our second hypothesis expressivity moderated discriminationparentadolescent conflict moreover when expressive traits were accounted for differences between mothers and fathers in links between discrimination and coparent cooperation and marital satisfaction became nonsignificant this finding highlights the idea that sex alone may not explain the association between discrimination experiences and relationship qualities consistent with the expressivity hypothesis in the face of discrimination parents with more expressive traits reported more positive relationship qualities whereas parents with fewer expressive traits reported fewer positive family relationship qualities these findings draw attention to the potential protective function of expressivity for womens and mens family relationships in the face of discrimination findings related to expressivity also have implications for family interventions in that mothers and fathers who draw on expressive behaviors in the face of a sociocultural stressor may experience more positive family relationships when stereotypically masculine instrumental traits were examined as moderators links between discrimination and family relationships emerged for fathers only results supported our third hypothesis that in the face of discrimination fathers with fewer instrumental traits reported more positive qualities in parent and coparent relationships whereas those who were more instrumental had poorer family relationships importantly for men who never experienced discrimination being more instrumental was related to more positive relationship qualities suggesting that effects of instrumentality may differ by context for men instrumental traits which include attributes such as selfreliant aggressive and defends beliefs may characterize men with problemfocused approaches to handling stressors despite the fact that discrimination is a type of stressor that is usually beyond the individuals control thus fathers with more of these characteristics may engage in strategies aimed at eliminating discrimination only to face increased frustration and negative arousal that spills over into interactions with their family members another possibility is that more instrumental fathers depend less on informal support networks when faced with discrimination in contrast less instrumental fathers may not resort to fighting discrimination instrumentality was not a factor in the links between mothers discrimination experiences and family relationship quality for mothers who were less instrumental than fathers on average and who have more scripted family roles these types of traits do not appear to have implications for family relationships in the face of discrimination these findings may be useful to practitioners in drawing attention to the susceptibility of fathers relationships and highlighting the utility of tailoring interventions to individual characteristics overall our findings revealed that the negative effects of discrimination were most consistent for conflict in couple relationships there was no evidence that sex differences or gendered traits moderated associations between discrimination and either coparent or marital conflict it is important to note that levels of couple conflict in this sample were low thus variability in coparent and marital conflict was limited which may explain why moderators did not emerge for these links alternatively it may be that the stress of discrimination experiences spills over into interactions between parents and the nature of parents gendered traits are less effective buffers for marital relationships in contrast the implications of discrimination for positive family relationships and for parentyouth relationships in general were more complex results differed for mothers versus fathers and also depended on parents gendered qualities like prior research that has found links between reports of discrimination and selfreported mental health problems a limitation of the present study was the reliance on selfreports furthermore our correlational design did not allow for inferences of causality examining these links longitudinally rather than crosssectionally would provide insight into the sequence of events and could prove useful in ruling out some alternative explanations for the findings it is also of note that 21 of fathers were not biologically related to youth though all parents lived together for 16 years on average finally our small convenience sample of twoparent families limits the generalizability of our results despite these limitations the present study extends existing research in several important ways first much of the literature on african american families focuses on mothers our findings not only highlight african american fathers family experiences but also draw attention to differences between mothers and fathers family roles and relationships when they experience racial discrimination in addition whereas prior research on gender and stress has focused on biological sex differences this study examined differences between mothers and fathers in addition to withinsex variability to shed light on the implications of gendertyped attributes for links between discrimination and family relationship quality overall the pattern of results suggests that for mothers and fathers expressivity is important for positive family interactions and for fathers having high levels of instrumentality may be detrimental for family relationships in the face of a significant stressor for african american individuals in the us racial discrimination

mothers and fathers in 156 african american families reported on racial discrimination experiences gendered traits and warmth and conflict in family relationships discrimination was linked with relationship quality but links differed for mothers and fathers more expressive parents and less instrumental fathers had more positive relationships in the face of discrimination but for more instrumental fathers discriminationrelationship quality links were negative findings imply consideration of sociocultural and individual characteristics for family relationships

peers in england the socioeconomic attainment gap is evident at age 5 and increases as students progress through the compulsory education system when students are 16 years old it has been estimated that it would take two and a half years of additional schooling to bring the academic performance of economically disadvantaged students up to the same level as their wealthier peers these inequalities are not explained solely by differences in academic ability or by the structural and economic inequalities that exist between these groups indeed metaanalyses have suggested that a substantial proportion of the variation in attainment between groups can be attributed to social psychological differences between them in this article we investigate the role of identity compatibilitythe perception that ones social identities or background are compatible with the stereotypes associated with academic achievement in explaining socioeconomic inequalities in results from national exams taken at age 16 in england we draw on the identities in context model of educational inequalities to predict that identity compatibility will help to explain the socioeconomic attainment gap but also that the association between lower socioeconomic status and identity compatibility will vary across schools in such a way that it will be more strongly negative in schools with larger preexisting socioeconomic attainment gaps we elaborate on these predictions and the background research that led to them below identity incompatibility within education identity compatibility refers to the perception of compatibility or conflict between ones social identities or social background and the stereotype of a successful student given the large existing socioeconomic attainment gap in the uk and the overrepresentation of individuals from higher socioeconomic status backgrounds in positions associated with educational attainment and prestige the stereotypes of academic achievers and those of individuals with high ses are likely to heavily overlap and thus be perceived as highly compatible in contrast students from groups that have been historically marginalized in educationsuch as students from lower socioeconomic groups or from certain ethnic minoritiesare likely to have few if any role models in positions associated with educational achievement and thus may perceive educational success as incompatible and at odds with their groups social identity identity compatibility has been shown to be associated negatively with feelings of isolation and alienation within educational institutions and positively with academic aspirations and performance we therefore expect that lowersocioeconomic students will perceive that their social identities are incompatible with the stereotype of high academic achievers and that this will contribute to the socioeconomic attainment gap in english schools research focusing on gender has shown the importance of identity compatibility in explaining gender inequalities in stem subjects reflecting womens historical underrepresentation in stem fields and the masculine stereotypes associated with stem women tend to perceive lower levels of compatibility between their gender identity and the stereotypes about successful stem students than men do lower levels of identity compatibility in stem are associated with reduced belonging confidence motivation and performance in stem fields and thus contribute to genderbased inequalities in stem outcomes there is evidence that identity compatibility is also associated strongly with ses although this body of research focuses exclusively on higher education university students from lower ses backgrounds have been found to perceive less identity compatibility between their backgrounds and the stereotype of a university student and this in turn predicts lower levels of identification with the university less positive affect greater levels of depressive symptoms over time less social integration and poorer academic performance other evidence has shown that even while controlling for academic grades students in the uk from lower socioeconomic positions were more likely to plan to apply to lower ranking universities and that this association was partly explained by a lower sense of compatibility between their social background and being a university student identity compatibility therefore helps to explain ses inequalities in educational outcomes among university students in this article we extend the concept of identity compatibility to refer to the perceived fit between ones socioeconomic background and the stereotype of someone who does well at school we argue that the social identities of those from lower ses backgrounds are unlikely to incorporate academic success or academic possible selves that the stereotypically highachieving student is considered to be of higher ses and thus that lower ses students will perceive less compatibility between their social backgrounds and the stereotypes of high achieving students students from lower ses backgrounds have on average lower performance in national exams lower rates of progression to higher education and are underrepresented in positions associated with educational attainment these sociocultural factors contribute to the stereotype that high academic achievers are from high ses backgrounds and feed into those groups social identities indeed there is evidence that ses is associated strongly and positively with stereotypes of competence and that there are descriptive and prescriptive stereotypes that link lower ses with academic incompetence among adults and children those of lower ses also experience discrimination stigma and threat within educational institutions which tend to be associated with belonging to a group that is expected to perform poorly it is likely therefore that low ses students will be stereotyped as academically less competent and that current or potential educational success will not be a meaningful part of the social identity of students from low ses backgrounds to our knowledge the only study relevant to the investigation of identity compatibility among a sample of school students is an intervention study conducted in the united states examining academic possible selves research into academic possible selves has demonstrated that students from lower ses families have fewer academic possible selves and fewer behavioural strategies to achieve those that they do possess the intervention sought to encourage lowincome us middleschool students to see their social identities as compatible with the possible future identity of someone who successfully completed the academic year this was found to improve students academic performance suggesting that compatibility between ones social identities and the stereotype of a successful student is positively related to academic outcomes among school students building on the above research we expect that identity compatibility will be lower among students from lower socioeconomic backgrounds and that this will be negatively associated with their academic performance the school context the identities in context model of educational inequalities details various sociocultural factors that if present in the local context and relevant to a particular group are likely to contribute to a sense of threat or the perception of identity incompatibility among members of that group the sociocultural factors outlined by the model are negative stereotypes about the groups performance their historical performance the presence and availability of role models the groups numerical representation in positions and institutions associated with educational attainment and their orientation towards education including cultural capital norms and values if one or more of these factors is present for a particular group then that group is likely to experience a sense of threat and perceive identity incompatibility and thus social psychological factors are likely to dampen that groups educational success and ambitions here we focus on one of these sociocultural factorsthe groups historical performance we empirically test predictions derived from the identities in context model which suggest that historical performance of ses groups will moderate the association between students socioeconomic background and their identity compatibility sociocultural variables such as a groups relative performance can signal the value or status of that group within the relevant context and so contribute to the content and meaning of their social identities within a school a large socioeconomic attainment gap is likely to act as a signal indicating that students from lower socioeconomic groups are not expected to do well in education and that educational success is something that members of low ses groups are unlikely to achieve this may mean that members of low ses groups develop few if any academic possible selves and will fuel perceptions of identity incompatibility among low ses students according to this theorizing the socioeconomic attainment gap alters the meaning of groups social identities and so should only moderate the association between group membership and identity compatibility we do not expect it to moderate the direct association between group membership and attainment nor the association between identity compatibility and attainment which we expect to be stable across contexts although our prediction that the school context will moderate the association of socioeconomic position with identity compatibility has never been directly investigated some results suggest it has merit firstly there is evidence that promoting the visibility of highperforming members of poorly performing groups can boost the belonging compatibility and performance of members of those groups this implies that group members do indeed perceive and react to visible indicators of their groups academic performance secondly two papers suggest that the size of attainment gaps can moderate the association between group membership and social psychological variables related to social identities a metaanalysis found that the average effect size of interventions designed to reduce the effects of stereotype threat on womens maths performance is smaller in contexts that have smaller genderbased attainment gaps in mathematics and an intervention study found that selfaffirmationan intervention designed to reduce the negative effects of stereotype threat on attainment was most effective at raising the attainment of african american and latino students in schools that had larger preexisting ethnic attainment gaps and a smaller proportion of ethnic minority students these results presumably arise because in contexts with smaller attainment gaps the lower status group members are less threatened and perceived their social identities as more compatible with academic success this leaves less scope for social psychological interventions that target social identity processes to improve academic performance no studies have investigated such moderation among ses groups yet the socioeconomic attainment gap is heterogeneous across regions and schools and is we argue likely to feed into the stereotypes and social identities of students from lowerand highersocioeconomic groups in the local context fuelling their perceptions of identity compatibility we expect therefore that in schools with larger socioeconomic attainment gaps low ses students will have lower levels of identity compatibility and in turn poorer academic performance in contrast in schools with small or nonexistent socioeconomic attainment gaps low ses students will have similar levels of identity compatibility to higher ses students with correspondingly smaller differences in attainment the current study we report results from a study conducted in 29 english secondary schools with 1516yearold school students students completed selfreport questionnaires that contained measures of identity compatibility in september at the beginning of the academic year these were later matched with students demographic characteristics and their results from national standardized exams taken in may at the end of the same academic year we also collated government data on the socioeconomic attainment gap in the previous year for all schools and used this in our multilevel models to directly test our hypothesis that the preexisting schoollevel socioeconomic attainment gap will moderate the association between seswhich we measure using the proxy variable eligibility for free school meals and identity compatibility our prediction is specific to the fsmidentity compatibility association although for completeness we also investigate whether the schoollevel socioeconomic attainment gap moderates the fsm to exam results association and the identity compatibility to exam results association we expect that it will not moderate these associations we aim to test the unique role of identity compatibility in explaining the socioeconomic attainment gap and of the fsm attainment gap variable in moderating the fsmidentity compatibility slope to test the specificity of these predictions we also include in our models two other psychological variables that have been found to robustly and strongly predict academic attainment namely academic selfconcept and academic effort this allows us to examine the unique and additional predictive utility of identity compatibility while accounting for these wellvalidated variables we expect that identity compatibility will mediate the association between fsm and exam results whereas academic selfconcept and academic effort will not do so in addition we expect that the association of fsm with identity compatibility will be moderated by the schoollevel socioeconomic attainment gap whereas the associations of fsm with academic selfconcept and academic effort will not be moderated by this variable we thus test whether academic selfconcept and academic effort mediate the association between fsm and exam results expecting that they will not and whether the associations of fsm with academic selfconcept and selfreported effort are moderated by the schoollevel socioeconomic attainment gap again expecting that they will not be we also include gender and whether english was an additional language which are often associated with attainment in our models and explore whether the psychological variables mediate any attainment gaps between these groups the study was part of a larger randomized control trial evaluating the impact of a psychological intervention the survey was conducted before any aspect of the intervention was implemented however and so was not confounded by the condition that students were allocated to we test the following hypotheses which are also represented in figure 1 hypothesis 1 eligibility for fsm will be associated negatively with students exam grades hypothesis 2 identity compatibility will be associated positively with students exam grades hypothesis 3 eligibility for fsm will be associated negatively with identity compatibility hypothesis 4 there will be a significant negative indirect effect from fsm eligibility to exam grades via identity compatibility hypothesis 5 the relationship at the individuallevel of analysis between fsm eligibility and identity compatibility will be moderated by the schoollevel variable socioeconomic attainment gap such that the association will be more strongly negative in schools with larger socioeconomic attainment gaps method procedure twentynine schools participated in this study 1 we planned for all year 11 students in the 29 participating schools to complete a survey in personal tutor time in the first 2 weeks of the academic year in the event 27 schools returned the completed surveys most schools were recruited through brief recruitment presentations given at conferences for headteachers whereas a minority were recruited through the researchers existing contacts if headteachers expressed an interest in taking part we sent them a memorandum of understanding and a consent form which they were required to sign in order for their school to take part in the study we sent information sheets and optout consent forms to the parentsguardians of all students in year 11 allowing at least 2 weeks for them to be returned schools were given a £1000 honorarium for taking part we recruited 30 schools although one school dropped out before the study began leaving 29 all year 11 students in the schools took part unless they opted out or were absent from their tutorial time for 4 weeks the study received ethical approval from all the relevant institutional ethics boards and adhered to all relevant ethical guidelines measures the following measures that are directly relevant to our hypotheses were included in a larger questionnaire relevant to the intervention see table s3 in the supporting information for a correlation matrix for all variables student characteristics and academic attainment schools provided us with unique student numbers for all participating students as well as whether students had english as an additional language we used the upns to retrieve data from the national pupil database including whether students were eligible for fsm at any point in the last 6 years gender and attainment data our primary outcome variable was students attainment 8 scores which are the average grade across eight subjects in their general certificate of secondary education assessments with double weighting for english and mathematics we had attainment 8 data for n 5079 students we controlled for students prior grades by including the mean of their total score in the standardized attainment tests for key stage 2 english and for ks2 mathematics taken at age 1011 labelled ks2 score we had ks2 mathematics scores for n 5046 students and ks2 english scores for n 4999 students identity compatibility we adapted measures of identity compatibility used in previous research to create a threeitem measure of identity compatibility we provided the following definition of social background before the items the next questions are about you and your social background by social background we mean people who are from the same social class or community as you who live in the same types of places as you and who do similar things as you and whose family has similar amounts of money and do similar sorts of things as yours the items were working hard at school fits with my social background my background is compatible with someone who does well in school and people with my social background usually get good grades at school responses were made on a 7point response scale with the anchors strongly disagree neither agree nor disagree and strongly agree we took the mean of the three items as our measure of identity compatibility the scale had good internal reliability academic effort and academic selfconcept we measured academic effort using the mean of slightly adapted versions of the four items from the student approaches to learning questionnaire and measured academic selfconcept using the mean of the three items from the same questionnaire an example academic effort item is i work as hard as possible an example academic selfconcept item is im good at most school subjects responses were given on a 7point scale from strongly disagree to strongly agree both academic effort and academic selfconcept had good internal reliability socioeconomic attainment gap to test our hypothesis regarding school context we collated data from the uk governments website regarding the percentage of disadvantaged and nondisadvantaged 1516yearold students in each school who were awarded a to c grades inclusive for english mathematics and at least three other subjects in the gcse exams taken in may and june 2016 the percentage of students at a school achieving a to c grades is typically used by the uk government as its criterion for good academic attainment we computed the gap between disadvantaged and nondisadvantaged students for each school by subtracting the percentage of disadvantaged students who achieved a to c grades from the percentage of nondisadvantaged students who achieved these grades this is therefore a schoollevel variable that we include in our models below as a schoollevel predictor and in crosslevel interactions results we first conducted confirmatory factor analysis on the three selfreport measures which suggested they had good construct validity full results are reported in the supplementary information we then tested our hypotheses and accounted for the clustering of students within schools by conducting multilevel regressions in mplus version 8 we used maximum likelihood estimation with robust standard errors which uses all available data and estimates standard errors that are robust against violations of the assumptions of linear models all the continuous variables were standardized except the schoollevel socioeconomic attainment gap variable which was grandmean centred we first specified a model that regressed attainment 8 scores on the individuallevel variables fsm female eal and ks2 score the results showed that all the predictor variables were associated significantly with attainment 8 scores confirming h1 students eligible for fsm had lower attainment 8 scores than students not eligible for fsm in addition females had higher attainment 8 scores than males students for whom english was an additional language had higher scores than students for whom english was not an additional language and ks2 score was associated positively and strongly with attainment 8 score next in model 2 we added the individuallevel variables identity compatibility academic effort and academic selfconcept to the model as fixed effects and investigated whether there were indirect effects from the student characteristics to attainment 8 via these psychological variables confirming hypotheses 24 fsm negatively predicted identity compatibility identity compatibility positively predicted attainment 8 scores and there was a significant and negative indirect effect from fsm to attainment 8 via identity compatibility identity compatibility was significantly associated with attainment 8 over and above student characteristics and the other psychological variables and was the only psychological variable to be associated significantly with fsm in addition eal positively predicted identity compatibility eal and female positively predicted academic effort eal positively predicted academic selfconcept and female negatively predicted academic selfconcept academic effort and academic selfconcept also predicted attainment 8 scores we also observed significant indirect effects from eal to attainment 8 via identity compatibility and academic selfconcept and from female to attainment 8 via academic effort and via academic selfconcept across the next few models we allowed the fsmidentity compatibility fsmacademic effort fsmacademic selfconcept fsmattainment 8 and identity compatibilityattainment 8 slopes to vary across schools to maximize power we specified one random slope per model all the slopes varied significantly across schools 2 we then added ses attainment gap as a betweenlevel predictor and as a moderator of the random slope in a crosslevel interaction in each of the models ses attainment gap did not predict attainment 8 nor did it moderate the fsmacademic effort slope the fsmacademic selfconcept slope the fsmattainment 8 slope or the identity compatibilityattainment 8 slope ses attainment gap did however moderate the fsmidentity compatibility slope confirming hypothesis 5 as shown in figure 2 the association between fsm and identity compatibility was negative in schools with a large ses attainment gap but was virtually zero in schools with a small ses attainment gap general discussion we report the first empirical evidence that the socioeconomic gap in academic attainment is partially explained by lower levels of identity compatibility among low ses students previous research has found that identity compatibility helps to explain the relationship between college students ses and the ranking of the university they plan to apply to and between university students ses and their identification with university wellbeing and academic performance we extend this body of work by applying the concept of identity compatibility to school students we found that perceptions of identity compatibility among 1516yearold school students in england positively predicted their performance in highstake national exams that were taken 8 months after the measurement of identity compatibility and that it did so over and above students gender english language status academic effort academic selfconcept and prior exam results it is noteworthy that the only psychological variable that was associated with fsm was identity compatibility showing the importance of identity compatibility in explaining the socioeconomic attainment gap our results demonstrate that identity compatibility is an important social perception that predicts hard academic outcomes among school students and contributes to the socioeconomic attainment gap it is important to note however that we also found that the association between fsm and identity compatibility was moderated by school context the results showed that fsm students reported lower levels of identity compatibility than their peers but only when they attended schools that had relatively large socioeconomic attainment gaps in the previous academic year in schools with small or nonexistent socioeconomic attainment gaps there was no association between fsm and identity compatibility interestingly while the other associations in our model varied across schools it was only the fsmidentity compatibility slope that was moderated by the size of the socioeconomic attainment gap these results provide support for the identities in context model of educational inequalities which attempts to describe the features of the local educational contextwhich include a groups historical performancethat moderate the association between students group memberships and their experience of threat and perception of identity compatibility the model stipulates that sociocultural factors in the local school context can change the meaning of students social identities and thus their subjective experience of school with indirect effects on their performance via identity compatibility and threat it follows that only social psychological variables that incorporate some aspect of students social identities should be moderated by the sociocultural variables outlined by the model as indeed we found although this study was primarily testing theoretical predictions it is worth considering the practical implications for interventions our results suggest that interventions that can reduce identity incompatibilitysuch as interventions that develop academic possible selves andor raise the visibility of ingroup role models may reduce the socioeconomic attainment gap in english schools however these are likely to be effective only in schools that have historically large socioeconomic attainment gaps to avoid wasting resources interventionists should therefore gain a deep understanding of the local social context before they intervene as well as a groups historical performance the identities in context model stipulates that negative stereotypes the visibility of academically successful role models representation in positions and institutions associated with academic success and a groups cultural orientation towards education can all moderate the association between students group membership and their sense of threat and perception of identity compatibility these sociocultural factors should therefore help to explain any observed heterogeneity in the associations between students group memberships and a sense of threat and identity compatibility across contexts indeed the model and this initial test of its predictions can be seen as efforts to incorporate and quantify the role of the local educational context in educational inequalities and were in part inspired by the context sensitivity of wise psychological intervention effects and the predicted heterogeneity revolution in behavioural science from this perspective heterogeneity of effects is not a failure of psychological science as the replication crisis often frames it but an opportunity for developing theories and studies that account for contextual moderators of effects the identities in context model and the analyses we report here are attempts to seize this opportunity besides the findings related to our theoretical predictions we also found evidence for a gender attainment gap in which girls outperformed boys which was partly accounted for by greater selfreported effort among girls however we also found a negative indirect effect of being a girl on attainment 8 scores via lower levels of academic selfconcept contrary to previous research that has found that gender inequalities in subject specific academic selfconcepts tend to map onto gender inequalities in attainment we also found that eal students outperformed noneal students in attainment 8 scores in line with the latest national figures and this was in part accounted for by higher levels of identity compatibility and academic selfconcept among eal students strengths and limitations there are several noteworthy strengths of the current research we utilized a large sample of students across 29 schools and analysed the english governments preferred measure of academic attainment attainment 8 scores we also controlled for students gender eal academic effort academic selfconcept and crucially prior academic performance within our models allowing us to demonstrate that identity compatibility is uniquely associated with academic ability over and above these other variables the survey measures were collected some 8 months before the exams that comprised our outcome measures implying that the effects associated with students identity compatibility persist at least over the course of one full academic year there were also some limitations of our research designs that could be improved in future research our results are based on correlational data and so do not allow us to draw conclusions about causality however the fact that identity compatibility was measured before the exams that our outcome measures were based onby 8 monthsdoes confirm the directionality of the relationships if not their causal nature we also could not include ethnicity in our models and so can make no conclusions about whether identity compatibility plays a role in ethnic attainment gaps this is an important gap in our knowledge that should be addressed in future research conclusion in summary our results demonstrate the importance of social perceptions in explaining educational inequalities and of understanding the role of the local educational context in determining which groups if any may be experiencing psychological barriers to their educational success students who are members of groups which have historically underperformed may be at a psychological disadvantage because of social cues in the local context that are perceived as indicating that their social identity is incompatible with academic success our work suggests that treating academic success as something everyone can achieve may help to make educational opportunities less unequal data availability statement the data that support the findings of this study are available on request from the corresponding author the data are not publicly available due to privacy or ethical restrictions conflicts of interest all authors declare no conflict of interest author contribution supporting information the following supporting information may be found in the online edition of the article

background school students who are eligible for reduced or free school meals fsm an indicator of economic disadvantagehave lower academic attainment than their peers aims we investigated whether identity compatibilitythe perceived compatibility between ones social identities and the stereotype of a highachieving studentcontributes to this socioeconomic attainment gap and whether the association between socioeconomic status and identity compatibility is moderated by school context sample our sample was 4629 students aged 1516 years old across 29 schools in england method we assessed students perceptions of identity compatibility via selfreport questionnaires 8 months prior to them taking national standardized exams results multilevel regression analyses revealed a negative indirect effect from eligibility for fsm to exam results via identity compatibility these effects existed even while accounting for students gender and language status other psychological variables known to predict academic attainment and their previous exam results furthermore school context moderated the relationship between fsm eligibility and identity compatibility in line with the identities in context model of educational inequalities there was a significant negative association between fsm and identity compatibility only for students attending schools in which there was previously a relatively large socioeconomic attainment gapour results demonstrate the importance of social psychological variables in explaining educational inequalities and of the local educational context in determining the educational experience of students from lower socioeconomic status backgrounds in many western countries students from families of lower socioeconomic status attain lower grades in national exams have lower progression rates to higher education and consequently have less economically prosperous life trajectories than their wealthier this is an open access article under the terms of the creative commons attribution license which permits use distribution and reproduction in any medium provided the original work is properly cited

introduction the overturning of roe v wade which caused intense controversy around the world took place on june 24 2022 which meant that american womens right to abortion was no longer protected by the us constitution therefore there were many fierce protests in the us the real reason for the decision made by the supreme court of the united states is that the united states needs more population to promote social development under the background of population aging and declining fertility rate the reason for the protests is that this decision infringes on human rights it seems that womens choice between abortion and nonabortion is limited the fact is that removing the constitutional protection of a womans right to abortion is tantamount to a direct violation of a womans human rights and that when a child is born at an unanticipated time such a childs right to education is also affected the overturning of roe v wade is actually part of the decision of countries around the world to increase fertility however this study finds that restricting womens reproductive freedom not only violates womens human rights but also ignores childrens human rights from the perspective of jurisprudence at the same time it will have a bad effect on the whole society research shows that the social impact of such decisions is not only detrimental to the realization of partial human rights but also detrimental to national development which is contrary to the original purpose of the state to promote national development the decision to raise fertility rates in many countries has become a hot topic in peoples lives this study fills the gap in the research on the adverse effects of restricting womens reproductive freedom on society and at the same time studies the new human rights violations in modern society in this paper comparative method is adopted to study and compare the fertility policies of some countries to promote fertility in order to solve the social and legal issues related to population fertility 2 jurisprudential perspective restricting womens reproductive freedom is a violation of womens human rights reproductive right is a basic human right people have the right to choose and the outside world has no right to interfere with it but now some decisions made in modern society to promote the use of fertility rate violate womens human rights taking the overturning of roe v wade case as an example restricting womens reproductive freedom will not bring the desired result to human society this study shows that the restriction of female reproductive freedom will only bring social regression the fundamental purpose of restriction of female reproductive freedom is to increase fertility ratenevertheless almost all of them ended up in failure even though these decisions may lead to a recovery of fertility rate in some countries in the short term the downward trend will not change 1 the world fertility level is still declining and the fertility transformation continues this trend is inevitable whether it is ongoing in africa asia latin america or in europe and north america where the fertility transition has been completed 12 in order to recover the fertility rate measures must be taken by countries at the beginning it is to gently encourage people to have children although the policies introduced by different countries seem to be different the actual means and purpose are the samegiving better treatment to people willing to have children to achieve the purpose of increasing the fertility rate for example the uk uses its annual budget to reduce the burden of raising children and provide childcare allowance nordic countries provide public childcare while reducing the cost of raising children they also actively match the commuting time of parents in opening hours give both husband and wife childcare leave and high allowance prevent the employment discrimination of employers on the gender of employees and increase the female work participation rate this contributes to fertility such policies have a positive impact on fertility promotion while japan and south korea are also facing the aging population and low fertility rate but the fertility rate continued falling under these too shortsighted policy which ended in failurehowever in the increasingly serious aging social background the effect of such policy still cannot achieve the expected results of the society leading to the transformation of some policies from encouraging birth to forcing birth and the overturning of the roe v wade case can reflect such a transformation from gentle urging to hard forcing forcing women to have children in order to achieve the purpose of increasing fertility rate is not only a restriction on womens reproductive choices but also a violation of womens human rights through the comparison of policies to increase the fertility rate it can be seen that the overturning of roe v wade in the united states is a coercive means to violate human rights similarly the birth encouragement policies in south korea and japan are influenced by family values and work ethics in confucian culture and their deeprooted awareness of gender division of labor as a result japan and south korea have introduced a large number of policies and supporting measures to promote fertility but these policies are in essence more inclined to encourage women to return to the family women have to make sacrifices for the family womens personal value is to contribute to the family women have to bear children women have to raise children women have to take care of the family and the united nations programme of action of the 1994 international conference on population and development mentioned that all couples and individuals have the fundamental right to decide freely and responsibly the number and spacing of their children 3 in china the reproductive right is a basic human right and the choice of whether to give birth or not is the embodiment of human rights people have the right to choose and the outside world has no right to interfere with it in united states overturning the roe v wade case and making the american constitution no longer protect american womens right to abortion is an embodiment of human rights violation which is one of the legal issues caused by the restriction of womens reproductive freedom restricting womens reproductive freedom is a violation of womens right to development if the restriction of womens reproductive freedom is a naked violation of human rights then it has to be mentioned that the invisible violation of some human rights of women in modern society with the rapid development of the world economy peoples desire for money is increasingly strong and many people spend most of their time on work which makes it difficult to care for their families under the background of the development of digital economy mens work efficiency is higher than that of women which means that mens working opportunities are expanded while that of womens are relatively reduced as a result the social division of labor between men and women tends to be more men taking the lead in working outside while women taking the lead in working inside 4 and mens time with family is further reduced taking care of children and taking care of the family has become womens work taking care of children is not a simple work it not only needs to pay the bills for women to give birth will consume a lot of health costs childrens education is also time and energy consumingtime costs spiritual costs and for the whole family as a wife she also needs to take care of her husband and deal with the trifles of the whole family so maybe women without children can still have the opportunity to develop but if they have children from the perspective of intereststhe development right will be sacrificed only for women with low work efficiency this is the invisible violation of womens development right by society which seems reasonable but does violate womens human rights it infringes on womens right to development and womens realization of selfvalue is restricted by their families after understanding the overturning purpose of roe v wade it has to be mentioned why women choose to have abortions in short this child is a fruit of the wrong time for a woman who is about to become a mother if its an accident for a family then for a woman who has an unintended pregnancy the inability to get an abortion is a lifelong pain that can seriously affect a womans mental health for married women it may be difficult to accept for a while for her it is just not perfect enough to accept the child then for unmarried pregnant women this is a lifelong pain her physical and mental health will be severely affected often fall into selfblame fear anxiety and other emotions because of the unexpected birth situation the health status of children is also one of the reasons for parents to worry about which is also an important factor leading to mental health problems of pregnant women 5 the mental health of women conceived as a result of rape is more acutely affected when abortion is not available and the victims authority as a mother is often undermined by rape it is difficult to face the children conceived as a result of rape 6 and under the influence of negative emotions for a long time will also limit womens right to development from a jurisprudential point of view restricting womens right to reproductive freedom not only violates womens human rights but also violates womens right to development violation of childrens human rights and right to education restrictions on womens reproductive freedom will affect the human rights of some children and their right to education when children grow up in the social environment it can be found that most children spend more time with their mothers in their childhoodas mentioned above in the social background of rapid economic development and male employment advantages men spend less time with their families compared with women 4 therefore in such a situation if the mother is not fully prepared or does not want to raise the child the childs right to education will be seriously affected moreover studies have found that the mothers attitude towards the emotional performance of the child directly affects the level of problem behavior 7 if the mother is fully prepared for pregnancy the childs education will be more fully prepared mothers are able to have more positive emotions towards their children which is more conducive in their childrens development on the contrary if a woman has not decided to become a mother her love attention and emotional expression for her child will have a certain negative impact on the childand child will born in such an environment to grow up in a family with a father who lacks love and a mother who finds it difficult to express her love and even dislike the childwhich is a violation of the childs right to educationto take a more extreme example if women get pregnant under the circumstance of sexual assault when their reproductive freedom is limited the situation of their children will be worse their mothers most of these women who are assaulted and give birth to children raise their children alone and it is found in the research that they are difficult to adapt to the society in a short time difficult to deal with the family they might be extremely vulnerable and sensitive and having difficulty raising children after the abuse these women often lose control of their emotions and become irritable while caring for their children children conceived as a result of rape may face abandonment rejection or abuse 8 these are violations against childrens human rights these children often struggle to receive a good education and suffer from mental health problems to some extent therefore the violation of womens reproductive freedom is also a violation of the human rights of some children social perspective the reason for restricting womens reproductive freedom is the crisis of social development due to the aging of population and the decline of fertility rate however in order to solve such problems it is far from enough to restrict womens reproductive freedom they want to have high fertility they want to increase fertility the most important thing is to understand why the fertility rate is fallingit is necessary to first understand the relationship between the restriction of womens reproductive freedom and the social problems behind it it is believed that the two have mutual influence social environment affects womens reproductive intention and the reduction of reproductive intention will naturally lead to the decline of fertility rate which will inevitably lead to policies to recover the declining fertility rate which will affect womens reproductive freedom the restriction of womens reproductive freedom will lead to a series of social problems such as violations of human rights and their adverse effects so if people really want to solve these populationrelated social problems they should start by solving social and environmental problems it makes no sense to restrict womens reproductive freedom influence of social fertility environment on fertility intention the root cause of the decline in fertility rate is the social psychology of fear of childbearing caused by the high cost of childbearing 9 the cost of childbearing is not only the cost of money raising children in modern society is not only the cost of feeding and warming children but also the cost of time and energy for children with the rapid development of the world economy many people put a lot of energy on work even though it is difficult to afford the cost of healthy growth of children in a good environment in such a society the concept of family becomes increasingly weak and the disfamilyoriented development occurs in various countries 10 women who pay more health costs for childbirth choose not to have children in the face of the optional family and the burden of raising children which leads to the decline of fertility rate due to the uneven division of labor caused by the development of digital economy 4 children and family have to a large extent become the limiting factor for the realization of womens selfworth which further reduces womens fertility intention meanwhile in such a social background the role of father is usually tired of working and rarely gets involved in family and children grow up in the environment of widowhall education 12 absence of father is also a factor that is not conducive to the growth of children 1112 and it is also the social psychological cause of fear of childbearing because the generation of social psychology of fear of childbearing further reduces the fertility intention influence of reproductive intention on female reproductive freedom the decline of fertility will inevitably affect the fertility rate faced with the decline of fertility rate the society inevitably takes measures to prevent its continuous decline therefore different countries adopt different decisions to achieve the same goal and these decisions will more or less affect womens reproductive autonomy conclusion studies show that from the jurisprudential perspective restricting womens reproductive freedom is a violation of womens human rights and the right to development as well as childrens right to education and human rights restricting womens reproductive rights is not only detrimental to the protection of human rights but also has many adverse effects on society which is not conducive to the development of society ， and cannot make slow down the social problems such as declining fertility rate the author suggests that in the face of problems such as population aging and declining population growth rate we should look through the phenomenon to see the essence reduce the cost of childbirth and rearing such as the development of painless birth reasonable planning of men and women in child rearing responsibilities and obligations reduce the work burden of both men and women so that children grow up in a sound family reduce gender discrimination in work especially postpartum women this study fills the gap in the research on the negative impact of the restriction of womens reproductive freedom on society and at the same time conducts a study on the invisible human rights violation in modern society it is conducive to promoting the protection of human rights

with the aging of population and the continuous decline of fertility rate social problems are becoming more and more serious in order to stop the continuous decline of the fertility rate many countries have implemented the policy of increasing the fertility rate based on the method of comparative research this study has studied the partial birth policies of many countries and the research theme is divided into two parts the legal theory behind womens reproductive freedom on the one hand in order to promote womens human rights some fertility decisions violate womens human rights on the other hand unwanted births affect childrens human rights and the social issues behind womens right to reproductive freedom studies have shown that despite the increasing number of decisions made to increase fertility rates fertility rates are still falling and the negative impact of some related decisions on society cannot be ignored the decision of some countries to increase birth rates is a serious violation of human rights at the same time this study found that such a decision goes against the original intention of the state not only damages the protection of human rights but also causes jurisprudence problems and social problems

introduction in subsaharan africa adolescent sexual activity is known to be closely associated with negative consequences such as unintended pregnancies and sexually transmitted infections including hiv as well as poor educational attainment and achievement while numerous studies have documented the determinants of sexual behavior among subsaharan african adolescents the possible effects of a broader social context including school and neighborhood environments have been largely ignored as school enrolment and grade attainment have substantially increased in subsaharan africa during the last few decades a growing number of adolescents in these regions are at risk of initiating sexual intercourse while enrolled in school school environment is one of the most important ecological contexts where adolescents learn values and norms that can influence their attitudes and behaviors through channels such as the formal curriculum school resources and interaction with many important social entities including teachers friends and friends parents schools specific characteristics may increase or decrease adolescents probability of engaging in sexual activity among diverse dimensions of schoollevel disparities much of the previous literature mostly in developed countries views socioeconomic composition of the student body as an important contextual factor that might affect adolescent outcomes this literature suggests that school socioeconomic composition informs peer norms and culture shaping adolescents attitudes and behavior more specifically theory and empirical evidence suggest that there are a number of different explanations for the underlying mechanisms by which socioeconomic composition of the student body could affect adolescent sexual activity according to the institutional resource model greater school resources may lead to improved quality of learning through better trained teachers more support from parents and other factors related to school financing thus enhancing the protective effects of school attendance and involvement on students sexual behavior for example socioeconomically advantaged parents may contribute to creating a better atmosphere for studying by financially supporting schools or putting more pressure on headmasters and teachers responsible for curriculum quality and school learning climates as a result better school quality in these schools may lead to a lower level of school dissatisfaction and grade repetition there is mounting evidence that school dissatisfaction or detachment is positively associated with sexual behavior among adolescents relatedly it is well documented especially in the educational literature that students attending schools with a more advantaged student body benefit from a learningoriented environment that is created from highly motivated and capable students from high socioeconomic backgrounds this learningoriented peer culture has also been known to enhance students educational aspirations as well as educational attainment given that the normative environment of a school influences academic outcomes it may also affect other adolescent behaviors as well for example in subsaharan african settings more socioeconomically advantaged schools may have a normative environment that discourages early sexual activity childbearing and marriage because these factors may have seen as major obstacles to educational attainment focusing more on the roles of nonparental adults the collective socialization model suggests that students behaviors and activities in socioeconomically advantaged schools may be better supervised and monitored by peers parents and adults in the school or community schools with low socioeconomic status often lack social networks among parents and an effective monitoring supervision system thereby leading to increased risk of students involvement in problem behaviors moreover the collective socialization model implies that students attending schools without socioeconomic enrichment of a schools student body tend to be less motivated to study and less optimistic about their future due to a paucity of adult role models while no studies in subsaharan africa have explicitly examined the relationship between school socioeconomic contexts and adolescent sexual outcomes two studies have investigated whether school contexts are important to adolescents sexual behaviors those studies emphasize the importance of classmates age composition as a social environment that may shape adolescents sexual behavior marteleto and colleagues find that in urban south africa students who had higher grade attainment for their age were more likely to have sex suggesting that high rates of grade repetition may create a risky environment where adolescents are influenced by the behavior of older peers using the same data lam and colleagues find that cumulative exposure to classmates who are at least two years older is associated with girls likelihood of engaging in sexual activity role of gender in school context in rural kenya mensch and colleagues find that among a wide range of school quality characteristics only the percentage of female students who report that they feel being treated equally is associated with lower likelihood of engaging in premarital sex among girls while none of the school characteristics is associated with boys sexual activity the authors suggest that boys tend to engage in sexual activity largely independent of school factors while girls sexual activity may be more responsive school environments in contrast while there is little empirical evidence on gender differences in the relationship between school socioeconomic composition and sexual behavior recent research from industrialized countries suggests that male students are more sensitive to the effect of school socioeconomic composition on academic achievement the authors argue that boys gain more than girls from a learningoriented environment since academic competition is facilitated as an important aspect of masculine identity for males while girls peer groups tend to encourage attachment to teachers and school often independent of school context assuming that there is a link between strengthened academic aspirations and sexual and reproductive behaviors it can be argued that school socioeconomic composition may influence males likelihood of sexual initiation more strongly than females given gender differences in friendship formation and social interactions in schools we can also expect that the effect of school socioeconomic composition on sexual debut might vary by gender girls tend to maintain more intense friendships exclusively with a few close friends while boys interact less intimately but with wider groups of peers girls friendships tend to be based on greater similarity in attitudes and behaviors while boys typically emphasize shared activities these gender differences contribute to different lifecourse trajectories for male and female adolescents in light of these differences it can be argued that boys may be more responsive to the norms and characteristics of a larger and less intimate group of peers such as schoolmates whereas girls may be more influenced by smaller peer groups thus i hypothesize that the relationship between school socioeconomic status and sexual activity is more pronounced among males than females data and methods data malawi is a small landlocked country in subsaharan africa basic education in malawi consists of eight years of primary education and four years of secondary education unlike the universal primary education policy adopted in 1994 secondary school admission is determined based on performance on the primary school leaving certificate examination the passing rates for pslce in 2011 are 75 for male students and 62 for female students according to the ministry of education as of 2012 there were approximately 419 million children enrolled in primary schools and 260000 children in secondary schools among 1015 secondary schools in the country 60 are community day secondary schools and only 10 are conventional secondary schools the remaining schools are either religious institutions or private schools the disparities between cdsss and csss in terms of physical and human resources are distinctively large because csss are supported directly by the government while cdsss are run by communities thus students attending csss considerably benefit from both quality of teaching and basic physical resources including availability of libraries toilets electricity and books in contrast private schools tend not to be categorized as a homogenous group in malawi because the size and quality of private schools in malawi considerably vary this study uses two waves of data collected in 2011 through 2013 as a part of hivaids prevention program for malawian adolescents supported by daeyang luke hospital in malawi the korea international cooperation agency and africa future foundation in korea the target population of the baseline survey was all students from form 1 to form 3 who were initially enrolled in thirtythree public secondary schools in major traditional authorities within lilongwe district chimutu chitukula kalumba and tsabango in 20111 these four tas cover a large part of lilongwe district2 these regions were chosen as target areas for the program because they are the catchment area of daeyang luke hospital the wave 1 survey consists of two sets of questionnaires 1 an inclass selfreport survey and 2 a private interview with hiv voluntary counselling and testing in the first part students completed the questionnaires about basic demographics household assets health labor market participation school performance timerisk preference hivrelated knowledge and behaviors attitudes towards hivaids and friend networks after the inclass survey each student was interviewed about sexual experiences by a samesex enumerator in a confidential manner at baseline between october 2011 and march 2012 7971 secondary school students participated the baseline survey the wave 2 survey conducted in 2013 includes 5431 students who were successfully followed up leading to almost 70 followup rate the remaining 2540 students were lost between two waves in order to reduce sample attrition bias 15 of 2540 lost students were randomly sampled for home survey out of these randomly sampled 381 students 711 were successfully tracked and interviewed3 therefore at wave 2 5702 students completed the school or home survey and the effective survey rate reached 908 4 in the analyses the sample was weighted to account for the different likelihood of followup through the school and home surveys the major strengths of the data lies in the fact that sample size is large and that the data is a virtual census of students in each school so that the measures of schools characteristics will contain less error compared to the data representing a sample of the population of students within schools among those who participated the wave 1 survey twentyfive respondents whose marital status was not never married at the time of survey were excluded because sexual activity for those who have ever cohabited or married or are currently married is universally accepted and expected after additionally dropping 30 students who had any missing values on individuallevel controls the final analytic sample is 7916 students in 33 schools the restriction of the analysis in this paper to students who were enrolled in public secondary schools produces a very select group of adolescents especially for malawi where the net secondary enrollment rate was only 312 in 2013 6 however in the context of the rapid school expansion that most subsaharan african countries have been experiencing understanding how school contexts influence adolescent educational and sexual outcomes may be critical for developing policies and programs to effectively integrate more disadvantaged students into the existing educational system in addition given relatively large variation in school characteristics and quality even among this select group of adolescents the school effect on adolescent outcomes should differ across schools dependent variable the primary focus of this analysis is to examine whether the timing of students transition to first sex is associated with their schools socioeconomic composition in each wave students were asked at which age they had sexual intercourse for the very first time based on the responses to this question in both waves the dependent variable was created with multiple categories to reflect the longitudinal nature of data 7 had no sex by wave 2 initiate sex between two waves already had sex by wave 1 and losttofollowup at wave 2 8 key independent variables school socioeconomic composition as the main explanatory variable is measured by a combined index reflecting socioeconomic composition of students attending the same school the percentage of students with top 10 assetbased wealth index of household 9 the percentage of students whose father or mother completed secondary school or more and the percentage of students whose father belonged to the occupation category of professionalmanagerial or government officer 10 because of the high correlations among these variables i use principal components analysis to create school socioeconomic composition index in addition to the composite measure of school socioeconomic composition i also examine whether each constituent measure has any noticeable differences in the relationship with students sexual debut in each model the corresponding level1 socioeconomic characteristic that was used to create schoollevel measure was groupmean centered to distinguish the estimated effect of schoollevel socioeconomic characteristic from the individuallevel effect to examine the extent to which the measure of school socioeconomic composition reliably capture a schoollevel construct i assessed the ecometric properties of school socioeconomic composition scales using threelevel multilevel models in the model level 1 corresponds to the three survey questions that measure socioeconomic status within individuals level 2 corresponds to persons nested within schools and finally level 3 corresponds to schools variance components were estimated for each level and then using these estimates i calculated the intraclass correlation coefficient and the reliability of the schoollevel measure the icc was calculated as the ratio of the variance between schools divided by the sum of betweenand withinschool variances the icc ranging from 0 to 1 will be high 7 i used new stata generalized structural equation modeling command gsem which allows to model a multinomial logistic regression model with random effects additionally i confirmed that the results of this study are not sensitive to using another stata command gllamm 8 364 respondents who produced inconsistent information about their sexual activity were coded already had sex by wave 1 555 respondents who reported sexual activity at wave 1 and were lost to follow up at wave 2 were coded losttofollowup at wave 2 however coding them already had sex by wave 1 did not affect the results of the study 9 i tested the robustness of the findings in the paper by using different levels of wealth index as a cutoff and found that the results are very consistent 10 the choices for fathers occupation given to students were as follows no job farmer laborer clerical and sales professional managerial government officer and others i chose professionalmanagerial and government officer as relatively prestigious jobs in malawi that are closely related to social status in addition these occupations are salaried employment which tend to provide access to a stable sources of income and networks of social relations although these occupations might be correlated with other socioeconomic status including incomeasset and educational attainment fathers occupational status might better and more directly capture social status than incomeasset and educational attainment when there is greater agreement between respondents within a school the school level reliability on the other hand is a function of the icc and the number of individuals in each school the reliability ranging from 0 to 1 will be high when the variance across schools is large or 2 the sample size within schools is large in addition this measure also depends on the number of scale items the interpretation of this measure is similar to a cronbachs alpha in psychometrics scale analysis the ecometric properties of the scales measured by the icc and reliability were good 0423 for the icc and 0973 for reliability suggesting that the measure of school socioeconomic composition is adequately capturing school attributes and thus the mean of the three scores used in the paper is a reasonable estimate for the true schoollevel socioeconomic status other control variables a set of control variables at the individualand schoollevel was chosen on the basis of relevant prior empirical studies all models include the following individuallevel control variables gender age ethnicity selfreported math performance top 10 assetbased wealth index parents completion of secondary education fathers high occupational status and parental survival i use assetbased wealth index of household as a measure of socioeconomic status not necessarily because data on household income or expenditures are absent but because wealth seems to better capture longterm socioeconomic position of a household following filmer and pritchetts method i construct assetbased wealth index which includes source of drinking water types of toilet facilities household durable assets and the number of rooms in the home information on livestock ownership is not used because the respondents in this study are from both rural and urban areas livestock ownership may be a good indicator for wealth only in rural area but not in urban areas in order to control for schoollevel characteristics that may confound the association between school socioeconomic composition and sexual debut the following schoollevel variables are included average class size rurality and type of schools while not perfect these schoollevel variables could control for schoollevel confounding factors such as quality of teaching and access to basic physical resources i also include specific features of schools that may affect sexual debut to examine whether school socioeconomic composition has an effect on sexual debut independently of those characteristics of schools the following set of schoollevel aggregate measures were included students satisfied with school 11 students who have ever repeated grade during secondary school and mean study after school 12 11 school satisfaction is measured based on students response to the question how satisfied are you with your school in general the response is a fivepoint scale ranging from very dissatisfied to very satisfied to create the percentage of students who are satisfied with school this variable is dichotomized into very dissatisfieddissatisfiedsoso and satisfiedvery satisfied 12 study after school is measured based on students response to the question do you study after class the response is a sixpoint scale ranging from no not at all to four times or more a week analysis in this research multilevel modelling with hierarchical structure is employed to predict students sexual behaviors multilevel modelling approach is based on the assumption that each school is responsible for a part of the variation in students sexual activity and that ignoring the nested structure of the data might lead to misattributing the effects of studentlevel characteristics i use twolevel multinomial logistic regression models to explore how schoollevel socioeconomic composition relates to adolescents sexual initiation between the two waves in the final tables i only present the result comparing those who remained sexually inexperienced by wave 2 to those who initiated sex between wave 1 and 2 13 when using a longitudinal data multinomial logistic regression is especially beneficial for reducing bias potentially resulting from nonrandom loss to followup in addition this joint model may benefit from obtaining smaller standard errors than the separatefitting models although the efficiency loss for a stratified model is minimal when using the most frequent category of the outcome is set as the reference group for example since the primary comparison of our interest is between had no sex by wave 2 and initiate sex between two waves and the category of had no sex by wave 2 is the most frequent 14 fitting independent binary regression models comparing these two categories is expected to produce similar results 15 findings descriptive statistics table 1 presents weighted descriptive statistics for all variables included in the multilevel modeling analysis at both the individual and school level descriptive statistics are presented for the students who are included in the final analytic sample the total number of students included in this study is 7916 with 3950 male students and 3966 female students while 16 of the respondents already had sex by wave 1 about half of them remain sexually inactive by wave 2 between wave 1 and wave 2 approximately 11 of male students reported sexual debut only 8 of female students initiated sexual intercourse half of the sample have at least one parent who has ever completed secondary education and 26 of the students have father who is employed in professional or managerial occupations or serves as a government officer for 24 of the sample students at least one parent has died 14 of the students in the sample attend schools located in rural area it seems that there is substantial variation across schools in various schoollevel characteristics the percentage of the students who have ever repeated a grade ranges from 4 to 22 and the percentage of the students satisfied with school ranges from 7 to 61 average score for studying after school is 49 meaning that students on average study two or three times a week after school more importantly there are significant variations between schools in their aggregate socioeconomic characteristics between 0 and 31 of 13 the results for the remaining pairs of comparisons had no sex by wave 2 vs already had sex by wave 1 and had no sex by wave 2 vs losttofollowup at wave 2 are included in the appendix 14 the weighted sample shows that 51 of the students remain sexually inactive by wave 2 15 as a robustness check i fitted the independent binary regression model to confirm that the results including the magnitude of the effect and statistical significance are considerably similar students in a school were in the top 10 of the wealth index between 13 and 72 of parents had completed secondary education and between 7 and 46 of fathers had high occupational status table 2 reports the relative risk ratios and standard errors obtained from twolevel multinomial logistic regression with random intercepts where the effect of school socioeconomic composition on sexual debut is examined model 1 shows that without controlling for individualand schoollevel characteristics higher school socioeconomic composition is very strongly associated with decreased odds of initiating sexual activity between waves in model 2 where a set of individuallevel factors is included attending schools with higher socioeconomic composition is still very strongly associated with the odds of sexual debut although the association is considerably reduced as expected gender and age are strongly associated with the odds of sexual debut in addition higher selfreported math performance decreases the odds of initiating sexual intercourse after controlling for a set of structural characteristics of school the association between school socioeconomic composition and sexual initiation remains statistically significant at the 99 level adding three additional schoollevel characteristics that are believed to influence students sexual activity reduces the strength of the association between school socioeconomic composition and sexual debut while the association is still marginally statistically significant these findings suggest that school socioeconomic composition seems to be associated with adolescents sexual initiation independently of other important schoollevel characteristics as well as individuallevel characteristics among the schoollevel characteristics higher school satisfaction among students decreases the odds of initiating sexual intercourse to interpret the effects of school socioeconomic composition and sexual debut and test possible nonlinear effects model 5 presents the result from the analysis using terciles of the school socioeconomic composition index compared to students attending the most disadvantaged schools the odds of initiating sexual intercourse between waves for those who attend schools in the top and middle tercile of school socioeconomic composition is reduced by an estimated 30 and 24 respectively 16 suggesting that the effect of school socioeconomic composition appear to be nonlinear table 3 presents the results from the separate models for male and female students models 1 and 5 show that without any control variables school socioeconomic composition is associated with the odds of initiating sexual activity for both males and females similar to the pooled sample even after controlling for a set of individuallevel variables the association is still statistically significant for both gender male students from families with top 10 wealth index are less likely to have sex while for female students high selfreported math performance decreases the odds of sexual debut interestingly female students whose mother was dead are less likely to have sex than students with both biological parents alive 16 attending the middle tercile schools is marginally associated with a reduced odds of initiating sexual activity once the first set of schoollevel variables is added the association between school socioeconomic status and initiating sexual activity between waves still remains statistically significant for both gender for males the inclusion of three additional schoollevel characteristics slightly increases the standard errors and slightly decreases the magnitude of the odds ratio in female samples however with very slight change in standard errors the substantial decrease in the magnitude of the odds ratio of school socioeconomic leads to statistical insignificance these findings suggest that attending schools with higher socioeconomic composition decreases the odds of initiating sexual activity only among male adolescents17 while aggregated school satisfaction decreases the odds of sexual debut only among males the percentage of students who have repeated a grade is only associated with females odds of initiating sexual intercourse table 4 presents the results from the models by constituent socioeconomic measure and also by gender 18 the result shows that in the pooled sample the percentage of students who belong to the top 10 wealth index is most strongly associated with the odds of transition to first sex 19 on the other hand the percentage of students whose parents have at least secondary school education is associated with the odds of sexual debut at the 90 level while no statistically significant association is found for the percentage of students whose father has high occupational status the exactly same patterns are found in the male samples the results show that a one standard deviation increase in the percentage of top 10 wealth index decreases the odds of sexual initiation by an estimated 29 while a one standard deviation increase is associated with an increase in the odds of initiating sexual intercourse by an estimated 21 however similar to the results from the model using the composite measure of school socioeconomic composition among female adolescents no constituent school socioeconomic measures are found to be associated with the odds of initiating sexual activity these findings suggest that high family economic status at the school level appear to be more salient to delay of first sexual intercourse than other aspects of school socioeconomic status such as parental education and fathers occupational status especially among male adolescents discussion and conclusions as access to education has significantly expanded in less developed countries in the past few decades more adolescents in these countries spend a large portion of their adolescence in school despite the importance of schools as a social context that influences students attitudes and behaviors little is known about how school environments shape adolescents sexual behavior in less developed countries drawing on two waves of data from a schoolbased longitudinal survey in malawi this study deepens our understanding of the role of school socioeconomic context in influencing adolescents premarital sexual activity this study has two main findings first attending high socioeconomic status schools is associated with a reduced odds of engaging in early premarital sexual activity among malawian adolescents in particular it is important to note that despite the modest correlations between school socioeconomic composition measure and three specific features of schools that are believed to influence adolescents sexual behavior an independent association between school socioeconomic composition and sexual initiation has been identified these findings provide empirical support for the hypothesis that schoollevel socioeconomic contexts are important for early premarital sexual activity among adolescents independent of other important characteristics of schools as well as individuallevel factors among three constituent measures of school socioeconomic composition the percentage of students from the wealthiest 10 families is found to be the most strongly associated with sexual debut for both the pooled and male samples these findings suggest that with regard to sexual activity students may be more responsive to schoolmates material resources than cultural resources while the opposite seems to be true for educational outcomes second this study provides some suggestive evidence on gender differences in responding to school contexts the results from separate models for male and female students suggest that school socioeconomic composition is associated with sexual debut only for male students when controlling for a complete set of individualand schoollevel characteristics for females the magnitude of the effect of school socioeconomic composition is substantially reduced when three specific characteristics of schools are accounted for suggesting that school socioeconomic contexts may be less related to sexual debut for females than males the results are in line with the work of legewie and diprete who argue that male students are more sensitive to socioeconomic composition of the student body interestingly however these findings seem to be inconsistent with some of the previous studies in subsaharan africa which have demonstrated that male students sexual behavior tends not to be influenced by various aspects of school environments including the level of gender equality and the age composition of students one possible explanation for these mixed findings is that male and female students may be differently responsive to different school characteristics and environments for example in this paper congruent with the past research the percentage of students who have ever repeated a grade during secondary school is very strongly associated with the odds of transition to first sex only among female students whereas students school satisfaction and the academic atmosphere of schools are associated with only male students sexual initiation however the interpretation of the results from genderstratified models should be interpreted cautiously considering that in less developed countries including malawi girls are more likely to underreport premarital sexual activity due to social norms and school policies against adolescent sexual activity and pregnancy this underreporting of sexual experience by female students may lead to an underestimation of the association between school socioeconomic composition and sexual debut this study has several limitations that need to be acknowledged selection bias is often considered a critical barrier in school effects studies as well as neighborhood effects studies because it is likely that people select a place to live and a school for their children to attend specifically school assignment in malawi is not random although the system of selecting students for these schools varies across different school types the selection process for public secondary schools which are of primary interest in this analysis is relatively straightforward simply speaking the top performing students on the national placement exam are selected into conventional secondary school and then community day secondary school select students from their own localities in the public educational system students hardly ever choose a school although it is possible in theory for students to select a school at the same level of their originally assigned schools or below after enrolment it is very difficult to transfer to another school because a transfer can be made only when a school has a slot to fill hence it can be concluded that students academic performance and residential locations of their family or relatives mostly determine school selection among adolescents in malawi it may be hard to address this selection issue without random school assignment in this study i attempted to account for selection issue by controlling for several individuallevel characteristics that are believed to be correlated with sexual debut and school socioeconomic composition although by including many of these variables more assumptions are needed with sparse data however it is still possible that unobservable or unmeasured factors are correlated with the choice of school and neighborhood thus confounding the effect of the school on sexual debut in addition although i tried to control for schoollevel characteristics that may confound the association between school socioeconomic composition and sexual debut the estimated coefficient of school socioeconomic composition may be biased if important schoollevel variables are omitted from the analytical models one might argue that peers sexual experience is a more natural schoollevel measure that might be associated with adolescent sexual activity although in principal using the lagged measure of school peers sexual activity might not suffer from reflection problem the lagged behavior among peers can simply be a proxy measure of contemporaneous behaviors when the lagged and contemporaneous peer measures are highly correlated and the lag length is misspecified another related problem is that because more students in low socioeconomic status schools had already experienced sexual debut by wave 1 the percentage of sexually experienced students by wave 1 and school socioeconomic composition are highly correlated thus making it impossible to distinguish effects of the two schoollevel factors because separating them is beyond the scope of this paper and the primary focus of this study is to examine the effect of school socioeconomic composition peers sexual experience was not included in the final estimation model it is also possible that school effects may be confounded by neighborhood effects because in many settings school and neighborhood environments are closely related due to empirical difficulties and data unavailability only a few studies in developed countries have attempted to understand how these two different contexts separately and jointly affect adolescent outcomes although the existing literature suggests that the magnitude of neighborhood effects is relatively smaller for nonacademic outcomes such as transition to first sexual intercourse than educational outcomes the influence of schools may be overestimated when neighborhood effects are at work in addition since this study targets students attending public secondary schools in the lilongwe district the generalizability of the findings from the study should be limited accordingly as the public educational system in many subsaharan african countries fails to absorb an increasing number of graduates from primary schools and more private secondary schools rapidly emerge examining the effects of private secondary schools may be critical the effects of school socioeconomic composition among private secondary schools might be different from public secondary schools in both developed and developing countries early premarital sexual activity places adolescents at heightened risk of stis and unintended pregnancies which in turn often result in low educational attainment poor health and low socioeconomic status later in life with the rapid expansion of education in subsaharan africa school contexts have gained more attention as an important social context where adolescent culture and norms are produced and learned through peer influence as adolescents delay marriage and stay in school longer than before they tend to initiate sexual activity while in school though numerous individualand familylevel risk factors have been found to be associated with sexual initiation in less developed countries the role of schoollevel factors has been neglected this study suggests that a schools socioeconomic context plays an important role in shaping adolescents sexual activity independently of other characteristics of schools that are known to influence sexual behavior further research is required to understand the mechanisms through which school socioeconomic composition influences adolescents transition to first sex and involvement in unsafe sexual behaviors more specifically it would be interesting to explore how school socioeconomic composition is connected to school normative environments about adolescent sexual behavior and educational attainment in addition it may be important to understand what roles smaller peer groups such as close friendships within a school can play in the relationship between adolescent sexual behaviors and schoollevel factors table a2 relative risk ratios from twolevel multinomial logistic regression models of school socioeconomic composition on sexual initiation between two waves ref had no sex by wave 2 males 20112013 table a3 relative risk ratios from twolevel multinomial logistic regression models of school socioeconomic composition on sexual initiation between two waves ref had no sex by wave 2 females 20112013 relative risk ratios from twolevel multinomial logistic regression models of school socioeconomic composition on sexual initiation between two waves by gender 20112013 male male male male female female 7 appendix table a1 relative risk ratios from twolevel multinomial logistic regression models of school socioeconomic composition on sexual initiation between two waves had no sex by wave 2 20112013

while numerous studies have documented the determinants of sexual behavior among adolescents in less developed countries relatively little is known about the influence of social contexts such as school and neighborhood using two waves of data from a schoolbased longitudinal survey conducted in malawi from 2011 to 2013 this study advances our understanding of the relationship between schoollevel socioeconomic contexts and adolescents sexual activity the results from twolevel multinomial logistic regression models suggest that high socioeconomic composition of the student body in school decreases the odds of initiating sexual activity independently of other important features of schools as well as individuallevel characteristics this study also finds that the association between school socioeconomic composition and sexual activity is statistically significant only among males but not females suggesting that schools socioeconomic contexts may be more relevant to male adolescents initiation of sexual activity

introduction currently indonesia is ranked fourth most populous country in the world based on population census data in 2020 it was recorded that indonesias population touched 2702 million people in the last 10 years indonesias population has increased to 3256 million people with an average of 326 million people per year the population growth rate in 20102020 reached 125 per year this amount is classified as a number that is not ideal ideally the population growth rate in indonesia is 2 million people per year or 077 per year control of the rate of population growth needs to be done to avoid a population explosion the continuous increase in population will certainly cause various problems such as high maternal mortality unemployment and declining welfare of the community the government has pursued various programs as part of controlling the rate of population growth in indonesia given the current conditions it seems that the most realistic effort is the family planning program birth control programs are defined as efforts to delay pregnancy to regulate the spacing of childbirths and limit population growth by reducing the number of births that occur in addition family planning programs will reduce mmr the high mmr in 1950 was the background of the implementation of family planning programs in indonesia the government then formed the indonesian family planning association in 1957 to socialize conduct training research and provide family planning services to the community the implementation of family planning programs during this period succeeded in reaching all regions in indonesia and achieving national targets the birth control program is inseparable from the use of contraceptives the thing that is superior in the family planning program is the use of contraceptives in family members to create stability between the birth rate and the death rate of the population until now the types of contraception for women are much more when compared to contraception for men this proves that there is still an imbalance in contraceptive use between men and women a balance of roles between husband and wife is very necessary in running family planning programs based on data from the national population and family planning board many husbands assume that contraceptives are only used by wives or have views about the use of contraceptives that interfere and cause discomfort this is evidenced by the bkkbn report in 2011 regarding the very minimal participation of men nationally as family planning acceptors which is only 16 in total based on bkkbn data condoms are one of the contraceptives that are widely known to the public as instant contraceptives to prevent unwanted pregnancies or to regulate birth spacing in 2014 the use of contraception in indonesia was dominated by injectable contraceptives pills and condoms although condoms are easy to reach they do not necessarily increase male participation as birth control acceptors the rate of using male condoms to regulate pregnancy spacing is only 07 and birth control is still mostly imposed on women the governments efforts to reduce the population through family planning can even be said to be hindered by the awareness of indonesian men of childbearing age who are too lazy to use condoms the low participation of men in family planning can be influenced by several factors such as the level of knowledge limited information and accessibility to family planning services people who are poor less educated remote and live in slums tend to have less awareness of using family planning compared to residents who live in urban areas therefore further socialization about contraception is needed to attract male people to use contraception and increase knowledge method this study is a quantitative descriptive study with a crosssectional research design where variables are observed only once at the same time the number of samples in this study was 93 respondents the criteria for sample inclusion in this study are husbands of productive age at puskesmas i south denpasar in 2023 who are willing to participate in the research willing to be interviewed or taken data characteristics and fill out a complete questionnaire husbands must be able to show proof of family card as a sign of being legally married wives use one of the alternative contraceptives results and discussion result a characteristics of respondents the table above shows the characteristics of respondents where the age of 2635 years is the most age namely 34 respondents and most respondents have received high school education as many as 45 respondents b husbands knowledge of condom contraception from this study a picture of the husbands knowledge about condom contraception can be seen in the charts and tables as follows graph 1 husbands knowledge of condom contraception based on the graph above from 93 respondents the total score obtained varied from the lowest score of 23 points to the highest score of 37 points the majority of respondents received a score of 35 points namely 20 people discussion a characteristics of respondents age influences contraceptive use because the fertile period and sexual desire are influenced by age the results of this study showed that there were three age groups encountered in respondents respondents were dominated by the age group of 2635 years as many as 34 people followed by the age group of 1725 years as many as 29 people 3645 years as many as 23 people and the age group of 4655 years as many as 7 people the early adult age group is an age group that falls into the category of couples of childbearing age the results of this study are in line with research conducted by fatchiya et al in south bogor district bogor city and cijeruk district bogor regency where the population of couples of childbearing age is the target of family planning programs pursued by the government this is because couples of childbearing age are in good and optimal conditions in reproducing according to notoatmodjo education affects his perspective this is what causes the difference between highly educated people and people who are poorly educated in responding to a process or problem and interacting with the environment generally the higher the level of education the more open a person will be in receiving information so the wider the knowledge he has low education tends to be an obstacle in the development of a persons attitude toward the new things he gets therefore the level of education of respondents is quite influential on the picture of knowledge in this study the majority of respondents encountered were 45 people who graduated from high school followed by 25 people who graduated from academycollege graduated from junior high school as many as 16 people and graduated from elementary school as many as 7 people these results are in line with research which comes from bertands theory namely education not only makes respondents decide which contraceptives to use but also the mindset to understand and evaluate the contraceptives used however another study by kamaruddin in sapanang village kajang district bulukumba regency showed different results namely the majority of respondents had elementary and high school education the difference in research results can occur due to many factors such as because it is influenced by the condition of the surrounding environment the ease of access to education and the conditions of each individual b husbands knowledge of condom contraception knowledge has a very important role in facilitating and influencing the husbands involvement in choosing contraception and participating in family planning programs in this study the husbands level of knowledge about condom contraception at puskesmas i denpasar selatan was categorized into low knowledge and high knowledge based on the total score of all respondents divided by the number of respondents a mean value of 3266 was obtained based on the data obtained as many as 33 people respondents have a low level of knowledge and as many as 60 people respondents have a high level of knowledge this illustrates that the majority of respondents at puskesmas i denpasar selatan already have a high level of knowledge about the purpose of contraceptive use types of male contraception the purpose of condom use the advantages of condom use disadvantages of condom use where to obtain condoms frequency of condom use and problems encountered during condom use a high level of knowledge about condom contraception is very important especially for men knowledge of the purpose of contraceptive use types of male contraception the purpose of condom use the advantages of condom use disadvantages of condom use where to obtain condoms frequency of condom use and problems encountered in using condoms need to be clearly understood to remove the stigma that contraception is only used by women and increase awareness of men of childbearing age to use condoms and become birth control acceptors conclusion thus it can be concluded that the husbands picture of knowledge about condom contraception is at a high level of knowledge this is because the majority of respondents already have a high level of knowledge about the purpose of contraceptive use types of male contraception the purpose of condom use the advantages of condom use disadvantages of condom use where to get condoms frequency of condom use and problems encountered during condom use

the uncontrolled increase in population in indonesia causes various problems an effort to overcome this situation is the family planning program however currently mens participation in family planning programs is still very low this study aims to determine the description of husbands knowledge about condom contraception at puskesmas i denpasar selatan in 2023 this research is a quantitative descriptive study with a crosssectional research design the population of all husbands and wives receiving family planning at puskesmas i denpasar selatan the sample consisted of 93 respondents who were collected using nonprobability sampling with purposive sampling technique data was collected using a questionnaire and then carried out univariate analysis the majority of respondents were aged 2635 years 366 high school 484 private employees 323 income idr 5000000month 591 the purpose of contraceptive use that is most widely known by respondents is pregnancy spacing and family welfare 100 condom 100 the purpose of using condoms to avoid venereal disease and wait for more permanent use of birth control 100 the advantages of using condoms are practicaleasy to use 968 the disadvantage is that they can only be used once 100 and the place to get condoms is at the health center and midwifeprivate doctors practice 100 the description of respondents knowledge regarding condom is at a low level of knowledge 409 while at a high level of knowledge 591 description of husbands knowledge about condom contraception at puskesmas i denpasar selatan in 2023 is at a high level of knowledge

introduction p olicy visions such as the united nations agenda 2030 and the african unions agenda 2063 identified science as critical means for advancing sustainable development whilst the pivotal role of science in generating relevant knowledge for sustainable transformations is gaining traction across science and policy communities globally research in the global north and south are providing evidence of vast differences in the potential of science to drive ongoing transformations in a sustainable direction this paper responds to the need of transforming science systems to foster transformative change in african cities we focus on two challenges that should be addressed within science systems 1 the need to strengthen sciencesocietypolicy interactions and 2 the need to tackle existing science inequalities between research in the global north and south transdisciplinary research is increasingly recognised as a useful approach for improving these interactions whilst the need to support and amplify research capacity of the global south is seen as a priority in fostering global science and education systems that are equitable and context relevant the way science funders design their research funding programmes plays a significant role in determining how tdr is conducted and where and how investments in science capacity are utilised this article aims to contribute evidence on how science funders can achieve the dual role of fostering sciencesocietypolicy interactions whilst simultaneously tackling science inequalities through capacity building more specifically the question is how research funding programmes can foster tdr for advancing sustainable development in the global south the focus is the research funding programme of the international science council leading integrated research for the agenda 2030 in africa lira 2030 africa by focusing on the benefits and challenges presented by the programmes pathways to foster tdr and associated activities this paper contributes to debates on the scale and scope of transformations of science and highereducation systems in africa and the role of science funding transdisciplinarity and the role of research funding programme designs tdr aims at linking scientific knowledge production and societal problem solving in processes of knowledge coproduction it is a reflexive research process that addresses societal problems by means of interdisciplinary collaboration as well as the collaboration between researchers and extrascientific actors its aim is to enable mutual learning processes between science and society tdr has been developed as scholars realised that traditional ways of disciplinary knowledge production are insufficient to accommodate the complexity uncertainty and contested nature of sustainability challenges in these situations researchers from social and natural sciences need to collaborate with various societal actors throughout the research process in order to jointly generate the knowledge needed to act towards sustainability consequently tdr is often depicted as an idealtypical process composed of three phases phase a collaboratively framing the problem and building a collaborative research team phase b coproducing solutionoriented and transferable knowledge through collaborative research and phase c integrating and applying the produced knowledge in both scientific and societal practice over the years a considerable body of literature has emerged about tdr on the project level one key conclusion of these studies is that tdr requires conditions that differ from those needed for basic disciplinary research for example barth et al stressed that tdr requires additional knowledge and skills which are usually not covered by traditional highereducation curricula bromham et al found that tdr proposals have difficulty in obtaining funding reasons for this are despite a widespread call for tdr most research funding instruments are structured along disciplinary lines reviewers tend to apply disciplinary quality criteria when assessing them and when successfully evaluated typical tdr components such as joint problem framing or stakeholder collaborations are often not covered by the traditional funding instruments finally patel and van breda et al stressed that tdr careers of young tdr scholars can be at risk because classic academic career metrics still heavily favour publications in academic disciplinary peerreviewed journals whereas contributions to societal transformations such as capacity development social and institutional learning engagement with policy and the public and relationshipbuilding are less valued consequently many scholars have stressed that for tdr to reach its full potential not only suitable methods and epistemological foundations are required but also fundamental institutional changes in its governance and funding structures as a consequence while the broader research funding landscape remains organised along disciplinary lines several national and international research funding bodies started to develop dedicated funding programmes promoting tdr initiative however to date relatively little evidence exists on how research funding programmes can effectively foster implementation of tdr in particular in the global south researchers studying such funding programmes identified several areas of influence that are important for improving the conditions of grantees to successfully undertake tdr the areas of influence include solicitation conditions proposal review funding coverage building of tdr capacity implementation support and evaluation and learning involvement of societal actors in related activities is considered key eg in evaluating research proposals or impacts in addition there are several factors that affect successful navigation of the overall funding programmes including identification of the appropriate placelocus of tdr knowledge integration as a deliberate step throughout the programme inspiring leadership and active management although empirical research is still limited an increasing number of studies have examined activities of individual funding programmes in relation to specific areas of influence for example arnott et al tested if changes in solicitation conditions encourage interactions between researchers and societal actors and hoffmann et al examined the process of knowledge integration others focused on the overall design of research funding programmes for instance schneider et al developed a model that highlights three overlapping phases and ten key stages within a lifecycle of a research funding programme that require special consideration to foster tdr throughout that programme the stages address various areas of influence described above programme preparation project proposal elaboration interactions with applicants project selection research activities joint agenda setting networking and integration interactions with participating projects external communication and implementation programme conclusion and evaluation reflexive application of the model is intended to help funding agency staff in identifying the key stages in a funding programme that require special consideration in order to improve conditions for tdr however the model does not specify how the identified stages should be designed and implemented in distinct contexts the authors of the model argue that this depends on the particular programmes thematic focus goals epistemological assumptions contextual factors and envisioned pathways to societal impact research capacity in africa the global distribution of research capacity is very unequal be it regarding classical science metrics such as number of researchers publications access to publications funding research infrastructure or regarding tdr capacities more specifically this is particularly true for africa while many african research institutions have increased their research capacity in recent years africas share of world science as measured in published papers doubled from around 15 to 3 over the past 10 years overall research productivity is still lower compared to other parts of the world reasons explaining these imbalances are multifaceted and includebut are not limited toaspects ranging from historically grounded inequalities going back to colonial times current funding priorities of national governments lack of stable scientific institutions to brain drain although many african governments expressed strong commitment to strengthen the science systems by increasing research funding the research expenditures of many african governments are still less than 05 of their gdp this results in multiple challenges first african scholars are regularly challenged by underresourced and weak institutional structures including unstable budgets and administration support inadequate quality of research infrastructures and education facilities and high teaching loads all negatively impacting their research productivity second african scholars often depend on international funding that reinforces the influence of the global north on setting research agendas which often have little resonance with the african realities furthermore the prevailing science metrics disregard scienceinternal as well as social processes and poorly recognise and reward scientific contributions that focus on local issues of social relevance researchers of the global south directing their capacities to issues of local societal benefit can lead to less receptive scientific environment concerning global issues consequently they tend to be indirectly excluded by selfreinforcing global academic networks that are known to enhance publication rates of certain authors while indirectly excluding others publication of scientific results in other than english languages and the general underrepresentation of table 1 overview on the ten key stages according to schneider et al key stages short description programme preparation in this stage the overall parameters of the programme and the future research are set namely the research and transformation goals pathways to impact as well as available funds by outlining the research requirements it also defines the room for manoeuver applicants have in designing and implementing tdr processes within specific projects project proposal elaboration in response to the programme call the research consortia then prepare and submit project proposals specifying their goals research questions and methodological approaches interactions with applicants during proposal writing research programmes interact with their applicants in different ways project selection in this stage the programme evaluates the proposals and decides which projects will be included in the programme what is expected of them and how much funding they will receive research activities the approved research projects implement the tdr described in their proposal scientists from africa in editorial boards are among other factors that affect appropriate recognition of african scientific work the situation is particularly challenging for early career scientists because there are limited career opportunities lack of postgraduate programmes and fellowships mentoring and training and restricted access to the scarce funding schemes consequently up to 30 of highly qualified african scholars leave the continent every year to take over positions in other countries leading to brain drain currently there are more african phd holders outside the continent than inside these existing science inequalities are putting africa at disadvantage in achieving sustainable development against this background several authors argued that massive financial investments in research capacities are needed by both national governments and international funders in order to enhance research capacities for contributing to sustainable development in africa this is relevant for science in general but is even more crucial for tdr undertaking this type of research requires strengthening related capacities although alternative funding prioritising tdr has emerged in recent years most research funders are not yet effectively supporting this type of research questions case study and methodology to address our overall research question of how research funding programmes can foster tdr we seek to answer the following subquestions rq1 through what pathways can a research funding programme foster tdr for sustainable development in africa rq2 how did the lira programme shape its design and activities to advance these envisioned pathways rq3 what were the benefits and challenges of the programmes design and activities for fostering tdr case study the key goal of the studied research funding programme lira 2030 africa is to increase the production of highquality solutionsoriented and policy relevant knowledge on sustainable development in african cities and to build a new generation of scientists with the ability and capacity to produce and communicate this type of knowledge its distinctive feature is that it promotes tdr in a specific urban context in africa the programme is funded by the swedish international development cooperation agency and delivered by the international science council together with its regional office for africa and the network of african science academies from 2016 to 2021 since the programme started it has launched three calls on different sustainability themes understanding the energyhealth and healthnatural disasters nexuses in african cities advancing the sustainable development goal 11 in africa and pathways towards sustainable african urban development resulting from these calls the programme has funded three cohorts 28 research projects in total up to the value of €90000 each over the course of two years each project brings together cities in two african countries to foster learning across cities and research collaboration across research institutions in africa ensuring the participation of lowincome countries in research collaboration was particularly emphasised the programmes total funding volume is 5 million euros over the course of six years whereas over 60 of the total funding is allocated specifically for tdr projects additionally the projects are supported by the programme through various other resources such as training peerlearning and networking activities method our research is embedded in a learning study accompanying the lira programme the core team of the learning study consisted of two tdr experts and two programme managers one from africa and one from europe each hence our research was guided by what burawoy calls a reflexive model of science which considers engagement with rather than detachment from the object of investigation as the suitable approach to generate new knowledge in this research approach scientists and reflective practitioners cogenerate new knowledge by combining established methods of social sciences with structured methods for selfreflection hence this method differs from classical programme evaluation studies were independent researchers evaluate the performance of a programme the advantage of our approach is that the study team embraces both independent researchers as well as practitioners deeply knowledgeable about the investigated structures and activities combining rigorous scientific analyses with the knowledge of the involved practitioners helps generate truly actionable knowledge however our approach also bears the disadvantage of possible blindness to alternative interpretations due to reduced distance between researchers and research object to address our research questions we used a case study approach which combined interviews surveys document review and participatory observation to understand the programmes envisioned pathways to foster tdr and implemented activities we conducted a qualitative content analysis of programme documents and of expert interviews with programme representatives based on these insights we mapped key programme stages and activities over time by using the generic model of a td research funding programme as developed by schneider et al to assess the benefits and challenges of the programmes activities we used data gathered through participatory observation formal postactivity evaluations programme monitoring a survey conducted with all grantees at project end as well as the interviews with the programme representatives mentioned above this data was assessed using qualitative content analysis and descriptive statistics and attributed to the programme stages identified before finally we reassessed the information gathered according to the programme stages against the background of the three identified pathways to foster tdr the generated data allowed to understand the benefits and challenges as perceived by the grantees and programme representatives perspectives and impacts beyond these sources could not be considered findings in the following we present our findings along the three identified pathways to tdr impact each pathway outlines a set of key assumptions that the programme deems essential for fostering tdr in africa the first pathway centres on enabling individual earlycareer scientists to acquire the funds and skills needed to lead highquality tdr projects the second pathway emphasizes the career progression of tdr scientists beyond the project level lastly the third pathway explores the institutional context in which tdr scientists are integrated although these pathways are distinct on a conceptual level certain programme design features and activities can contribute to the advancement of more than one pathway and the pathways reciprocally strengthen each other an overview on the programmes design and activities is shown in fig 1 pathway 1 enabling african early career scientists to lead highquality tdr the first identified pathway to foster tdr in africa is to enable african early career scientists to lead highquality tdr sustainability projects through provision of dedicated funding and capacity building the programme assumed that the young scientists need not only funds but also additional knowledge and skills to develop conduct and lead highquality tdr projects in a successful way to advance this pathway the programme decided in stage 1 to combine collaborative research grants that dedicate substantial funding for knowledge codesign and coproduction and capacity building activities covering all phases of tdr the grants were announced in three calls one per year each call was developed by a scientific advisory committee composed of prominent african scientists the calls were explicit that the grants are for tdr projects and included details of the solicitation conditions review criteria and funding coverage regarding tdr the calls mentioned namely that participation of social and natural scientists are obligatory research questions must be codesigned with key stakeholders and a convincing communicationoutreachengagement approach must be presented after each call a meeting between the scientific advisory committee and the programme management took place to reflect on the lessons learned and improve the consecutive calls for instance as applicants of the first call found it difficult to understand what was meant by tdr more guidance and links to key tdr literature were given in the second and third calls the grant application process was organised as a twostep process of preproposals and full proposals with a fiveday td training course in between the key objectives of this process were to provide the applicants time to build meaningful interand transdisciplinary teams undertake initial codesign of research questions and build scientific capacity to develop highquality tdr full proposals compared to other funding programmes interactions with the applicants during the grant application process were rather intense and involved in addition to the training course detailed feedbacks on the preproposals in total 475 preproposals and 98 fullproposals were submitted to identify the most promising tdr projects the proposals were assessed using the review criteria shown in table 2 and efforts were made to identify reviewers with tdr competences however only a handful of td experts could be identified to undertake this task consequently to do justice to the tdr character of the proposals thematic experts from different relevant disciplines and practitioners were selectedin total three reviewers per proposal based on the expert reviews the scientific advisory committee selected a set of fundable projects and advised the isc on the final funding decision finally 28 projects were awarded involving 22 african countries within the funded projects the tdr approaches were diverse and ranged from singular engagements with specific stakeholder groups to engagement of other stakeholders and interdisciplinary expertise at several stages in a project timeline tdr was an integral part of the programmes monitoring and reporting system the progress reporting template included questions related to tdr which were designed to stimulate regular reflections within the project teams on their tdr experiences and to document progress and learning as a consequence of the evolving programme design projects of the second and the third cohorts were also asked to conduct a customdesigned selfreflection activity with their whole research team before the official reporting the activity aimed at fostering exchange among the team members about their td progress and growing understanding reflecting challenges and opportunities as well as identifying strategies to improve future td work the capacity building activities started with the 5days training course in the proposal elaboration stage and were continued during the research project implementation the 5days training course was offered to all 98 principal investigators of the shortlisted preproposals and aimed at enhancing the early career scientists capacities to develop tdr proposals and implement tdr projects it was designed as a modular event whereby the participants received tailored training inputs on what tdr is and how to do tdr presented their preproposals and worked on their full proposals integrating the training inputs and feedbacks after the projects started the programme supported them through further capacity building activities aiming to enhance their skills in implementing tdr the activities included training modules at the annual research fora a coaching workshop aiming to support the projects in enhancing the transformative potential of their research through designing promising theories of change the abovementioned selfreflection activities as well as peertopeer exchanges and feedbacks on the project designs and implementation performance benefits and challenges generated by these design features and activities overall the grant provision and capacity building efforts were described as the most crucial benefits by the large majority of the interviewed grantees of all three cohorts the grantees expressed that these enabled them in successfully developing the necessary knowledge and skills for designing and leading tdr projects two quotations of grantees of the second and third cohort illustrate this finding 1 the programme has allowed us to develop a deeper understanding of td research and engage stakeholders in a more meaningful manner our experience in leading projects across multiple countries has significantly enriched our expertise key learnings included the stepbystep and meticulous process of designing and implementing a td project requiring careful attention to coidentifying the research problem coimplementing the project and colearning adapting and disseminating research findings working with diverse interests and balancing power dynamics the td project has enabled me to pay attention to and recognise the significance of thinking about how to navigate issues of power within complex environments especially the 2step application process with the tdr training course between the preand full proposal and the tailored feedback from programme management and experts was perceived as particularly useful because it helped the grantees to better understand tdr and to strengthen their writing skills for tdr project proposalscompetences they did not acquire during their previous higher education training the following statement of a grantee of the first cohort illustrates this insight i believe that maintaining the twostage call is essential for the lira grant during the preproposal stage most of us were unfamiliar with td research however the td training conducted after this stage allowed us to develop our skills in tdr and enabled us to develop proposals that aligned with the programmes requirements this aspect was confirmed by the interviewed trainers and programme representatives who also stated that the quality of the proposals improved substantially throughout this process the training further helped to increase the grantees confidence in approaching societal actors as they felt better equipped to integrate them into their research projects many grantees also underlined the benefits they received from the capacity building events which were held at later stages such as coaching workshops and selfreflection activities these enabled a deepening of their understanding of what tdr is broadening of their method knowledge gaining a more accurate picture of the project progress and reevaluating the project work plan a grantee of the second cohort put it as follows the project coaching workshop proved to be valuable as it provided updated skills that had the potential to enhance project implementation at that specific time on the other hand the selfreflection workshop conducted before reporting was beneficial for ensuring proper and detailed reporting and harmonising results among collaborating partners other grantees pointed out the benefits of exchanging with their peers since this provided them with demonstrations of the many ways of doing tdr when learning about these benefits during the evaluation of the first cohort the programme extended the target audience of capacity building to further include not only pis of the second and third cohorts but also their copis the challenges highlighted by the grantees mainly concerned the programmes high expectations regarding scientific and societal impacts against the background of available time staff resources and budget grantees of the first cohort mentioned insufficient time between the tdr training and the fullproposal as an important challenge preventing them to fully integrate the learnings from the training build an interdisciplinary team and codesign the research questions together with societal actors moreover many grantees of all three cohorts stressed that 2year grants are too short for implementing tdr processes aiming at societal as well as scientific impact in two countries with different sociocultural contexts and languages some mentioned the time needed for establishment of trust and collaboration with societal actors and crosscountry exchanges others the time needed for the production of tdr academic articles the following quotation exemplifies how a grantee of the second cohort experienced this challenge the only aspect i found challenging was the funding amount per project engaging meaningfully in two different countries designing societal outcomes for these specific areas and producing publications within the provided budget proved to be very demanding other grantees experienced difficulties in implementing the research in addition to their ongoing teaching duties or highlighted the institutional bureaucracies and inefficiencies of their home universities such as accessing funds and transferring funds between different african universities grantees expressed this in statements such as we encountered logistical challenges particularly with the protracted procurement processes at our administering institution and delays in the release of the 2nd tranche of funds these issues resulted in several problems including the delayed implementation of project activities the loss of data due to the unavailability of data logging equipment deployed in participating communities a decline in motivation among research team members and study community participants as a consequence the quality of data collected was negatively affected the programme representatives acknowledged these challenges and some members of the scientific advisory committee found that the grantees were overburdened with otherthanresearch duties such as administration as the overall programme framing was set only some of these challenges could be tackled for example the programme increased the timespan between the tdr training and the submission of the fullproposals in the second and third calls from 6 to 810 weeks however the short project duration of 2 years could not be changed in addition programme representatives also highlighted the need to include university administrations into capacity building to enable proper backoffice support for scientists of future programmes i believe lira 2030 africa did not anticipate the challenge of providing funding to early career scientists who lack significant influence within their own universities to manage this funding properly i think there is a need to address this issue in a future project training must be provided to universities on how to handle seed money for early career scientists effectively an additional identified challenge was the organisation of the review and selection process namely the lack of experienced tdr reviewers for the proposal evaluation pathway 2 supporting african early career scientists to pursue a career as tdr researchers the second identified pathway to foster tdr in africa is to support african early career scientists to pursue a career as td researchers the pathway expects that africanbased tdr can only flourish if young tdr scientists can establish themselves in the existing science institutions in the long term while the first pathway also contributes to career advancement the programme found that more is needed than tdr funding and tdr capacity building to enable the early career scientist to pursue a career as td researchers this is leadership competences network building as well as scientific and institutional visibility and recognition reciprocally it is obvious that progress towards these additional goals also positively influences the grantees capacity to lead a tdr project to deliver this pathway lira decided in stage 1 to include career advancement of its grantees as an important strategic goal of the programme as a first measure the applicants had to demonstrate institutional support and mentorship by a senior researcher aimingamong othersto guarantee institutional embedment and advice once the projects started the programme regularly provided information about career opportunities such as relevant global events and funding calls moreover lira organised leadership trainings focusing on issues like scientific publishing science communication and project management as part of the annual threeday research fora these fora also fostered scientific exchange network building and the building of a community of practice with peers and experienced african tdr researchers facilitators and trainers to deepen these collaborations and enabling joint publishing the programme reallocated funds to special crossproject collaborative grants in the second part of the programme in addition the programme supported the grantees in gaining visibility and recognition in the scientific community by providing opportunities for external communication via the development of blogs and videos furthermore the programme appointed several grantees for international scientific conferences working groups and intergovernmental policy events the provided career building opportunities generated through the activities of the first and second pathway were described as helpful by the interviewed grantees they stated to feel confident in continuing to use tdr approaches in their future research and to pursue careers as td researchers a grantee of the first cohort expressed this as follows the lira project has moulded and developed me into a more mature researcher fully prepared to face and overcome the research challenges that may arise in future projects additionally it has significantly boosted my career providing me with academic credibility in my university and societal recognition for my efforts in building more resilient communities the benefits highlighted by grantees of all three cohorts included acquired knowledge and skills for doing tdr increased leadership record to independently implement own research projects improved selfconfidence and recognition within their research community and at their home universities due to their enhanced research portfolio enhanced participation in local national and international policy processes and stronger recognition by decisionmakers and community members and strengthened international networks with peers and highlevel actors from africa and beyond in the words of two grantees of the first and second cohort this sounds like this i am now part of an incredibly strong network of african td researchers which is invaluable i received sponsorships to attend and present at the 2018 united nations science technology and innovation stakeholders forum in new york exposure to high level policy processes at the international level enabled me to develop very useful networks and contacts in research and policy many interviewees trusted that their future career path will be facilitated by these benefits namely finding potential collaborators acquiring new research projects and joining forces for change some of the interviewees reported about immediate career advancements or enhanced external recognition by policy makers others were able to acquire additional funding to continue their research or dissemination activities after the programme ended the following two quotations exemplify these findings very importantly drawing on the insights and knowledge i have gained through the lira project i have been able to write much better integrated td research proposals and two of such have been funded before my acquisition of the lira 2030 africa grant i was just a senior instructor in my department which was a contract position valid for 2 years upon my acquisition of the grant firstly i was given the position of an assistant coordinator and later i was fully recruited in the university as an assistant lecturer pending promotion to the grade of a lecturer all thanks to the lira project however while increasing their competences networks and scientific recognition pursuing a career as td researcher and acquiring additional research funding continued to be challenging for the grantees several grantees reported the challenge of becoming independent tdr scientists at their home institutions and that the intended institutional mentorship by senior researchers was partly hampered due to their limited involvement and experience with tdr two grantees quit their academic careers altogether to work for civil society organisations overall the interviewed members of the scientific advisory committee were very satisfied with the achieved career advancement of the grantees and their presence at highlevel science and policy processes in particular against the background of the available funding one member even noted i think the fact that some of the grantees have had very useful intellectual and global platforms for them is phenomenal i dont think all of the achievements are visible yet often strong research relationships can take a decade or more to mature fully people go back and work with those they met years ago and this longterm impact may not be immediately apparent however another member also criticised the underfunded and opportunity driven approach which was based on the engagement of individuals rather than a systematic career building process as well as the limited institutionalisation of measures namely regarding the longterm existence of the established network one of the things i think lira should be proud of is creating a new layer of capacity building that moves away from the paternalistic approach of bringing knowledge from the north i believe the networking of sustainability scientists is one of the most outstanding outcomes of the lira programme in africa it has paved the way and provided a model for capacitybuilding programmes however the institutional connection was just an opportunistic connection not a structural one that helps continue the activities beyond the lira programme we have to question that model and that particular side of institutional collaboration the programme representatives concluded that in order to better address these issues in future research programmes more human resources and financial capacity need to be mobilised and the grantees home institutions as well as existing african networks should be more strongly integrated pathway 3 enhancing context conditions within which tdr researchers operate the third identified pathway to foster tdr in africa is the enhancement of context conditions for doing tdr it is about the context tdr scientists are embedded and reaches beyond the focus on the individual scientists the pathway assumes that existing context conditions are often unfavourable for tdr and that universities and funding agencies need to better acknowledge the characteristics of tdr to enable african early career scientists pursuing a career as tdr scientists aiming to create an enabling environment for tdr the programme fostered synthesis and communication of the projects experiences with doing tdr in africa promotion of tdr capacity building at research institutions and engagement with global research funders to mobilise further funding for african research on sustainable development synthesis and communication activities aimed to showcase the experiences of african tdr initiatives furthermore they served to demonstrate the value of tdr in these specific contexts and importantly to encourage other researchers and institutional actors to implement and support tdr efforts in africa it included the following activities grantees of eight projects jointly wrote a report about their experiences in doing tdr the learning study out of which this paper emerged was established synthesis of learnings across lira projects through collaborative grants that resulted in eight articles and programme representatives are involved in the development of guidelines for conducting tdr training courses and training for trainers initiatives that integrate african perspectives subsequently the projects insights and the related roles of tdr were communicated via videos blogs and reports to promote tdr capacity building in african research institutions the programme invited representatives of various african universities and national academies of sciences to attend the tdr training courses and to learn how tdr can be integrated in their curricula in 2019 the isc launched the initiative global forum of funders under the lira framework this forum regularly brought science funders representing national research funding agencies international development aid agencies and private foundations together to explore collaborative actions for maximising the impact of science and science funding in achieving the 2030 agenda for sustainable development particularly in the global south to date two forums took place one in 2019 and one in 2021 regarding benefits of these programme activities the interviewed programme representatives concluded that they see a certain increase in awareness and recognition of tdr in the involved african and international science institutions and among science funders they derived this conclusion from the strong interest for the programmes knowledge products which featured the value of tdr for urban development in africa as well as the work at the global forum of funders several grantees also described how their home universities have become increasingly interested and open for tdr they attributed theses changes in attitudes to the implementation of their projects and the involved tdr capacity building activities including the involvement of master students and nonacademic stakeholders some grantees also indicated that the growing responsiveness to ongoing social challenges at their institutions led to an increased acknowledgement of the importance of tdr in tackling those challenges however our findings also demonstrate how institutional policies within many science institutions still remain partly unfavourable for tdr the programme representatives recognised that this pathway focusing on the context of tdr requires longterm strategic and collaborative action from scientists universities science funders science policy makers and governments far beyond what can be provided within the framework of a single programme against this background they emphasised the programmes engagement with other science funders at the global forum of funders which is perceived as an important first step towards upscaling collective efforts that enables science funders to foster tdr more effectively moreover more explicit and formal commitment towards this pathway would be needed including substantially more resources and time dedicated to interactions with african science institutions and other existing networks and programmes for creating strategic longterm institutionalisation of the emerging changes discussion and concluding remarks this paper aimed to contribute to evidence building on how research funding programmes can foster tdr for advancing sustainable development in africa the lira programme served as an empirical case as it is the first funding programme supporting tdr in africa on a continental scale studying the programme we identified three interrelating pathways to impact and related activities through which the programme aimed to foster tdr a enabling african early career scientists to undertake highquality tdr projects b enabling african early career scientists to pursue a career as tdr researchers and c enhancing the context conditions for doing tdr in africa programme activities related to each pathway came along with manifold benefits such as learnings related to tdr scientific recognition visibility of african researchers in international debates and enhanced collaboration across funders overall the programmes contributions to tdr capacity building might be most innovative going far beyond reported activities of other funding programmes capacity building started with a training course during the application process and continued with additional training and learning activities such as the coaching workshop or the selfreflection activities during research implementation these enabled the grantees to deepen their understanding reflect on their own processes learn from the experiences of other researchers and continuously finetune their tdr approaches to our knowledge no standardised capacity building curricula for tdr funding programmes exist to date hence the experiences gained in the lira programme can serve to contribute to the development of such a curriculum from the broad range of benefits and learnings mentioned by the grantees we conclude that it is important to cover the whole value chain of tdr but with a clear focus on actionable knowledge learning by doing and selfreflection moreover it is important to adequately phase the learning activities starting with inputs that are needed to design high quality proposals followed by instructions for operationalization of research and eventually providing insights for bringing results to fruition challenges were also substantial andnot surprisinglyincreased from the first to the third pathway as the impact goals became more ambitious and systemic nevertheless we conclude that the very combination of the three pathways is required for fostering african leadership in tdr in the longterm taken that many applicants and later grantees had only limited experiences in tdr the combination of research funding with capacity building and career development proved to be key moreover several experienced challenges were related to unfavourable context conditions such as limited institutional awareness and recognition of tdr approaches as well as limited opportunities for longterm td career development and for acquisition of additional funding all of these challenges underline the importance of the third pathway to impact however truly enhancing this third pathway would require more dedicated focus activities and resources than the programme could provide these findings correspond with studies about african science systems which highlight that improvement of research capacity in africa requires not only capacity building of individual researchers but also institutionbuilding interventions moreover it corresponds with recent studies stressing that funders can and should support and incentivize tdr through various means ranging from provision of grants capacity building to collaborations among funders the three pathways specifically targeted african early career scientists taking into account their specific contextual conditions and needs nonetheless we think that the pathways might also be suitable for other target groups both in the global south and north as competences in tdr are still not part of most university curricula and context conditions are notoriously unfavourable for tdr careers the study also confirms previous insights about tdr funding programmes stating that such programmes must plan their activities throughout the programme stages to adequately support whatever pathway they have chosen to pursue namely these activities involve the programme development and application process project support monitoring and evaluation and external communication while activities at all programme stages are important we found that those at the beginning need particular attention as they not only determine the framework but also develop the skills required for the later stages while this finding on setting the scene is broadly recognised for issues like solicitation criteria we could show that it is also true for engagement with societal actors and capacity building in this respect we would like to highlight the twostep application process with time allocated for codesign and the tdr training course taking place during this process which was highly valued by all participants and considerably helped to secure initial engagement of project partners and improved the quality of the proposals and later research in conclusion the results of this study highlight the importance of implementing and critically reflecting such novel funding programmes for strengthening the sciencesocietypolicy interactions in africa and tackling science inequalities between the global north and south taking the learning of this study into account the programme can be regarded as a prototype for future funding programmes aiming to foster tdr research tdr capacity building and tdr leadership competences more exploration and research is needed to identify suitable programme activities for transforming the context conditions of tdr as outlined in the third pathway to impact last but not least the challenging context of the endeavour suggests that implementation of such novel programmes are embedded in systematic learning processes which allow to learn from early experiences and continuously implement improvements data availability different datasets were generated andor used in this study data of the final survey is accessible on request via doi 105281 zenodo8238101 the analysed programme documents and the transcripts of the interviews are not publicly available due to confidentiality reasons competing interests the two coauthors representing the programme were employed by isc on the funding line mentioned in the acknowledgements ethical approval the applied method followed swiss regulations neither approval from an ethics committee nor written consent to participate is required according to swiss regulations we certify that the 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

advancing global sustainable development hinges on strengthening the connections between science society and policy as well as addressing existing science inequalities research funding programmes play a pivotal role in this context but little is known about how they can actively nurture required transformations of the science systems in this paper we investigate how science funders can actively promote sciencesocietypolicy interactions through transdisciplinary research tdr as a means to advance sustainable development in the global south our primary focus is on the research funding programme lira 2030 africa our research has revealed three closely intertwined pathways for cultivating tdr in this context 1 enabling african scientists to lead highquality tdr projects 2 empowering african scientists to pursue a career as tdr researchers and 3 enhancing the context conditions for doing tdr in africa by scrutinising the advantages and challenges associated with these pathways and their associated activities we conclude that fostering tdr in africa necessitates a multifaceted approach this approach entails a combination of measures such as providing research grants offering tdr and leadership training fostering networks developing institutions and facilitating collaboration across various funders

introduction conventional risk factors for cardiovascular disease such as smoking hypertension high cholesterol levels and physical inactivity have been associated with later risk of cvd 1 and shown to explain most of the cvd cases in many populations 2 knowledge on these risk factors forms the basis for primary and secondary prevention in populationwide efforts and clinical settings 1 early life factors 3 4 have been proposed as important contributors to adult cvd risk and mortality as well as to cvd risk factors 5 6 factors in early life could be shared by siblings such as parental socioeconomic position parental practices housing and neighbourhood and include a 50 shared germ line for full siblings nonshared factors include systematic elements such as birth year and birth order and nonsystematic chance events such as siblingsibling interactions differential parental treatment and peer groups the socioeconomic gradient in cvd has been partly explained by early life factors in some 7 8 but not all 9 10 studies in one study the association between education and body mass index was attenuated when adjusting for early life family factors 11 a recent norwegian study reported a confounding effect of early life factors on the association between cvd risk factors and education 12 early life family factors have however not been shown to explain the association between ► additional material is published online only to view please visit the journal online to cite kjøllesdal mkr ariansen i mortensen lh et al the importance of early life family factors in the association between cardiovascular risk factors and early cardiovascular mortality open heart 20174e000608 doi101136 openhrt2017000608 early life circumstances have been shown to be important for later cardiovascular risk and mortality and to partly explain socioeconomic differences in cardiovascular disease what does this study add this study explores the influence of early life family factors on the association between cardiovascular risk factors and cardiovascular mortality this indicates to which degree cardiovascular risk factors are established in early life or modifiable in adulthood how might this impact on clinical practice the association between cardiovascular risk factors and cardiovascular mortality was not extensively influenced by early life family factors thus targeting conventional risk factors in adulthood should continue to play a major role in the prevention of cvd even though early life interventions also are of importance the actual risk estimates used to target highrisk individuals in adulthood can continue to be used in practice cvd 13 14 or its risk factors like hypertension 13 15 and low birth weight to what extent the association between levels of cvd risk factors and cvd mortality is confounded by early life family factor remains to be explored this has practical implications as it indicates to which degree risk factors for cvd are established in early life or modifiable in adulthood large data sets such as register data and data from large health surveys give the opportunity to explore the importance of factors shared by siblings by comparing results from analyses of associations between all individuals in a cohort to results from sibship analyses which omit factors that are constant within sibships in the same sample thus the aim of this study was to explore the importance of early life factors shared by full siblings for the association between each of the cardiovascular risk factors systolic blood pressure total cholesterol bmi height and smoking and later mortality from ischaemic heart disease cerebrovascular disease and all cvd combined the study was carried out in a sample of relatively young adult women and men using data from the norwegian family based life course study 16 methods study population data from national and regional health surveys in norway were linked with data from the norwegian population registry data from the nflc study 16 and the cause of death registry using personal identification numbers in the counties study all men and women aged 3549 years living in three different counties in norway were invited to cardiovascular screening 17 in the age 40 program inhabitants aged 4044 years from all counties in norway except from oslo were invited 18 the cohort of norway is based on data from regional health surveys with participants aged 20103 years 19 the attendance rate of the three surveys were 86 70 and 58 respectively 17 18 19 for the current study all participants from the counties study the age 40 program and conor born in 1940 or after were selected if they attended more than one health survey data from the first survey attended were used the study population consisted of participants with at least one full sibling among the health survey participants the index persons mother and father were identified by linkage in the nflc study 16 parental identification has proven to be reliable for persons born in 1940 and after 16 the study population consisted of 271 643 participants cardiovascular risk factors in all health survey screenings selfreported smoking status and current treatment of hypertension were recorded blood pressure was initially measured manually by sphygmomanometers and later by automatic oscillometric measures 20 height and weight were measured and bmi was calculated nonfasting tc was initially measured by nonenzymatic and later enzymatic method nonenzymatic values were converted by a correction factor 21 acceptable stability of bp measures and laboratory analyses over time in the population surveys have been reported 20 21 cardiovascular mortality data on underlying causes of death from ihd 410414 international classification of diseases 10th revision i20i25 cerebrovascular disease and all cvd combined were obtained from the norwegian cause of death registry participants were followed from time of survey to death or end of followup with a mean followup time of 19 years statistical analyses sbp and tc were categorised according to the framingham model 22 with low medium and high risk bmi was categorised according to established cutoffs normal weight 25 overweight 25299 and obesity ≥30 kgm 2 very few participants were underweight so those participants were included in the normal weight category height was categorised into tertiles 167 1671759 and ≥176 cm cox proportional hazards regression model with age as underlying time was used to estimate hrs of mortality from cvd ihd and cerebrovascular disease according to categories of risk factors time at risk was counted from a participants entry in the study individuals who did not die during followup were censored at their age at the end of followup in the cohort analyses where all participants were analysed with no regard to sibships we used huberwhite sandwich estimator to correct standard errors which otherwise may be underestimated due to familiar clustering the cohort analyses should produce results similar to those found in studies of unrelated individuals for the within sibship analyses where each sibship had a groupspecific baseline hazard we used the stratified cox regression model of holt and prentice 23 the proportional hazards assumption was examined by first plotting the scaled schoenfeld residual against age supplemented by a global test of a zero slope in the association between age and the scaled schoenfeld residuals the analyses were run adjusted for sex and birth year in regressions were sbp was the exposure analyses were additionally adjusted for being under current treatment for hypertension we compare the cohort and sibship analyses to assess the importance of shared environment in sibship analyses only those with a sibling in a discordant cardiac risk factors and prevention risk factor category contributes to check the impact of this we run cohort analyses including only those with a sibling discordant in risk factor category sensitivity analyses were also run adjusting for size of sibling group and index health survey spline curves showing the predicted hr for cardiovascular mortality at different levels of sbp tc and bmi were estimated from cox proportional regression models entering risk factors as restricted cubic splines the intraclass correlations for continous variables describing how strongly individuals within sibling groups resemble each other were estimated using a random effect model adjusted for age the population attributable fraction was estimated in both cohort analyses and sibship analyses for the association between the risk factors sbp tc bmi height and smoking and mortality from ihd cerebrovascular disease and cvd using cox regression reference value was lowest risk category data was analysed using stata v14 the study was approved by the norwegian regional committees for medical and health research ethics results the mean age of the participants was 41 years and 84 of the sample was between 40 and 45 years only 4 were below the age of 40 at the end of the followup 2512 had died from cvd including 1662 from ihd and 552 from cerebrovascular disease mean age at the time of censoring was 60 years of participants 60 had one sibling in the sample 26 had two 9 had three and 4 had four or more siblings the proportions of participants having a sibling in a discordant risk factor level were about or above 50 for all risk factors the intraclass correlations for the cardiovascular risk factors were strongest for tc and lowest for sbp the risk of total cvd mortality and ihd mortality increased with higher values of sbp tc and bmi with smoking and with lower height the hrs in higher risk factor levels were somewhat attenuated in within sibship analyses compared with cohort analyses the increasing hrs of cvd mortality with increasing values of sbp tc and bmi are shown in figure 2ac respectively with the risk factors entered as restricted cubic splines spline curves for ihd are shown in online supplementary figure 1 the risk of cerebrovascular disease mortality increased with higher levels of sbp and tc with smoking and with lower height in within sibling analyses estimates were slightly attenuated for sbp and smoking however not for tc and height for which the estimates were slightly increased pafs of sbp tc bmi height and smoking on mortality from cvd ihd and cerebrovascular disease are shown in table 5 the paf estimates show how much of the cvd mortality that could be accounted for by each risk factor for example 43 of all cvd deaths were attributable to smoking and if everyone had been in the lowest risk category for tc half of all ihd deaths would be avoided the risk factors contributing the most to cvd and ihd mortality were smoking and tc and to cerebrovascular disease mortality smoking and sbp paf estimates in sibship analyses were somewhat lower than in cohort analyses adjusting for index health survey or size of sibling groups in sensitivity analyses did not change the results essentially when including only those with a sibling discordant for risk factor category in cohort analyses on cvd mortality no substantial changes were seen for sbp bmi and height regarding tc per step hr was attenuated towards the hr in sibship analyses and the per step hr for smoking became lower than in sibship analyses for ihd mortality no substantial changes were seen in per step hr for sbp or bmi however estimates were attenuated towards sibship estimates for tc and height and below sibship estimates for smoking regarding cerebrovascular disease mortality cohort estimates were increased for sbp tc bmi and height and attenuated for smoking only discussion the risk of cvd mortality increased as expected with raised levels of sbp tc and bmi as well as with smoking and with lower levels of height 2 within sibship analyses suggested that early life factors to some degree confound the association between cvd risk factors and death from cvd and ihd however importantly most of the association between risk factors and mortality was unrelated to early life factors the results should be interpreted in light of the fact that the sample was relatively young for cvd one previous study in a cohort overlapping ours have reported less variation of cvd risk factors within table 4 continued sibships than between individuals 12 confirming some importance of early life factors on cvd risk factors an association between childhood sep and adult bmi has previously been reported by some 24 but not all 25 studies sbp has been weakly associated with childhood sep 24 25 and smoking has been mostly attributed to adult sep 26 childhood sep is one of the important early life factors siblings share thus a modest intraclass correlation for risk factors within sibships suggesting fairly large variation is in line with previous research we found early life factors to be less important for the association between the cvd risk factors under study and cerebrovascular disease than for the association with ihd and total cvd risk factors not included in this study such as previous heart disease and diabetes could be more important for cerebrovascular disease 27 if we had such risk factors included the importance of early life family factors for the association between cerebrovascular disease and risk factors might have been stronger height in adulthood is a composite measure of health and nutrition during growing years and genetic disposition it is a trait potentially modifiable in the period where most siblings share environment but will generally not be influenced by adult lifestyle factors up to late 1980s the height of norwegian conscripts was increasing but has later been stable 28 the majority of our study population was born before the flattening of the height trend it is thus plausible that adult height is related to environmental factors during childhood like access to material resources including adequate nutrition height therefore serves as a model exposure for shared early life environment in sibling design as other cvd risk factors examined are modifiable also in adult life where most siblings does not share environment and the effects of shared early life environment within sibships might be diluted by differential adult lifestyle the attenuation of association between height as well as bmi and cvd mortality was considerable between cohort and within sibling analyses confirming our hypothesis that early life factors are at play assumptions in sibling design only siblings discordant in exposure contribute to the estimation of the impact of early life family factors on the association under study using more risk strata would have given more siblings in different categories we did cardiac risk factors and prevention however consider the use of three conventional risk categories practically and clinically relevant confounders could be the cause of discordance in risk factors and thus cause estimates for risk factor levels to become stronger in the sibship analyses 29 families with discordant and concordant risk factor levels among siblings may differ for example in families where all siblings have a preferable risk factor profile this may be due to both health related habits and genetic disposition siblings with discordant risk factor levels despite shared childhood circumstances may differ more in nonshared factors than two random persons do it may also be that they were in different age groups including only those with a sibling in a discordant risk factors group in cohort analyses did not change results essentially matching siblings on known mother and father probably gives siblings sharing more of early life environment as well as of the germ line than siblings defined as having the same mother only we do not know however whether some parents separated during early life a divorce might have influenced the extent of early life factors shared by siblings up to the 1960s divorce rate was low and constant at 4 per 1000 marriages in norway during the 70s and beginning of the 80s it rose to about 7 per 1000 marriages 30 we rely on shared early life factors to contribute to the estimation of early life confounding on risk factor differences in cvd mortality if such factors are not fully captured by being siblings the confounding effect may be larger than our estimates circumstances in a family may change due to factors not shared by siblings for example more children means less resources on each adjustment for size of sibling group produced little change in results strengths and limitations this populationbased study had a large sample size and the ability to study the impact of early life environment on associations between cardiovascular risk factors and mortality using sibship analysis use of register data by large sample size eliminates problems related to loss to followup the response rate of the health surveys from which data originated was reasonable the majority of the sample was in their 40s at screening and many subjects did not reach an age during followup where cvd mortality is probable mean age at censoring was 60 years and mean age of death was 55 years thus our results confine roughly to premature cvd death if we had the possibility to follow the participants for a longer period more deaths would have occurred and the importance of early life factors for the associations between risk factors and mortality might have changed to account for possible secular trends in risk factors cvd deaths and attained levels of education we adjusted the analyses for birth year we also adjusted for sex as stratification on sex would have left fewer sibling comparisons and considerably reduced the power of the analyses further the inclusion of any variable that is associated with the outcome may cause the estimates of other variables to inflate even in the absence of confounding in a cox regression 31 this might counteract the attenuation of confounding by early life factors implications associations between adult risk factor profile and future mortality from cvd and ihd vary to some degree with shared early life family factors however the cvd risk factor profile is strongly associated with mortality regardless of early life factors targeting conventional risk factors in adulthood should thus continue to play a major role in the prevention of cvd even though early life interventions also will be of importance for later cardiovascular risk contributors øn conceived the idea for the article mkrk did the statistical analyses and the drafting of the article all authors contributed in the final stage of the writing funding the work was supported by the norwegian research council competing interests none declared patient consent new consent is not required as consent was obtained at the time the data was collected and by those who undertook the study

objective to explore the importance of early life factors shared by siblings such as parental socioeconomic position parental practices housing and neighbourhood for the association between cardiovascular disease cvd risk factors and mortality from cvd ischaemic heart disease ihd and cerebrovascular disease methods norwegian health surveys 19742003 were linked with data from the norwegian family based life course study and the cause of death registry participants with at least one full sibling among survey participants n2 71 643 were included data on cvd risk factors body mass index bmi height systolic blood pressure sbp and total cholesterol tc were stratified into low medium and high risk and smoking to daily smoking and not daily smoking results mean age of participants was 41 years mean followup time was 19 years and during followup 2512 died from cvd for each category of increased risk factor level the per step hr of cvd mortality was increased by 191 95 ci 178 to 205 for sbp 167 158 to 176 for tc 144 136 to 153 for bmi 126 118 to 135 for height and 289 266 to 314 for smoking in analyses where each sibship groups of full siblings had a groupspecific baseline hazard these associations were attenuated to 1 74 151 129 118 and 263 respectively the associations between risk factors and ihd mortality followed the same pattern conclusion early life family factors explained a small part of the association between risk factors and mortality from cvd and ihd in a relatively young sample

the year 2022 marked the twentieth anniversary of the social evolution history journal so there is a nice reason to sum up some results and evaluate the path of the journal over the past two decades one may argue that the achievements are very impressive the journal has obviously become a significant phenomenon in the world science over the past twenty years 375 articles have been published in the journal while among the authors one may find many worldrenowned experts in the field of the social evolution theory undoubtedly the main merit here belongs to the inspirers and founders of the journal who managed to gather all these great scholars into a single and very productive scientific community on the one hand the subject matter of publications is very wide on the other hand the journal obviously focuses on the key problems of social evolution in modern science i think even just the titles of the articles may be rather illustrative here let me list only some of them alternative pathways of social evolution was the chiefdom a congelation of ideas was the state inevitable democracy and early state bands fertility and within the framework of the present review article it is impossible to consider all the published articles or even just mention each of them however i do not see the point in doing this since i do not set myself such a task here moreover in the age of the internet an interested reader can visit the journal homepage and use the available index of articles to find any article needed therefore not to turn into a simple telegraphic retelling of just a part of the works published in the journal we define the objective of the present review as a reflection and commentary on some of the most important and interesting issues raised by the authors of publications and first of all of course it is worth performing a certain generalization of the considered set of articles so if one decides to group all the articles published in social evolution history according to the topic it becomes clear that they mainly focus on several issues which will be presented below in particular a number of articles are devoted to social evolution in general parallels between biological and social evolution to industrial revolutions discussion of the creative heritage of ernest gellner the problem of periodization of history big history mathematical modeling of population dynamics and sociodemographic cycles evolution of globalization i would also point out the subject of the formation of world systems is covered in a significant number of interesting articles and here the ideas of andrey korotayev and leonid grinin who proposed the emergence of the first world system during the neolithic revolution in the middle east are of particular interest according to korotayev and grinin the formation of the first world system should be attributed to the end of the upper paleolithicmesolithic the physical substratum of this first worldsystem was the migration of speakers of denecaucasian languages from eastern eurasia to the west and native speakers of the altaic languages from western asia to the eastern part of eurasia 1 articles devoted to the study of particular societies occupy a prominent place in the journal considerable attention is paid to the societies of africa there is also a noticeable number of articles examining the societies of ancient mesoamerica and china polynesia ancient and especially medieval nomads of central asia ancient societies of the middle east egypt and india and also medieval europe 2 however a considerable part of the journals articles are devoted to the origin of the state and the early state one may count at least eighty articles yet we should note that one way or another the problem of the emergence of the state is also covered by a number of other articles however on the other hand some of the articles addressing the early state issue de facto consider it on a much broader scale that is as a phenomenon of politogenesis albeit extremely significant as dmitri bondarenko leonid grinin and andrey korotayev emphasized among the students of politogenesis one can observe a tendency to narrow the analysis to the study of the state formation process only … in order to find solutions for a certain range of political anthropology problems it is necessary to consider the genesis of early state in the general context of socioevolutionary processes coeval with it or moreover as a part of social evolution in general starting from the emergence of the early state they eventually answer questions about the general laws of social evolution therefore in some cases it would be difficult to unambiguously attribute this or that article within the framework of the proposed classification anyway if we talk about eighty articles belonging to this group most of them present theoretical studies with a comprehensive coverage of considered data and with broad generalizations and in fact their central point is the discussion of robert carneiros concept of the socalled circumscription theory in which both supporters and opponents of his proposed model of the emergence of the first states participated however few of these eighty articles represent narrow studies of individual societies yet they are eventually also involved in the discussion on the relevant reasons for the emergence of the first states proposed by robert carneiro actually this is both an indicator and a direct consequence of the scientific importance that carneiros concept represents no doubt is one of brightest achievements in the twentieth century macrosociology rozov 2012 86 and although as some of the participants of the discussion rightly point out carneiro has many predecessors holding different political views beginning with gesiod it was carneiro who managed to give this idea which had been in the air for a long time the form and meaning that made it the central point in the discussion of any issue in connection with the problems of emergence of the first states for more than half a century nevertheless we should note that almost simultaneously and throughout the past halfcentury some alternative positions to carneiros concept were expressed and argued the authors of these alternatives are very authoritative scholars however carneiro himself presented many of his opponents in great detail in an extensive sixtypage article published in the journal in answers to critiques therefore it seems the best choice to arrange this article as a comment on the margins of the discussion about robert carneiros theory so first of all it seems to me that the assessment that carneiro gave to the idea of multicausality is completely justified the latter in its ultimate expression actually leads to the denial in general of the possibility of creating a general theory of the emergence of the state the first interpretation of multicausality let me repeat holds that in every case of state formation a different set of factors was at work each state that arose in egypt in china in the andes or anywhere had its own unique set of determinants no single theory could hope to account for more than one or two instances of it carneiro argues that it is possible to single out a certain limited set of factors that was common to all cases of the emergence of the first states all states regardless of how disparate they may have been in detail had at least certain basic elements in common they each arose through the combined action of the same small set of factors the role of each factor need not have been exactly the same in every case but their joint operation was sufficient to give rise to the state wherever it arose and as far as the degree of my awareness in the matter allows me to judge i believe that in this case it is robert carneiro who is closer to the truth moreover it seems that we should definitely take the next step in this direction and using the ideas and conclusions from synergetics we should raise the question of the socalled control parameter which acts as a kapellmeister in the orchestra in the group of four or five factors that carneiro speaks about however carneiro himself actually comes to defining such a control parameter summing up the results of the discussion on the circumscription theory on the pages of the journal carneiro formulates the following definition the core of the theory though remains the same it can be encapsulated in the following proposition a heightened incidence of conquest warfare due largely to an increase in population pressure gave rise to the formation of successively larger political units with autonomous villages being followed by chiefdoms the process culminating in certain areas with the emergence of the state without going into a discussion here about the pivotal role of war 3 in the emergence of the first states it seems appropriate here to focus precisely on the key factor defined by carneiro and this is just the control parameter for the emergence of the first states moreover this is the control parameter which retains its effectiveness throughout the whole existence of humankind and it is the population pressure in his works robert carneiro also spoke about population pressure elsewhere i introduced the parameter of complication of the anthroposphere however one should take into account that one of the key component of the complication of the anthroposphere is just the population growth thus using the terms close to those employed by carneiro we should rather define this parameter as complication pressure of course in each particular case the factor of complication of the anthroposphere interacted with a different set of variables in one way or another and obviously this is the reason for the possible alternative pathways of social evolution however in my opinion carneiro is absolutely right that this whole range of possible options for answering the call should not prevent us from seeing the forest for the trees however the critics of carneiros concept strongly disagree with its key idea about the role of population pressure thus henri claessen writes from the comparisons it appeared that all cases developed in a situation of relative wealth they were not a consequence of hunger or population pressure however it seems that in this respect the positions of carneiro and of many his opponents are quite prone to convergence below i will try to prove this first of all basing on the understanding of the complexity of the anthroposphere as the desired control parameter i should point out that some of carneiros ideas formulated in the framework of the circumscription theory probably need clarification in particular his idea about physical barriers as a crucial prerequisite for the emergence of the first states when population is growing in a region tightly hemmed in by physical barriers such as mountains deserts and oceans the pressure exerted by this growing population is prevented from dissipating by escaping into surrounding regions note that carneiros opponents doubt this thesis as well carneiro postulates that in a circumscribed area a shortage of food causes tensions between the inhabiting tribes that inevitably lead to a war of survival after which the defeated groups have to leave the region or accept a subordinated position the organization to suppress the defeated is the state the findings in this article are hardly supportive for carneiros views with the possible exception of tongatapu there was not found a region with circumscription neither the river valleys nor oaxaca nor china nor the grasslands of ghana show traces of it it is very well possible that after the emergence of the pristine state in one or more of the regions the population pressure increased so that a struggle for survival might have occurred this then however was not a cause of state formation but a consequence however contrary to the skeptics it seems to me that having proposed just two new types of circumscription carneiro brilliantly elaborated his theory so in its revised form the theory explains the examples cited by claessen to the full extent further it seems important to take the next step here and to generalize the idea of physical barriers to the level when mountains deserts and oceans are considered only as particular cases of the basic key parameter of social circumscription and respectively one should generally assume that every human society faced the most important and significant physical barrier that is the neighboring societies the impact of these barriers increased over time as human societies grew in number and complexity eventually turning into states mountains deserts and oceans were a very significant barrier at the dawn of human history however one should not overestimate to what extent they are impenetrable for potential migrants and the stronger was the stimulus for a particular society the more permeable were these barriers but from a certain moment their relevance as physical barriers became increasingly inferior to the significance of the primary factor of social circumscription as for the resource concentration i repeat it is actually only a particular case among a number of physical barriers so one may point to the fact that the constraining factor here is the area within which a successful functioning of a certain ect is possible at the same time i think such an area should not be necessarily anything extraordinary in terms of abundance of resources there may be no less resourcerich areas near but they may be different and requiring different management skills and approaches i am inclined to consider the history of reclaiming the prairies by north american indians as an example of this kind the richest region in terms of resources including inexhaustible food reserves was mastered by the prairie indians rather late and only as they were forced to leave their former habitat under the pressure of strong enemies thus it was often the habit of a certain economic mode that kept people in certain territory and in a relatively overpopulated region and its influence was often much stronger than of some external constraints and the more specialized this ect was the more expensive adaptation was required when moving to a new area and the stronger was the influence of the limiting factor moreover one should keep in mind that farming in different areas may vary thus farming for example in the forest zone of eastern europe requires different skills habits and knowledge than farming in the steppe zone of eastern europe there is also no doubt that the emphasis should be probably shifted to the term habit habits were the most important reason why the adaptation to a certain ect turned into a kind of a physical barrier that limited migration it was first of all the inertia of thinking and habits this conclusion can be exemplified by the attempts to relocate russian peasants to the far east which were undertaken during the socalled stolypin reforms they came across just the most powerful inertia of the russian peasant consciousness and habits which prompted them either to refuse resettlement or even to return back finally basing on the ethological observations over the behavior of species forming colonies we should apparently consider the ethological mechanisms that encourage individuals to concentrate in space as another significant component of the social circumscription which provides them with advantages in interacting with other individuals of their species having discussed these issues we can now return to the abovequoted claessens remark concerning the origin of pristine state from the comparisons it appeared that all cases developed in a situation of relative wealth they were not a consequence of hunger or population pressure elsewhere i presented my ideas on this issue while the idea about relative wealth is beyond doubt along with the fact that they were not a consequence of hunger then the conclusion about the absence of population pressure makes us pose the question does this conclusion relate to societies which are known exclusively due to archaeological data 5 in any case it is evident that even the assessment of the population size in such cases will be only approximate and even more doubtful is our ability to establish the presence or absence of population pressure in this case moreover we should remember that traditional societies had a number of traditional and apparently very effective mechanisms to control the population size which were applied when the resource limit was approached and i think these mechanisms normally kept traditional societies from slipping into the socalled malthusian trap thus taking into account these restraining mechanisms one may wonder to what extent the supposed overpopulation crises represented sharp population jumps and to what extent did they present what i would rather define as more or less small but constant smooth demographic pressure which would be even more problematic to define for the societies known only from archaeological data however claessen while denying population pressure for primary states apparently proceeds exactly from the fact that they were not a consequence of hunger but on the contrary were in a state of relative wealth well for me it is also explicit that a vast majority of archaic societies were able to obtain a surplus product yet they often did not use it that is why i offer to use the concept of a potential surplus product which as far as i can tell was characteristic of virtually any traditional society of the past even the kalahari bushmen the inhabitants of a very resourcepoor region periodically found themselves in a situation when they could not even get close to mastering the available food resources which literally rotted under their feet however the fact that all archaic societies were doing quite well with food security and they apparently did not experience permanent hunger at all does not mean that these societies did not perceive the pressure of population growth and pressure under the complication of the anthroposphere at that the population growth should have obviously influenced not only food but also many other resources including intangible ones that people need in particular population growth should have affected the provision of traditional societies with such a resource as space and one may suppose that one of the factors of the transition to settlements was caused just by reduced opportunities for free movement of human collectives over long distances in other words one should not reduce the concept of malthusian crises to excessive demographic pressure only on food resources since it is obvious that a person feels the need not only for material resources but also for nonmaterial ones and moreover a reasonable question arises here what kind of resources turn out to be the vulnerable aspect which comes first under demographic pressure so we can make an assumption that intangible resources may become just that vulnerable aspect therefore taking into account the above said one may argue that the conclusion of the most radical critics were only possible because they were in areas of unique abundant wildrenewable food resources stocker and xiao 2019 166 regardless of its validity is by no means a reason for rejecting carneiros theory on the contrary this conclusion fully agrees with carneiros theory and it should be interpreted in such a way that at a certain stage of humankind historical development the factor of population pressure became especially sensitive on a planetary scale for societies that lived in regions with abundant resources and at the same time possibly limited by some physical barriers which led to the fact that these societies perceived the pressure of social circumscription earlier than others and this in turn led them to the need to develop social mechanisms to compensate for the pressure of social circumscription which inevitably leads to the emergence of the state since the creation and maintenance of the state requires serious economic costs and expenditures the societies that lived in less favorable regions would come to the emergence of the state when under the influence of the complicated anthroposphere the costs of the absence of the state were outweighed by the efficiency of its creation and maintenance of functioning i believe that such an economic formula is the verbal model that expresses the essence of carneiros theory in the briefest form and which can also be used to create an adequate mathematical model of the process of the emergence of states and social evolution in general thus summing up we can say that in my opinion carneiros theory has completely passed the test of discussion in fact the opponents critical remarks may well be integrated into it and this may only contribute to its improvement and refinement and concluding this comment on the discussion on carneiros theory and the article in general i want to note that it was thanks to the journal social evolution history that such a significant clarification of the ideas about the causes mechanisms and processes of the emergence of primary states became possible thanks to this discussion notes 1 andrey v korotayev also investigates the early history of some of the main language macrofamilies of eurasia including in his extremely interesting articles published in social evolution history this is i think an example of a broad interdisciplinary synthesis based on data from linguistics genetics archaeology and anthropology i am really impressed by the approach used by the authors of the article i believe that it can be applied to other cases for example to establish the actual role of wars in the societies speaking afrasian nostratic and denecaucasian languages in the early period of their history also i quite agree with many of the conclusions made in that article in particular the authors supported the idea of alexander y militarev about the localization of the ancestral homeland of the afrasians in the area of the natuthian culture one may also agree with the idea that the recent genetic data do not contradict the soft version of the anatolian hypothesis however my approach proceeds from different reasons and is based on a different model and scenario of the formation of the indoeuropean linguistic community however the steppe hypothesis of the origins of the indoeuropean languages seems unconvincing even if one proceeds from purely genetic data even more so if one takes into account the respective archeological data i think also that attempts to connect the protonorth caucasian linguistic community with various branches of nry haplogroups g or j will fail as i tried to demonstrate the speakers of the denecaucasian languages at the time of their formation and up to the collapse of this community were carriers of haplogroups r and q of y chromosome 2 the question of the origin of the old russian state is of particular interest to me since it has long been the focus of my academic activities the scope of this article however does not allow me to pay any extensive attention to this issue here nevertheless i would like to draw attention to one fundamentally important point namely to the idea that ancient rus was created as a result of treaty between the local elite and part of the varangians and accordingly the emergence of the old russian state is associated with the control of the scandinavians over trade routes from the baltic sea to the caspian and the black sea the international trade which had been monopolized by the middle of the 9 th century by the strange varangians in my opinion this is obviously not the case as follows from the analysis of the entire set of sources ancient russia arose thanks to the consensus among the local elites who would invite only one varangian rurik with brothers and the squad of course however it does not mean a part of varangians moreover that rurik represented any center of power from scandinavia the agreement was not between the local elites and the varangians the agreement was between the local elites and rurik as a compromise that satisfied everyone in local elites besides following the sources we should not automatically equalize varangians with scandinavians and each case should be studies since the answer may be different well similar aberrations occur in many researchers of the problem they begin by adopting the model of the invitation of the varangians and the agreement with them then their reasoning and interpretations incomprehensibly start to follow the idea of the scandinavian conquest of the slavs and this by no means corresponds to the data from the written sources or to the data from archaeology linguistics and physical anthropology 3 also in the discussion if chiefdom represented a stage in the emergence of states norman yoffee rejects the traditional evolutionist views and holds that pristine states did not develop from chiefdoms our findings confirm his views with the exception of tonga there are no clear cases in which chiefdoms were found before state formation took place the case of oaxaca is not clear 4 however some of these defenders seem to have changed their minds somewhat later the general impression is that conquest warfare should be regarded not as a cause of chiefdom and state formation but rather as one of its results without going into the discussion again we think that their earlier point of view still seems to be closer to the truth in addition we must take into account such an important aspect of the problem as the sociocultural relativity of the phenomenon that we call war what representatives of one society consider as a nice morning squabble between loving spouses the representatives of the other society may figuratively speaking consider equivalent to a nuclear conflict of medium intensity the fact that at least some of the reasons for such a difference in the behavior of representatives of different societies are quite clear today and should not be regarded as a reason to doubt the existence of a causal relation between population pressure and the growth of conflicts within and between human societies on the contrary the idea that in extreme environment the huntergatherers behavior became flexibly territorial and mildly aggressive because it was absolutely necessary for survival allows explaining why the correlation between population pressure and warfare is so difficult to grasp for human societies at the same time the conclusion seems reasonable that the emergence of states became a new powerful factor for the growth of warfare 5 the societies considered by henri claessen belong precisely to such type i would like also to note that in the case of the first states in egypt the real course of events seems to me somewhat differs from the one from which claessen proceeds from also it seems doubtful that ghana and tonga may be attributed to the primary states as well it seems that claessen does not take into account such a parameter here which i would define as planetary historical time so one must take into account that societies that emerged relatively late in the regions separated from the primary centers of the emergence of statehood in fact were not radically cut off from planetary information flows thus in their emergence they could well rely on historical experience of other societies that have already become states

the paper presents a review of articles published in the social evolution history journal since the 2002 until present over the past twenty years 375 articles have been published in the journal the subject matter of publications is fairly comprehensive however the journal obviously focuses on the key problems of social evolution in modern science a considerable part of the journals articles are devoted to the origin of the state and the early state 24 per cent of all published articles the central point is the discussion of robert carneiros concept of the socalled circumscription theory considering this discussion the author comes to the conclusion that carneiros theory has completely passed the test in fact the opponents critical remarks may well be integrated into carneiros theory and this may only contribute to its improvement and elaboration

introduction in many countries the initial government strategies to address the coronavirus pandemic severely reduced community social interactions by closing workplaces and public spaces and implementing shelterinplace policies although these measures helped reduce covid19 infections they harmed the population in mexico many people lost their jobs due to government restrictions and layoffs or lack of demand for their services andor products under these conditions an undetermined number of unemployed people joined the informal economy offering services and selling essential goods with lower incomes a high risk of contagion and no social security they were structural victims of the inconsistencies of the anticovid measures experienced collectively as social suffering since they involved job loss social suffering can be defined as the harmful practices of social forces that negatively affect the human experience either as physical pain or mental health problems historically indigenous populations in mexico have experienced situations of permanent social suffering caused by poverty racism discrimination and the exclusionobstruction of the full exercise of their rights to health education decent housing and work although the government has invested in infrastructure and personnel to care for indigenous peoples in recent years their health remains precarious and they still lack medical personnel medicines and beds while the health services they receive are usually discriminatory for example there is less coverage of immunizations and care by medical personnel in the indigenous population than in the nonindigenous population when indigenous people seek medical care they wait longer to be treated receive fewer clear explanations about their illness and are less frequently invited to selfhelp groups the social suffering of the indigenous population worsened during the pandemic due to the tardy improvised government management of prevention and care actions consequently contagion and mortality due to covid19 were higher in the indigenous than the nonindigenous population in the early months of the pandemic the infection rate in the indigenous population was 43 and the fatality rate 204 vs 354 and 11 in the nonindigenous population infections in the indigenous population subsequently increased sixfold while the fatality rate reached 50 social suffering can vary in regard to the type intensity duration origin and combination of ordeals all of which can differ by gender for example in seven indigenous communities unlike men in addition to their traditional gender roles women assumed the school education of their children and community health education and coordination services and the overall care and support of their people these women reported stress due to insufficient income the inability to help their children with their online courses conflicts with their partners due to spending more time than usual with them at home as well as fear and distrust of poor medical services each of these ordeals was subjectively difficult to endure some women resorted to social support networks whether virtual or nonvirtual for help with care provision parenting education and work others set up cottage industries and bartered products between families another study found that indigenous women artisans employed a range of strategies to survive the health crisis they engaged in subsistence agriculture bartering manufacturing face masks loans marketing and exhibitions in online social networks as well as seeking government support the resilience creativity and adaptative capacity of indigenous women was also reported in studies prior to the pandemic they showed that women victims of domestic violence can use these survival social networks to listen and talk about their emotional distress such as sadness worry nervousness and irritability these are some of the selfcare resources that people and groups implement to diagnose explain care for control relieve endure cure solve and prevent the processes affecting their health berenzongorn saavedrasolano and alanísnavarro mention that such selfcare can treat a variety of physical and emotional health problems for example in mexico women selfmedicate with products ranging from herbalism to biomedical pharmacology to address emotional distress or physical ailments in addition to seeking support with their activities and emotional expressions below is a report of a study designed to understand the emotional distress derived from social suffering during the pandemic as well as the selfcare practices of a group of indigenous women living in mexico city they constitute a fraction of the migratory flow of approximately 78000 women who came from various indigenous towns to mexico city in the 1990s they accompanied their partners or parents or were sent by the latter to the city with family or friends to work as domestic servants others were single women or householders with children fleeing gender violence in their homes and in the community in mexico city they all experienced discrimination and exclusion from the right to housing decent work and comprehensive health services the main causes of the exclusion of indigenous residents are racism working in the informal economy sector which does not make them eligible for social security and gender inequalities during the pandemic various resident indigenous communities accused the mexico city government of neglect during the health crisis excessive requirements for accessing government resources and the unequal distribution of the latter which led them to adopt their own care protocols as well as to obtain food supplies due to the economic precariousness they were experiencing method design of the study a digital qualitative study was undertaken in which the field work was conducted in both real spaces and virtual spaces on the internet all used by the subjects this type of research met the need to continue the inperson work that had begun in september 2019 with a group of indigenous women and been suspended in late march 2020 due to the restrictive measures implemented to prevent the spread of coronavirus in mexico city it was resumed online in october 2020 and concluded in march 2021 instruments prior to the pandemic the authors visited the places and attended the events where the group congregated with an observation guide on indigenous parenting in urban environments they established rapport with the subjects for two or three hours in commercial premises or in their homes the parenting of young children and adolescents conflict resolution strategies and associated situations of violence were recorded in the field diary as a result of the pandemic it was no longer possible to witness parenting in commercial premises or homes several months elapsed before it was possible to contact the group again via whatsapp used by the subjects to arrange meetings send reminders provide information and show the progress achieved in the tasks they had pledged to complete the collective also used the zoom platform to hold workshops on the revival of indige nous languages during which the researchers continued to establish rapport with its members the observation guide was modified to address the emerging issues that arose the emergencies and problems caused by the shortage of resources spending more time than usual with other family members during lockdown the demands of the childrens online schooling the creation of economic subsistence alternatives and physical and mental health care the group leader recorded all the zoom sessions she and the other subjects were asked for a copy of the recording which was contextualized with notes in the field diary the zoom platform was also used to conduct interviews with the subjects which were recorded with their authorization the interviews were conducted according to an open question script on a identity b occupation c the best and worst experiences during the pandemic d the emotional reactions elicited and e the way the women responded to them descriptive questions were also asked to obtain a detailed portrait of the situation described by the women two onehour interview sessions were held all audio recordings were transcribed accompanied by notes on their context and reviewed by the subjects procedure first authorization was obtained from the leader of the indigenous cultures revival collective to conduct field work with the group it was decided to work with this group because it included indigenous women migrants and residents of mexico city in addition it was led by a woman known to the researchers from a previous study on alcohol consumption in indigenous communities during the fieldwork the researchers established rapport with the subjects in a workshop on positive parenting for fifteen women the field work was interrupted by lockdown and subsequently continued virtually on the zoom platform and the social messaging network whatsapp later on a workshop on breathing techniques to relax was given to fortyfour women in the group on zoom during the presentation the researchers established rapport with the subjects encouraging them to identify the emotions experienced during the pandemic and the events that had triggered them to ensure the confidentiality and anonymity of the women the researchers did not ask for details or explore their statements afterwards the researchers continued to establish rapport with the subjects during the crafts and poetry workshop whatsapp was frequently used to establish rapport with the subjects and express interest in the progress of their work whatsapp was also used to arrange interview appointments and send subjects reminders during the rapport greater trust developed with three of the fortyfour subjects who in turn invited other women from the collective to participate in the interviews in this way eight women were interviewed interviews were conducted on zoom in which only the researchers and subjects participated and what the women said about emotions situations and what they did about them was explored in greater depth all conversations were transcribed and contextualized with the authors notes in a field diary analysis both the recording transcriptions and their contextualization notes were analyzed with atlas ti v 7 software all documents were read several times until a general understanding was achieved which enabled the identification of expressions paragraphs and topics related to the research objectives two researchers worked separately and together using atlasti to encode the primary documents deductively and inductively the categorization grouped the written lines and paragraphs of the primary documents into codes capturing their meaning in turn each code was grouped with others into broader categories which in turn focused on various issues the material was subsequently recategorized to contrast the codes and issues according to the grounded theory constant comparison method until the information obtained was reduced to the following issues vulnerability and uncertainty dependent women and their distress and women providers and selfcare at the individual family and collective level ethical considerations each of the subjects was given a letter of introduction from the authors in their capacity as researchers with their name and work address this letter requested their voluntary consent guaranteeing confidentiality and anonymity to participate in the training workshops participant observation and interviews the objectives the nature of the research techniques where they would be implemented and how long they would last were explained to the women all of them were offered referral to psychological services in mexico city all the women signed the letters authorizing their voluntary participation in the interviews only the researchers and the subjects were present the material was transcribed by people unrelated to the research and reviewed by the authors to guarantee the anonymity of the subjects and ensure that the material was errorfree in addition the transcriptions were saved on a computer and assigned numerical codes not linked to indigenous names or groups the researcher responsible for the project was the only person with access to the password for this computer ethical approval was obtained from the research ethics committee of the ramón de la fuente muñiz national institute of psychiatry on june 4 2018 ceic0372018 results the subjects belong to different ethnic groups they had migrated from different parts of mexico and lived in an indigenous village in the south of mexico city one of these women asked the researchers to conduct a workshop to prevent violence in parenting with a group of fifteen women who used to meet with her during the workshop the researchers established rapport with the women in this way they learned that most of them spoke different indigenous languages learned in their respective families and places of origin and that almost all of them reproduced processes of invisibilization of these languages since they almost always concealed their knowledge of them in fact several no longer taught them to their children in their families and towns of origin the subjects had been taught that spanish was the language of civilization progress and modernity in this regard a woman pointed out the following at school children from the neighboring town looked down on us because they were already fluent in spanish and we hardly knew how to speak let alone write it and they sneered at us for being so indigenous because they believed that they were like less indigenous because they spoke spanish in this context the leader organized workshops to revive indigenous cultures in mexico city this woman speaks and writes nahuatl and is an interpreter and translator she is proud of her indigenous ethnicity and language and managed to bring together fortyfour women of different ethnicities in workshops on indigenous language crafts dances and songs from their hometowns in this way the leader and the women created a collective for the revitalization of indigenous cultures vulnerability and uncertainty during the pandemic all the families of the subjects suffered the loss or reduction of their partners jobs five of them lost their jobs and three were given fewer days and hours of work as a result of the precarious nature of their work they became selfemployed some as taxi drivers and others as stallholders in street markets tamale sellers or general assistants uncertainty during the pandemic was an experience shared by all the subjects they were afraid of becoming infected or infecting their family members with coronavirus and felt insecure about their future work and paying debts uncertainty became a permanently stressful situation for women who also incorporated supervision and support for their children in online classes into their household parenting and caregiving duties women who depended on their husbands made an extra effort to satisfactorily perform all those gender roles the majority experienced stress sleeping problems anguish and depression conversely female providers reported feeling this distress less frequently dependent women and their distress during the pandemic these women supported their childrens virtual school activities in the various school years they then felt nervous when they had to go online as most lacked the skills required to use new technologies they also experienced doubts and a sense of helplessness when they did not know how to help their children with their homework in the virtual interviews the mothers narratives show how complicated it is to manage school activities from home especially when there are two or three children at the elementary andor junior high school level for example the women were responsible for filling out the work guides for their childrens subjects using social networks to upload assignments and receive instructions from teachers and even connecting and managing digital resources on digital platforms for asynchronous andor real time activities they also had to help with the complementary activities derived from the learn at home program and perform their gender roles involving keeping the home clean washing ironing preparing food parenting children and looking after their husbands many of them resented this emotionally one of them said for women it was essential to have more than one cell phone use their childrens school media and communicate via the internet with teachers teachers implemented a weekly work plan one week students had to fill in the work sheets and the next week the work was collected and they were sent the following activities mothers served as the link in all this in addition to ensuring that children handed in their homework explaining the instructions and resolving their childrens doubts when they filled in the worksheets and handing in assignments in addition families had to pay for mobile phone data or guarantee internet service which sometimes involved visiting friends who had internet one of them said we did not have internet for a long time even though we really needed it because of their homework because i sort of kept putting it off and i went to a friends house but there came a point where we said thats it because there comes a point when you feel embarrassed about using it so much… so we had to contract it but at the end of the month you have to pay for the gas electricity water and internet and you wonder where the money is going to come from that caused us a lot of emotional problems because it increased the amount of money we owed during the second wave of the pandemic women mentioned experiencing fear anguish depression sleeping problems and despair and one had facial paralysis work became scarce and difficulties meeting family expenses including the use of internet multiplied women providers this distress was not experienced or at least was reported less frequently by women who were the breadwinners or who shared this responsibility with their partners these subjects had always had their own jobs to cover family expenses in this regard the leader of the group remarked as i always say we have always learned that we work and live from hand to mouth if we dont work today we wont eat tomorrow so i thought as far as i know today is today and who knows what will happen tomorrow and i have always instilled that in them i tell my children dont worry about tomorrow finish your homework today the most important thing is today because we have to make progress get ahead and so on but yes it is complicated the stress above all the worry the pressure and you wonder what shall i do just keep going one of the women was a householder and the other two together with their husbands shared household expenses one of them was the leader all of them had to find other ways or earning food andor money the householder who had always been engaged in domestic service set up a mobile food stand on her own the indigenous representative left her husband in charge of taking care of the children and preparing the family meals so she could manage institutional aid and support their economy and that of other indigenous families in the city the third subject and her husband were forced to find work as kitchen and food preparation managers for third parties and sent their children to the village to be looked after by their grandparents their accounts showed that they tried not to dwell on what would happen tomorrow or how they would deal with it adding that they were only concerned with the present they worked hard and said that they kept going they had faith in themselves and had the initiative to make changes at home modifying the roles of its members to guarantee an income when they were unable to make ends meet they became distressed but they had no choice but to continue fighting one woman said i sell my tortillas quesadillas and candy but also the same there are days when nothing is sold and sometimes you say what do i do im through with this what shall i do but no we have to continue fighting while we are here because we have to continue every day and well ask god to take care of us and our families as long as we are all well we will pull through… selfcare at the individual level all the women practiced selfcare for their emotional distress in a varied way and with a sense of immediacy they used various spiritual herbal and psychological resources to cope with their situation for example they made infusions to relax prayed talked about their problems and worries with their friends and sometimes with their husbands several women particularly housewives used the web to implement relaxing measures breathing techniques and prayer or do physical exercise listen to music and dance several admitted to feeling better after they cried or when they cooked or helped their children with their homework they also found relief and distraction by meeting weekly online with their cultural collective of indigenous migrants there they listened to each other encouraged each other shared remedies and strategies to pull through and in emergencies shared groceries and money for food medical expenses and ambulance transfers selfcare at the family level all the women had periods of crying despair and anger in their relationships with their partners these women did not have permission from their spouses to go out to work they had to deal with their spouses bad moods temper demands and outbursts they put up with many situations of mistreatment scolding and complaints from their spouses who said that they were stressed by the critical state of the economy they argued that they needed to eat and rest since they were struggling to support their families they postponed discussions and confrontation with their partners over the anger complaints and mistreatment they received because they thought that the health situation was dangerous and assumed that these other reasons did not warrant getting angry complaining or defending themselves since there was a more serious situation at hand the risk of getting sick and dying from covid or running out of money to eat they tried not to complain or say that they were experiencing such situations since they felt they could endure the cost of postponing them absorb them without talking about them and deal with the contingencies related to the pandemic especially regarding the care of their children and the family in general one participant said i was listening to my children i was going to check on them and i could hear they were already asleep and then when we got sick a year ago in may instead of recovering quickly my husband and i both relapsed and i was sort of depressed and overthinking things apart from that i often got up and cried to myself at night and thought why scare the children once or twice i cried with my best friend she did not do anything she just hugged me and told me that things would work out the women were aware that such episodes could increase stress and pressure on their children so they tried to hold on and contain themselves so as not to further affect the family dynamic and instead help their children to move forward they only discussed their emotions and financial problems with friends colleagues or trusted neighbors to avoid worrying their children mothers grandmothers or sisters selfcare in the womens collective during the pandemic the womens collective began using zoom and whatsapp to organize support for its members who were experiencing financial difficulties above all they used it to do the paperwork for obtaining financial and health care support from government authorities they achieved access to unemployment insurance the mayors grant for children and other emergency government support they made everything available to members to enable them to access their rights both as a result of their ethnic condition and their socioeconomic marginalization in the city the collective applied for these resources together with others of a cultural therapeutic and educational nature for its members for example they organized workshops on managing emotions promoting selfrecognition strengthening selfesteem indigenous public speaking and poetry and applying for government aid the researchers participated in these workshops providing relaxation and breathing techniques this workshop was divided into three sessions during which the techniques of deep breathing autogenic relaxation and guided imagination were practiced all the subjects practiced these techniques online and at home and most found them helpful for calming down and sleeping one woman remarked as for the last audio they made us listen to about meditation just now i can say i couldnt sleep in the past tense because the truth is that talking about it and since the workshop started for example like i tried to relax a little bit and also the audio that i listen to has helped me sleep a little more i really liked the one about imagination because with the others i used to close my eyes and go on thinking about all my problems but i liked that one a lot because i kind of let go of everything because we even though we have financial problems and so on you say… well were alright arent we…i managed to relax in those few moments…then you see that it is possible…you learn something that you didnt believe was possible but its just you didnt know how to do it during the pandemic women who were financially dependent on their husbands participated in the collective with other leaders and more selfsufficient women and householders this is how they learned to process and obtain financial support from the government during the health contingency and contribute to the income of the group members they also learned how to use digital technology to manage the groups use of zoom and whatsapp video as well as how to relax calm their anxiety and manage the stress that made them have difficulty sleeping discussion and conclusion stress anguish and depression are some of the expressions indigenous women use to diagnose their distress they appropriated the vocabulary disseminated in the mass media and popular sayings diagnosed ailments lose their individual symptomatic nature when conceptualized as social suffering in other words as expressions of pain or hardship caused constituted or conditioned by social circumstances the results obtained reveal that women do not uniformly experience distress since there are differences between those who depend financially on their partners and women who earn money in their own right the latter complained less about this distress than those who tacitly reproduced the patriarchal demands that value women as selfsacrificing mothers and caregivers who put their personal projects or selfsufficiency and social and economic independence on hold to look after their families and communities in this reproduction of the patriarchal scheme women displayed more distressing symptoms due to financial health and family care problems in these cases womens needs and distress were overlooked with emphasis being placed on the requirements of others rather than their own they intentionally postponed complaints and confrontation due to the excessive care burden andor the spouses complaints since they strove to achieve stability and calm in the family dynamic they did not wish to exacerbate conflict this can be seen as an act of submission but also as a strategic action to reduce stress it would appear that the women put the problems they encountered into perspective deciding what to minimizepostpone at the critical moment and attempting not to become caught up in the confrontation and distancing themselves from anger these actions designed to reduce stress are some of the selfcare practices implemented by the women in the family group in the indigenous cultural collective selfcare practices involved using various cultural economic educational and therapeutic resources to help women deal with social suffering such as breathing techniques indigenous poetry workshops selfesteem and financial support from the government moreover the insertion and participation of dependent women in this group enabled them to embark on a process of empowerment by attempting to revive indigenous cultures they began to question the inequalities and social injustices that affected them because they were indigenous and women during the postpandemic period some women sought mediation to resolve conflicts with their husbands and began to take pride in their language and ethnicity in addition to gaining a degree of autonomy by helping with or assuming responsibility for the management of government resources to support indigenous languages craft production and public cultural events this change in attitude in women towards their cultures has also recently been observed in certain indigenous groups it involves the rebirth of pride in indigenous peoples and resident communities which could be a key factor in the selfcare of the distress caused by discrimination such as stress low selfesteem and suicidal thoughts

during the coronavirus sarscov2 pandemic restrictive measures were implemented to reduce contagion however severely decreasing social interaction also negatively impacted the economy particularly that of indigenous groups objective this article seeks to understand the emotional distress identified by a group of indigenous women residents as well as their selfcare practices during the covid19 pandemic in mexico city method a digital qualitative study was undertaken since the fieldwork was conducted in person and online using various internet platforms which served as a field scenario data collection tool and a means of continuous connection with subjects results anecdotal records were obtained from the subjects who identified categorizations in the collective organization of the indigenous group which became a support network for mobilizing official material resources information was also obtained on the way the women engaged in the selfcare of their emotional distress in a range of ways with a sense of immediacy through physical spiritual herbal and psychological resources they observed how women managed to cope with their situation and continue caring for and supporting their families to enable them to get by distinguishing between those who were providers and those who were dependent on another provider discussion and conclusion the pandemic together with social restrictions created stressful situations causing various emotional problems among the indigenous collective nevertheless their capacity for selfmanagement and selfcare enabled them to cope with these conditions in the midst of structural contexts of violence poverty and social exclusion

introduction most rare diseases are genetic disorders including congenital defects autoimmune disorders congenital malformations toxic and infectious diseases and rare cancers even though some rare diseases are compatible with a normal life if diagnosed on time and professionally managed for thousands of people with rare diseases the greatest obstacle to improving quality of life are misdiagnosis and nondiagnosis 2020 compared to other diseases rare diseases can lack similar levels of interest amongst the doctors and medical communities most of these rare diseases receive little attention because they affect small number of patients worldwide also patients are not the only ones affected by rare diseases families friends caretakers doctors and society are all impacted by these diseases the lack of information about many rare diseases is a major obstacle often to obtain answers patients scour the internet for assistance with diagnosis treatments specialists and information on the symptoms and treatment methods of rare disease therefore rare disease awareness campaigns play a pivotal role in society as they are responsible for transmitting cultures and knowledge and it is one of the most important means that contribute to spread health awareness in addition to being a primary source of information about rare diseases and modifying attitudes and behavior of patients and society towards this diseases to accept and deal with them is often disseminated through many different advertising media including advertisements in social media newspapers magazines outdoor radio tv mail advertisements event marketing and email marketing so the importance of the research becomes clear by consolidating the importance of rare diseases health awareness campaigns as one of the basic means of promoting health awareness within the society and studying how to use them in the manner that contributes to raise the level of health awareness theoretical framework first definition and identification of rare diseases in the european union a disease is defined as rare when it affects fewer than five in 10000 people although there are many rare diseases each one is rare in and of itself more than 7000 diseases are classified as rare most of them are genetic have a chance of becoming deadly and have a longterm impact on peoples lives from early to late in life typically neither the patients lifestyle decisions nor any visible environmental variables may cause rare diseases definition of rare diseases there is no universal or standard definition of rare disease and it is impossible to prescribe threshold prevalence rates to classify a disease condition as rare in the absence of epidemiological data on diseases that are rare countries until such data are available and the world health organization defines a rare disease based on prevalence data the term rare diseases shall be defined as follows • a lifethreatening or chronically debilitating disease that affects five people or fewer in 10000 and requires special combined efforts to enable patients to be treated effectively • rare diseases are a group of diseases with exceptionally low incidence and prevalence • the council of the european union in its recommendation identifies rare diseases as a serious public health problem and a threat to the health of eu citizens insofar as they are lifethreatening or chronically debilitating diseases with a low prevalence and a high level of complexity confusion and discrepancies can arise from the usage of language with varied definitions most definitions as mentioned above seem to take disease prevalence into account but additional criteria such as disease severity if the condition is lifethreatening whether there are other treatment alternatives available and whether it is heritable 2 the different effects of rare diseases on patients rare diseases have several impacts and effects on patients lives including • emotional impact there are additional emotional consequences like worry stress and anxiety as there are with any disease these burdens are compounded by uncertainty the lack of available information and resources for many patients with rare diseases and their caregivers awareness campaigns have a significant importance in promoting desirable human behaviors the importance of these campaigns increases with the increase in the change in the surrounding environment and the development of technology which requires the planning and implementation of awareness campaigns to educate individuals and given the importance of awareness campaigns in changing behaviors many researchers have been interested in the concept of awareness campaigns and provide many definitions to clarify this concept according to their interests and the nature of their specializations in addition to the jobs that the campaign and the goals to be achieved awareness campaign also serves to educate the audience about a certain topic related to a certain society it aim to raise public awareness of a certain problem by providing convincing facts and highlighting the damage that may result from a certain undesirable behavior to direct the audience towards a more favorable one in addition to there is a long history of inconclusive evidence on the success of awareness campaigns in changing behaviors and specifically changing public health behaviors 1 definition of health awareness health awareness is an essential feature of societies in the current era that requires knowledge motivation to access understand evaluate and apply information to manage health and interact with services related to health and wellbeing the term health awareness has appeared in the academic literature since 1974 but it was quite different from the current understanding of the concept but with the beginning of the nineties of the twentieth century it began to appear in earnest and witnessed significant growth since the initiation of those efforts many definitions of health awareness and education have emerged all of which share the fact that health awareness is mainly focused on the behavior of individuals and health awareness is a broad concept and several definitions have grown including • peoples motivation knowledge and competencies to access understand evaluate and apply health information to make judgments and make decisions in everyday life related to health care disease prevention and health promotion to maintain or improve quality of life • knowledge and competence of people to meet the complex requirements of health operations 2 the concept of rare diseases awareness campaigns awareness campaigns are considered one of the tools that are used in health development and it is a motivator that pushes the recipient to pay attention and search for more information and encourages him to try to take a certain behavior it can be defined as following • one of the social communication methods that aims to make a certain impact on the target group which makes us use all means of mass communication with the aim of convincing the masses of a new idea or forming a mental image towards innovative ideas during a certain period • a set of organized efforts to change the behaviors attitudes and beliefs about the health and environmental conditions of a specific group of individuals at risk for health problems through various advertising media during a specific period hence the researcher has defined rare diseases awareness campaigns as a group of organized efforts that seek to make a specific impact on the target group either from patients doctors or caregivers using traditional and digital advertising with the aim of providing appropriate health awareness to the society and warning them of the dangers of rare diseases symptoms and how to deal with them to reach the optimal health values health awareness campaigns aim to help individuals create a clear picture of the nature of the health situation within the society and develop health awareness for them through the establishment of a healthy culture in addition to the fact that the lack of health awareness and its decline within societies is considered a silent killer objectives of rare diseases awareness campaigns health awareness is one of the goals that awareness campaigns seek to achieve and it is the goal that societies seek to reach and achieve among their members the goals of the awareness campaign for rare diseases are determined as follows • establishing certain positive values or spreading important knowledge concepts such as how to prevent epidemics and rare diseases • clarify the facts and educate citizens about their rights to demand the necessary health care • providing individuals with health information about their communities and knowledge of health problems and rare diseases the rate of their incidence their causes methods of prevention and means of combating them • introduce individuals to health services and facilities that deal and treat rare diseases in their communities and understand the purpose of their establishment and how to benefit from them in an organized and feasible manner • an individuals understanding of the health problems caused by rare diseases and ways to solve them and knowledge of methods to maintain the general health of the individual and society • mucopolysaccharidosis is a rare disease in which the body lacks or lacks enough of an enzyme necessary to breakdown long chains of sugar molecules glycosaminoglycans are these molecular chains as a result the molecules collect in various fig an awareness social media ad for the rare disease • that contains information about the disease importance of rare disease awareness campaigns when dealing with one disease that has an impact on so few people there is often a lack of information which confounds patients and doctors there is less information available to help determine the standards of care for rare diseases therefore awareness campaigns for rare diseases are so important for the following reasons • awareness campaigns are a tool to reach the largest segment of the target group with a high concentration because they consider the means of communication the locations of the recipient the use of the best method to influence the target group and achieve the desired effect • health awareness campaigns play a pivotal role in overcoming some of the barriers between complex medical information and the ability of individuals to understand and communicate this necessary health information places of the body and result in a variety of health issues source online • interpret and simplify information for medical professionals and nonprofessionals that can produce positive changes or prevent negative changes in health awareness of rare diseases and healthrelated behaviors among many recipients • seeks to reduce the incidence and prevalence of rare diseases by the creation of awareness through an integrated and so all preventative awareness campaign • increase knowledge of importance of premarital postmarital preconception and postconception screening and counselling programs to prevent births of children with rare diseases • seldom rare disease physicians see amass sufficient experience in all phases of diagnosis treatment and supportive care to become experts on a specific disorder this leads them to call for an increase in education and support to assist in gathering and sharing rare disease information with each other and it is an issue that can be solved through health awareness campaigns • charcotmarietooth disease is arere disease and a group of inherited conditions that damage the peripheral nerves source online fig a complete awareness campaign that encourages meeting and exchange of information between patients and those interested to raise awareness of the rare disease • factors affecting rare disease awareness campaigns there are some crucial factors that must be considered and studied well from all sides before heading for awareness raising rare diseases campaigns which are third dependency theory in awareness campaigns • gaucher disease is caused by a buildup of specific fatty chemicals in specific organs especially liver and spleen this can change the functionality of these organs by causing them to expand the theory of dependence in awareness campaigns is related to the formation of trends among the target group and the main idea of the dependency theory is summarized on the ability of communication means to achieve a greater cognitive emotional and behavioral impact with regard to health awareness of rare diseases which increases when these means perform the functions of transmitting information in a distinctive way it is extensive on the causes and symptoms of rare diseases and this possibility increases its strength in the event of structural instability in society due to conflict and change and it can be defined as • sources that help provide information or news related to the health field and those interested in following it • a group of ideas that refer to the direct dependence of individuals on the media fig awareness campaign in social media which works to achieve an emotional cognitive impact to increase positive health awareness of rare diseases goals and hypotheses of dependency theory in addition the idea of changing the behavior knowledge and conscience of the target group of patients can become a regressive effect of changing knowledge and awareness of rare diseases in society institutions and governments can rely on awareness campaigns on rare diseases to achieve the following goals • understanding such as knowing the symptoms of a rare disease its causes methods of treatment and obtaining experiences in addition to health understanding through knowledge of reliable  hunter syndrome is an extremely rare hereditary genetic condition caused on by an ineffective or absent enzyme iduronate 2sulfatase is a body enzyme that is missing in hunter syndrome source online information about rare diseases and patients and it means helping patients to discover their abilities support them for use in interpreting beliefs and special concepts and understanding aspects of rare diseases in general • orientation which means the behavior of the society and the medical staff in a manner consistent with social standards and the use of awareness campaigns to guide society members especially those close to patients and to make sound behavioral decisions in addition to interaction that includes ways of behavior and behavior towards others especially patients • entertainment it includes isolated entertainment such as rest and relaxation as the delivery of the awareness message in an attractive and positive way reduces the severity of fear of diseases and tension that afflicts patients dependency theory of awareness campaigns relies on a set of assumptions which are • the impact of awareness campaigns ranges between strength and weakness depending on the surrounding circumstances and previous experiences of society members with rare diseases the different influences of the dependence theory the dependence theory is related to the ability of health awareness campaigns to bring cognitive effects on the individuals who depend on them which contribute to the formation of their attitudes • cognitive influences a group of influences that contributed to strengthening the theory of dependence in awareness campaigns as it formed the intellectual trend of individuals and rearranging priorities towards the rare diseases that patients care about especially those that directly affect them • behavioral effects a group of effects that awareness campaigns contributed to enhancing by promoting a group of healthy behaviors and eliminating another group of them which leads to an increase in health awareness among individuals • emotional influences mean the feelings and emotions that the patient has about his surroundings such as emotional apathy or indifference fear and anxiety moral support and alienation and this effect appears when certain information is provided through awareness campaigns fig awareness ads tend to influence the emotions and feelings of the patient provide moral support and reduce feelings of fear anxiety and loneliness for goucher rare disease patients practical framework in the theoretical framework the researcher clarified the concept of awareness campaigns and how to use them to raise awareness of rare diseases followed by an practical study of three awareness posters applied in different medias and a closed questionnaire aimed at identifying the extent to which the recipient accepts rare diseases awareness campaigns and their ability to help recipients understand what a rare disease is and accept it positively which helps to speed up the diagnosis by asking specific questions related to the basic knowledge of rare diseases and design standards 80 individuals were selected as a sample to conduct the research and the following is a sample of the opinion questionnaire first the questionnaire form the lack of information about the nature of rare diseases • second question do you have any information or knowledge about rare diseases the results were different depending on the cultural background and the abundance of medical awareness of the sample and they were as follows yes by 30 no by 60 and maybe 10 • third question do you find rare diseases a mysterious and frightening disease that cannot be dealt with the results were as follows yes by 75 no by 15 and maybe 10 the fear of rare diseases was the result of a lack of health awareness and correct information available about the nature of rare diseases • fourth question are you aware of the symptoms and complications of rare diseases the results were expected due to the lack of health awareness related to rare diseases as follows yes by 35 no by 55 and maybe 10 design standards the results were as following first applied design fig first rare diseases awareness design and its application in different medias table description of the design idea of the first applied design idea of design the idea of the design is to encourage patients of rare diseases to defeat their fear and increase their awareness of the nature of the rare disease with the researchers tendency to use colors that suggest joy and positivity in the design to help the awareness message to be delieverd quickly easily and emphasize the importance of accepting and dealing with the rare disease while applying the design to many different advertising medias to clarify the possibility of applying the campaign in many places and repeating it to help spread the idea • first question did the awareness ads provide useful information regarding rare diseases the results were yes 25 no 55 maybe 20 • second question do you consider the design positive and attractive and help the recipient accept the idea of rare diseases the results were yes 66 no 12 maybe 22 • third question did the awareness ads help the recipient understand the nature of rare diseases the results were yes 41 no 13 maybe 46 • fourth question does awareness ads encourage patients with rare diseases to quickly diagnose and receive appropriate treatment the results were yes 57 no 17 maybe 26 second applied design fig second rare diseases awareness design and its application in different medias table description of the design idea of the second applied design idea of design the idea of design can be summed up in emphasizing the difference between patients with rare diseases and the rest of society in a positive and nonrepulsive way through the use of an image that shows the difference in a visually attractive way with the use of colors that give a sense of joy and happiness and the use of the slogan to emphasize the meaning of their distinction and difference and to help them positively accept the rare disease as apatient • first question did the awareness ads provide useful information regarding rare diseases the results were yes 42 no 21 maybe 37 • second question do you consider the design positive and attractive and help the recipient accept the idea of rare diseases the results were yes 78 no 8 maybe 14 • third question did the awareness ads help the recipient understand the nature of rare diseases the results were yes 52 no 19 maybe 29 in this design the researcher focused on providing the recipient with information about a specific rare disease turner syndrome which affects women and girls when one is completely or idea of design partially missing turner syndrome can lead to a variety of medical and developmental problems the researcher cleared the idea by using the shape of the chromosome and employing the pink color in it and mentioning a little data about the disease and explaining its nature which helps patients to identify it and direct to receive appropriate treatment • first question did the awareness ads provide useful information regarding rare diseases the results were yes 78 no 8 maybe 14 • second question do you consider the design positive and attractive and help the recipient accept the idea of rare diseases the results were yes 63 no 14 maybe 23 • third question did the awareness ads help the recipient understand the nature of rare diseases the results were yes 89 no 4 maybe 7 • fourth question does awareness ads encourage patients with rare diseases to quickly diagnose and receive appropriate treatment the results were yes 54 no 9 maybe 37 hence the assembled statistical results to answer the questions related to the design standards are as follows • first question the results were yes 48 no 28 maybe 24 conclusion although only a small percentage of individuals and families are affected by each rare disease when considered together they pose a significant health cost on society patients doctors face unique obstacles because of rare diseases they also pose unique difficulties for the biopharmaceutical firms creating novel medicines for patients the study of uncommon illnesses is a complicated and diverse area due to the constant detection and reporting of rare new disorders and diseases the discipline is still in its nascent stage except for a limited number of rare diseases where considerable progress has been made doctors and researchers were unaware about rare diseases for an exceptionally long time and there was little real study done on issues related to the field until lately such delays result in increased disease morbidity and mortality rates hence rare diseases are typically associated with significantly larger burdens on the patients the quality of life and outcomes of patients must be improved by accelerating the diagnostic process the society must deeply understand the typical patient journey and the patients interactions with gps and specialists along the way such an understanding will among other things help countries to identify strategies for overcoming the awareness problem as every awareness campaigns goal is to start and nurture change whereas awareness campaigns are a collection of coordinated acts that deliver messages that are specific to a concept or goal its success depends on the interaction it has generated in support of that aim so it is important to take serious steps towards increasing awareness of rare diseases and methods of diagnosing and treating them through awareness announcements because of their positive impact in helping patients and their companions and even the medical staff if necessary in realizing the extent of the disease its symptoms and effects in addition to its ability to reduce the sense of fear and alienation from the nature of rare diseases as a medical field it is new and does not contain enough specialists to deal with the disease through an attractive design that deals with the disease in a positive way as awareness advertisements have the ability to encourage patients and related parties to increase understanding and thus speed diagnosis and resort to treatment and avoid complications of the disease results the study confirmed the vital role played by awareness campaigns for rare diseases among different segments of society and the existence of a correlation between rare disease awareness campaigns and the prominent level of health awareness among members of the society rare disease awareness campaigns help provide information and interesting facts for the limited campaign time in addition raising awareness of rare diseases and providing the necessary information through awareness campaigns helps patients understand the nature of rare diseases help quickly diagnoses and receive appropriate treatment we can confirm that the positive and attractive design of awareness campaigns for rare diseases works to attract the attention of the target group through the distinctive design and how to formulate the awareness message it also helps patients and those around them to accept the disease including increasing the rates of receiving the small number of doctors who specialize in rare diseases and the small number of patients with it and their dispersal in different geographical places makes it difficult to control the disease and perform sound statistical procedures which calls for resorting to awareness advertisements to raise health awareness for its high ability to spread and reach the target group through various advertising means developing the awareness campaign message in line with the target group for these campaigns focusing on the benefits of the campaign and its repetition to consolidate of the awareness message in order to improve diagnosis and care in the field of rare diseases appropriate identification needs to be accompanied by accurate information provided through awareness announcements that include necessary information to raise health awareness of rare diseases the research recommends that doctors must get training to make early and accurate diagnoses diagnostic modalities must be standardized newer diagnostic and treatment instruments must also be developed and it is critical to provide the necessary information that helps patients keep up with the latest methods of treatment control and diagnosis of rare diseases especially considering the rapid development of rare diseases facing society and the speed of rare disease spread further research should be done on the impact of rare diseases on both patients with treatable rare diseases and those with ultrarare conditions where there are not any treatments available and use awareness campaigns to clarify the differences between them and it is important to pay more attention to rare disease health campaigns which aim to raise health awareness in the society references 1 second the results of the questionnaire demographics the results were as following • age less than 30 years old represent 65 between 3050 years old represent 25 over 50 years old represent 10 • gender males represent 45 and females represent 55 fig the percentage of age and gender in the questionnaire basic knowledge of rare diseases the results were as following the researcher seeks to study the role of awareness campaigns in introducing rare diseases as it proved their effectiveness in clearly influencing raising awareness of rare diseases hence the questionnaire aims to identify the extent to which the recipient accepts campaigns for awareness of rare diseases with an attractive design and its ability to help recipients understand the characteristics of rare diseases and accept it positively which helps to the speed of diagnosis and receiving the appropriate treatment the researcher hopes to find cooperation in providing accurate and objective information as this will undoubtedly lead to a better evaluation of the subject of the study and thus help in achieving the objectives of the study and produce appropriate proposals the answers to the questions in the questionnaire are used for scientific research purposes and to achieve the purpose of research study only

over recent years rare diseases affected peoples lives families and jobs and their cumulative effects on systems of health and social care have gained more attention the lack of health awareness of rare diseases and the scarcity of the expertise is translated into delayed diagnosis and difficult access to appropriate health care in the past few decades increased awareness of rare diseases has led to improvements in diagnosis treatment which led to change in thinking and in behavior towards rare diseases the research is trying to provide a response to the question of what is the role that awareness campaigns play in raising awareness of rare diseases and do they provide the necessary information to the target group and aims to clarify the importance of using awareness campaigns as an effective tool that can and raise awareness of rare disease nature characteristics and how to diagnose it so the research supposes that understanding the role played by health awareness campaigns helps to speed up the diagnosis of the rare diseases in addition the researcher followed both descriptive and the applied approach by presenting three rare disease awareness posters and a questionnaire as an attempt to develop the effectiveness of awareness campaigns to improve and speed up diagnosis and care of rare diseases and found out that the increased knowledge and understanding caused by awareness campaigns rare diseases give society the reasons and how rare diseases occur and change the way we view and how to treat disease

background adolescence is a critical developmental period for emotional and behavioral problems 1 the world health organization states that emotional and behavioral problems in adolescence are an increasing public health concern 2 information on adolescents problems can be obtained from different informants including parents and adolescents themselves and from achenbachs series scales which are widely used around the world when assessing problems in children and adolescents 34 achenbachs scales include the child behavior checklist which is completed by parents or teachers 5 and the youth selfreport which is completed by adolescents themselves 6 to assess emotional and behavioral problems in youth aged 1118 years parents are important informants on their childrens behavioral problems however it is unclear the extent to which parents are aware of their childrens diverse behaviors or have the same threshold as their children when rating emotional and behavioral problems 7 achenbach suggested that it was necessary to preserve the contributions of different informants and found that different informants reported different levels of problems for adolescents 8 therefore information from both parents and adolescents is needed to obtain a comprehensive assessment of emotional and behavioral problems among adolescents in china the parent report is in common use but the adolescent selfreport is rarely used few studies have collected information from both groups of informants in one survey many investigators have shown specific interest in parentchild agreement on adolescents emotional and behavioral problems using achenbachs scales most studies found poor to low cbclysr agreements on total problems and internalizing and externalizing scales 3910 and a few studies found moderate to high agreements 411 a study reviewing crossinformant agreement between parentreported and adolescent selfreported problems in 25 societies has found that the correlation varied with an r value of 027 to 065 12 the 2013 report by rescorla et al of cbclysr crossinformant agreement findings in 25 societies included a large chinese sample drawn from wang et al 1213 as rescorla et al reported the mean crossinformant r averaged across 17 scales was 46 for china 12 wang had previously reported correlations ranging from 035060 for the same sample 13 in addition it was reported that adolescents reported higher levels of problems than their parents in general populationbased studies 12 13 14 15 while a reverse pattern occurred in clinical samples 391617 many studies have examined factors that might influence the level of agreement across informants since this study mainly assessed the agreement between parents and selfreports we wanted to focus on the effects of parental and family factors as well as adolescent characteristics it has been well established in the literature that both parent and child characteristics were likely to contribute to discrepancies among informants 18 19 20 21 one study found that parents agreed more about the problems of girls than those of boys 7 and conflicting evidence existed regarding the direction of the age effect on informant agreements 102223 it was reported that the quality of the parentchild relationship could also influence the disagreement between parents and their children 19 one study also found that parental factors correlated with informant disagreements about the level of adolescents problems this was not only because those parents provided an accurate description of increased behavior problems occurring in the home but also because different parental functions can themselves influence childrens behavior and emotions 21 one previous study examined negative life events and found that they could have a negative impact on parents estimate of childrens problem behaviors 24 no study took the effect of family environment on the discrepancies into account it is widely accepted that the family environment has a direct and major influence on adolescents behavior 2526 previous studies have concluded that adolescents emotional and behavioral problems were consistently related to low levels of family cohesion and high levels of conflict 2627 china has the largest adolescent population in the world with the dramatic socioeconomic changes and the increasing social contradictions of the last 30 years the chinese family environment has changed dramatically 28 the chinese family is confronted with the difficulties of merging traditional ideas and modern styles 29 it has been reported that chinese adolescents are striving for autonomy from their parents and beginning to view them more as friends 30 furthermore after the implementation of the one child policy in the 1970s 31 chinese families have paid more attention to child rearing all of these changes may have a positive or negative impact on adolescents especially as eastern culture requires chinese adolescents to spend most of their time with their family whereas adolescents in western cultures spend more time with their peers 4 therefore chinese parents may be more familiar with their children and the family environment may greatly influence the understanding parents and adolescents have about adolescents problems unfortunately few studies have explored parentadolescent agreement in china and the associated factors have never involved the family environment only one study among chinese adolescents reported a mean cbclysr correlation of 046 which was above the average level among 25 societies when ranked according to the mean crossinformant r value in the summarized findings from the rescorla study 12 this study hypothesized that parentadolescent agreement on adolescents emotional and behavioral problems might be moderate and there would be more parentadolescent discrepancies when adolescents are in undesirable family environments because these adolescents would be more likely to keep their thoughts from their parents the aims of the present study were to explore the pattern of agreement between parents and adolescents on emotional and behavioral problems with large and representative samples of chinese adolescents using the cbcl and ysr and estimate factors associated with informant discrepancies including the characteristics of the child the parents and families to provide evidence about the importance of obtaining reports from multiple informants methods data collection and sample this study was conducted in liaoning province which is located in the northeast of china during november december 2010 liaoning province has a population of 48 million and encompasses three metropolitan cities with a population of ≥1000000 in each seven mediumsized cities each having a population of 5000001000000 and four small cities with a population of 200000500000 each three cities of the 14 cities were randomly selected from these three urban areas from each city and two counties from the large and mediumsized cities were randomly selected counties in small cities with few public schools were not included in this study three public schools were randomly selected from each area including one primary school and two senior schools according to the age range and two or three classes were randomly selected from each grade ordinarily there were 50 students in each classroom we randomly selected 30 students with an equal number of boys and girls aged 1118 years from each selected class using a preprepared list of random numbers a final total of 2700 students from 15 public schools were chosen as participants all the participants and their parents were informed about the content and the aims of this study after obtaining written consent from the participants to conduct the survey a questionnaire including the cbcl ysr and questions about the child parent and family factors was distributed to 2700 participants of the 2426 questionnaires returned 227 subjects were excluded because of incorrect information or missing data the final study subjects consisted of 2199 chinese adolescents attending school in our population the average age was 130 years old of the adolescents families 323 473 and 204 had low middle and high socioeconomic status respectively in our population ses was indicated by parents highest education level similar to the study of weine et al education levels were divided into three groups junior high school level senior high school level and college level or higher the effective response rate was 814 the procedures followed were in accordance with the ethical standards of the committee on human experimentation of china medical university measures child behavior checklist and youth selfreport the current study used the 1991 versions of the cbcl and ysr because the chinese 2001 versions of the instruments were not yet widely available at the time the study was conducted therefore the 1991 versions of the cbcl and ysr syndromes were used in the current study which differs slightly from the 2001 syndromes in item composition and in names the cbcl parent report form contains 120 items assessing the emotional and behavioral problems of children 418 years old 5 each item has three response categories not true somewhat or sometimes true very true or often true eight subscales are included withdrawn somatic complaints anxiousdepressed social problems thought problems attention problems delinquent behavior and aggressive behavior the total problem scale subsumes the eight syndrome scales the three syndrome scales constitute the broadband internalizing scale the syndrome scales delinquent behavior and aggressive behavior comprise the broadband externalizing scale higher scores denote greater problems good reliability and validity of the cbcl were confirmed for the chinese version 3233 the cronbachs alpha was 098 for the total problem scale 096 for the internalizing scale and 095 for the externalizing scale in this study the ysr 6 is used for ages 1118 to obtain adolescents selfreports on their own problems and the items are worded in the first person the ysr also includes 120 items similar to those on the cbcl and provides scores for the eight syndrome scales described above and the total problem internalizing and externalizing scales only those items that cbcl and ysr had in common were used in the analyses previous studies supported the good reliability and validity of the chinese ysr 3334 the cronbachs alpha was 096 in this study the cronbachs alpha was 092 for the internalizing scale and 091 for the externalizing scale child and parent factors child variables included age and gender in order to make data suitable for the variance analyses age was used as a categorical variable in this analysis age was divided into an 1114 years old group and a 1518 years old group parent factors included the parentadolescent relationship and parental expectations the parentadolescent relationship was measured by asking how did you experience your relationships with your parents with response categories very close and warm good intermediate somewhat poor poor parental expectations were measured by asking how high are your parents expectations for your learning performance using a fourpoint scale ranging from high to low expectations family factors family factors included family structure negative life events and family environment the classification of family structure included intact family and nonintact family 35 negative life events included responding yes to any of the following events having occurred in the past year in participants families serious medical problems of the participants suicidalviolentcriminal behavior of family members death of extended family members poor housing financial problems death in the nuclear family theft accidentdisaster or separation from parents family environment was assessed using the family environment scale a widely used and wellvalidated measure of family characteristics 36 it has 90 truefalse items and includes ten subscales cohesion expressiveness conflict independence achievement activerecreation intellectualcultural moralreligious organization and control higher scores indicated higher levels of the measure seven subscales were used in this study due to the inapplicability of the three excluded subscales of expressiveness independence and moralreligious when used in a chinese context 37 the chinese version of this scale has been well documented to have acceptable reliability and validity 3839 the cronbachs alpha was 083 for the total score in this study and 042081 for the seven subscales only two subscales alphas of achievement and activerecreation were lower than 070 and activerecreations alpha was close to 07 either the total score or the individual subscales of fes were taken to have good reliability and validity statistical analysis the correlations of the total problems internalizing and externalizing scales between cbcl and ysr were analyzed with pearsons correlation coefficient analyses of variance of repeated measures were used to test the differences between cbcl and ysr and to test the effects and interactions of gender and age on these differences to measure the parentadolescent discrepancies we subtracted cbcl scores from ysr scores for the total internalizing and externalizing scores and the absolute values were used as the outcome variables for this study higher scores in the absolute values indicated more discrepancies between parents and adolescents pearsons correlation was also used in a univariate analysis to examine the relationship between parentadolescent discrepancies on emotional and behavioral scores and child parent and family factors the categorical variables of gender and family structure were performed by ttests alone linear regression analysis was used to estimate the associated factors of parentadolescent discrepancies all variables related to parentadolescent discrepancies in univariate analysis were entered into the model because we wanted to include as many factors as possible in the linear regression analysis previous studies also used the changed standard of p value from 005 to 025 in the statistics 40 they were performed with spss for windows with a twotailed probability value of 005 considered statistically significant results the mean scores on the total problems internalizing and externalizing scales and correlations of the cbcl and ysr are presented in table 1 table 2 shows the percentages of variance the mean problem scores for ysr were significantly higher than for cbcl on the total problems internalizing and externalizing scales the effect sizes of interactions between the cbclysr discrepancy scores and gender or age were all very small most adolescents perceived that their parents had high expectations for them and 895 adolescents had good relationships with their parents the majority of the adolescents were living in intact families and slightly over half were living in families who had experienced one or more negative life events the average scores of subscales for fes were as follows cohesion conflict achievement intellectualcultural activerecreation organization and control the results of univariate analyses between the cbclysr discrepancy scores and all variables are shown in table 3 all indicators were significantly related to the ysrcbcl discrepancy scores except for family structure and control for all the scales parental expectations were not found to be significant for the internalizing scale gender had only a small but significant effect on total problems in cbclysr discrepancy scores the results of the linear regression analysis for discrepancies on the total problems internalizing and externalizing scales are shown in table 4 only the significant variables are presented the percentages of variance accounted for by all the associated factors were 108 for discussion this study estimated both the pattern of agreement between parents and adolescents on emotional and behavioral problems and its associated factors among chinese adolescents aged 1118 years a fairly large sample constituted by students from grades 512 of schools in each city size including urban and rural areas in liaoning province was used the effective response rate was 814 which was higher than the norm of 70 for questionnaire surveys 42 thus our study population was representative of the population which increases the generalizability of our study conclusions our results found a high parentadolescent agreement on emotional and behavioral problems which was a little higher than we had expected there may be numerous reasons why parentadolescent agreement was higher in our chinese sample than in many previous samples first it may be because of the special pattern of family life that exists in china chinese families deeply influenced by traditional culture are regarded as the most important living environment and adolescents depend on their parents the relationship between parents and adolescents is closer than that in western countries 4 in our subjects most adolescents had good parentadolescent relationships and most families in china have only one child because of this parents may pay more attention to their child and better understand their behavior and problems second parentadolescent discrepancies may be smaller in societies where cultural values promote familism and collectivism such as those with confucian or catholic traditions than in societies that promote individualism and autonomy 12 however one research study reported a lower mean correlation of 046 between the cbcl and ysr in a sample of 1022 participants in china 13 even though the correlation was higher than that in most other countries this result might reflect the dramatic change of the chinese family environment in recent decades to one where the way of rearing children has become more democratic than in the past and where the generation gap is reducing 33 the regional difference despite lack of supporting evidence might also explain more or less of the different agreement levels found as beijing is the capital it is one of the most developed areas of china people might have more opportunities to be exposed to and to accept new cultural norms adolescents here might be more independent and less willing to be controlled by their family liaoning in contrast is located inland in the northeast and has average economic and population levels people may have deeper traditional views and stronger orientation cohens standards 41 for 159 of variance are small 59138 are medium and above 138 are large less than 1 are indicated 1 p 005 p 001 p 0001 nonsignificant effect to familism even though westernization has also influenced their lives therefore parents may be closer and more familiar with their children and their agreement with adolescents problems is higher than that in beijing as a result further research should explore regional differences parentadolescent agreement was relatively higher in our study than in other countries and in earlier chinese research table 3 pearsons correlation coefficients between cbclysr discrepancies and related factors our study also revealed that adolescents reported more problems than their parents on all the problems studied most previous studies reported consistent results in the general population 1415 but contrary results occurred in the clinical sample 391617 this might be due to various reasons in the general population some problems of adolescents would be hidden from their parents view 24 in addition parents might conservatively assess the problems of their children because they do not expect them to be unwell whereas in a clinical sample parents hope for healing and therefore observe their childs emotions and behaviors closely 7 rescorla et al also reported that ysr scores were higher than cbcl scores among the general population in all 25 societies 12 the difference was the informant effect sizes of our study which were smaller than those rescorla et al reported the cohen d values of ysrcbcl were also quite small according to the study of cohen 43 the reason for the total large es from 25 societies in different culture was uncertain as mentioned above parentadolescent discrepancies may be smaller in societies such as china which are characterized by familism and collectivism cultural values it is worth mentioning that as the rescorla study clearly indicates the mean ysr cbcl discrepancy fails to capture the fact that in many studies dyad cbcl scores are higher than ysr scores this is a highly consistent finding across societies therefore both parents and adolescents are needed to obtain a comprehensive picture of adolescents mental health and it was important to obtain reports from multiple informants this study also contributed to understanding the associated factors of parentadolescent discrepancies previous research on discrepancies had mainly focused on adolescents age and gender 18 19 20 although the es was small for both age and gender our findings also found these effects which indicated that boys had larger discrepancies than girls possibly because boys are more guarded about communicating their feelings and problems at home 7 however as with age the findings were inconsistent some studies have reported that discrepancies decrease with increased age 1022 our study found that older adolescents had larger discrepancies than younger ones which is consistent with other studies 23 perhaps as adolescents grow older they increasingly keep their feelings and behaviors to themselves 44 future research is needed to explore this association negative life events were also found to have an impact on this discrepancy parents living in families encountered more life events and agreed less with their children than those in families who underwent fewer negative events this finding was in accordance with a previous study which reported that negative life events were associated with parents perceptions of their childrens problem behavior 24 an important finding of this study was that family environment had a strong effect on discrepancies in the total problems internalizing and externalizing scales which supported the hypothesis that there would be more parentadolescent discrepancies when adolescents are in undesirable family environment this was the first attempt to evaluate the influence of family environment on parentadolescent discrepancies regarding adolescents emotional and behavioral problems this finding showed that parents and adolescents living in undesirable family atmosphere such as those with decreased cohesion and organization and increased conflict tended to report more disagreement there may be several reasons for this family environment may be the key factor in influencing mental health for adolescents 2526 a recent study reported that family environment was related to childrens behavioral selfcontrol and emotional regulation 26 this indicated that adolescents in better family environments might more regularly express their emotional expressions and their behavior might be more easily observed thus these parents might be more familiar with their childrens behaviors and emotion and this may have contributed to less discrepancy moreover family environment may have a direct impact on parentadolescent conflicts some studies have found that parents and children in harmful family environments experience more divergence and conflicts conversely less divergence has been found in warm and supportive families 45 moreover our population had relatively higher cohesion and organization and lower conflict than found in western populations 36 the reason for these differences might be that most adolescents in our study population lived with both parents and this might have increased their chances of contact with their parents and established a good parentadolescent relationship moreover china has a generally collectivist culture which might generate higher family organization in contrast with the individualism of western societies 46 all of these characteristics might also be the reason that our study population showed relatively higher parentadolescent agreement these findings suggest that high family cohesion and organization together with low conflict may be important targets for parents who need help in understanding more about their children they may therefore provide some indication to clinicians and health care providers when considering the family environment in screening and helping the problem child several limitations of the present study must be mentioned the first limitation is the crosssectional design it is impossible to draw causal conclusions from information obtained in this study and longitudinal studies should be carried out in the future to confirm these findings second the informants were requested to complete the questionnaires without consulting each other however it may have been hard to avoid communication with each other which might have affected informant agreement despite these limitations we believe that these findings provide important information about parentadolescent agreement on chinese adolescents mental health conclusions our findings indicated important differences in patterns of agreement between chinese adolescents and their parents with regard to the adolescents behavioral and emotional problems relative to findings reported from western cultures our study revealed that parentadolescent agreement was greater than that in most previous studies and adolescents reported more problems than parents the characteristics of the adolescent parents and families were associated with the parentadolescent discrepancies on adolescents emotional and behavioral problems family environment was a crucial factor which was not taken into account previously these findings suggest that chinese parents have a relatively good agreement with their children but tend to underreport their childrens problems clinicians and health care providers should pay attention to the family environment when aiming to help adolescents with emotional or behavioral problems competing interests none identified we confirm that the content of this paper is currently not submitted or published in full or in part elsewhere authors contributions jnw ll hw xy yw and lw carried out the investigation among adolescents in school jnw thematically analyzed the data and collaboratively wrote the manuscript jnw and ll edited the manuscript for submission lw conceived the study and supervised its design and data analysis all authors read and approved the final manuscript

background most studies about informant agreements on adolescents emotional and behavioral problems have been conducted in western countries but this subject has not been well researched in china the aim of this study was to evaluate the pattern of parentadolescent agreement on adolescents problems and its associated factors among schoolage adolescents in china methods this crosssectional study was conducted in november and december of 2010 a questionnaire including the child behavior checklist cbcl the youth selfreport ysr the family environment scale fes and the characteristics of the child age and gender parents parentadolescent relationship and parental expectations and family family structure negative life events was distributed to our study population a total of 2199 chinese adolescents aged 1118 from 15 public schools in liaoning province who completed the questionnaire became our final participants pearsons correlation coefficient was used to assess parentadolescent agreement and linear regression analysis was used to explore the associated factors of parentadolescent discrepancies on emotional and behavioral problemsthe parentadolescent agreement on emotional and behavioral problems was high mean r 06 the scores of ysr were higher than those of cbcl factors that increased informant discrepancies on emotional and behavioral problems were boys older age the experience of negative life events low levels of cohesion and organization and high levels of conflict in the family conclusions a high level of parentadolescent agreement on emotional and behavioral problems was found adolescents reported more problems than their parents did family environment is an important factor to be considered when interpreting informant discrepancies on the mental health of chinese adolescents

introduction the covid19 pandemic prompted rapid adjustment to health services including the suspension or reduction of facetoface consultations increased remote provision and rearranged appointments due to staff unavailability 1 2 adjustments to contraceptive services included recommendation of methods not requiring facetoface consultations amended guidance on offlabel extended use of some longacting reversible contraceptives and streamlined remote repeat prescribing of the combined contraceptive pill 3 although aiming for equitable access 4 5 rapid adaptions during the pandemic had the potential to exacerbate inequalities particularly if these required digital access and literacy 6 7 service users might also interpret adaptations as deprioritising contraceptive services 8 and we know that some patients selfcensored their needs or were anxious about covid19 risk if accessing services in person 9 overall people in the uk and globally struggled to access contraception during lockdowns 1 1014 and prescribing data for the uk showed substantial drops in larcs fitted in 2020 versus 2019 15 several studies suggest that young people were disproportionately affected by service closures 10 16 however the pandemics effect on contraception and service use remains poorly understood previous studies have indicated difficulties accessing contraception alongside changing sexual risk behaviours however these often used small convenience samples in the early stages of the pandemic 8 14 16 17 the natsalcovid study a large national survey of sexual and reproductive health was set up to address gaps in representativeness of studies and a lack of detailed information about the ongoing effects of the pandemic wave 1 findings suggested young women were most likely to switch contraceptive and face barriers to sexual health service access 11 we have also reported wave 2 findings that one in ten female participants had stopped or switched contraceptive method in the year after the first lockdown 18 in this study we investigate inequalities in reproductive health service access contraceptive method switching due to the pandemic and pregnancy plannedness during the first year of the pandemic among women and trans and nonbinary people who can become pregnant methods study design and participants natsalcovid wave 2 is a quasirepresentative web panel survey of srh in britain following the initial natsalcovid1 data collection in julyaugust 2021 wave 2 survey data were collected between 27 march 2021 and 26 april 2021 to capture srh behaviour and outcomes during the first year of the covid19 pandemic 19 20 participants aged 1859 years answered an online questionnaire administered by ipsos in addition to demographic and behavioural factors participants were asked about srh and service use in the period before the first uk lockdown in march 2020 and in the past year the questionnaire is available online 21 we used sampling target quotas set by gender age region and social grade and weighting based on these demographics plus ethnicity and sexual orientation to achieve a quasirepresentative sample of the british general population 19 20 statistical analysis the wave 2 sample comprised 2098 recontacted wave 1 participants and 4560 new participants aged 1859 years the latter included a boost of 500 people aged 1829 years ensuring an overall sample of 2000 participants in this age group who are often at greater risk of adverse srh outcomes 19 to examine the impacts of the covid19 pandemic on pregnancy planning we analysed prevalence and plannedness of pregnancy among participants aged 1844 years who were described as female at birth and reported any sexual contact with a man since the start of the first uk lockdown twentyfive participants reported a pregnancy in the past year but did not report sex with a man these may have predominantly been conceptions occurring before the first lockdown and were not included in the sample we analysed contraceptive method use and service access among a subsample of those at risk of unplanned pregnancy that we defined by excluding those currently pregnant currently trying to conceive or not able to get pregnant to measure inequalities we used educational attainment by highest academic qualification reported and social grade based on occupation how this study might affect research practice or policy ⇒ ongoing efforts to ease the health impacts of the pandemic should aim to improve equality of access to contraceptive services original research participants were classified as having symptoms of depression or anxiety if scoring 3 on the twoitem patient health questionnaire2 or generalised anxiety disorder2 screening tools respectively 22 23 we categorised contraceptive methods by their effectiveness in preventing pregnancy based on typicaluse failure rates 24 25 we analysed emergency contraceptive use separately assuming that changes in motivation and access would have affected use of planned methods and ec differently participants using another method in addition to ec were classified by the effectiveness of the nonemergency method participants who only used ec were classified as using no method for the purposes of prophylactic methoduse comparisons unmet need for contraceptive services was defined as reporting trying but being unable to use contraceptive services plannedness of pregnancies in the past year was estimated using the london measure of unplanned pregnancy 26 27 comprising questions on contraceptive use timing of motherhood intention to become pregnant desire for a baby discussion with partner and preconception preparations 28 each item is scored 02 with each point representing an increase in pregnancy plannedness scores of 03 were categorised as unplanned 49 as ambivalent and above 9 as planned full definitions for outcome variables and the denominators used in each analysis are given in online supplemental table s2 we used complex survey analysis functions in stata figures were constructed in r 29 weighted estimates are presented with weighted and unweighted denominators and unweighted numerators we used the surveyequivalent chisquare statistic to determine whether there was statistically significant variation by sociodemographic and behavioural factors in the reported contraceptive method used since the start of the first lockdown and in the switching of contraceptive methods we compared odds of using ec preand postlockdown using a conditional logistic regression model to account for intraperson clustering we used logistic regression to calculate ageadjusted odds ratios to investigate how use of and unmet need for contraceptive services varied by sociodemographic and behavioural factors we used linear regression with robust standard errors to investigate differences in mean plannedness of pregnancy scores and logistic regression to estimate differential odds of an unplanned pregnancy adjusting for age proportions of missing demographic variables were relatively low ranging from 0 to 13 all comparisons were restricted to complete cases across relevant variables natsalcovid was approved by ethics committees at the university of glasgow and the london school of hygiene and tropical medicine participants provided informed consent electronically at the start of the survey patient and public involvement patients or the public were not directly involved in the design conduct reporting or dissemination plans of the natsalcovid study due to the urgency of the research during the pandemic however members of the public were involved in the design of the natsal4 questionnaire on which the natsalcovid questionnaire was based data availability the data used in this study are available via the uk data service online catalogue 30 results of 6658 participants in natsalcovid wave 2 1488 were aged 1844 years described as female at birth and reported sexual contact with a man in the past year of these most identified as female two described themselves as male and ten described themselves in another way most participants were white married or in a steady cohabiting relationship and identified as heterosexual of 1415 participants who provided information about contraceptive use 824 were deemed to be at risk of unplanned pregnancy just over half of the participants at risk reported using a more effective contraceptive method as their usual or only contraceptive method in the past year this was lowest among participants aged 1824 years and considerably lower for participants from black asian or asian british ethnic backgrounds or from a mixed or multiple or other ethnic background than participants from white ethnic backgrounds those with at least one marker of lower socioeconomic status were less likely to report using a more effective method as their only usual contraceptive method vs 609 of c1c2 grade however economic factors potentially related to the covid19 pandemic were not associated with effective contraception use among those at risk of pregnancy reported ec use was higher in the year preceding the pandemic than in the year from the start of the original research first lockdown conditional or 030 data not shown overall 128 of participants at risk of an unplanned pregnancy reported no usual contraception methods this was more likely in those who reported smoking lower educational qualification and poor mental health in total 227 participants of participants included in this analysis reported stopping or switching contraceptive method due to the pandemic for all users of contraceptives before the start of the pandemic stopping and switching directions are reported in online supplemental table s4 among those using a more effective contraceptive at the start of the pandemic 102 reported switching to a similarly or more effective method 32 switched to a less effective method and 38 stopped among users of effective methods we found differences in stoppingswitching by age ethnicity and sociodemographic factors those aged 1824 years were more likely than older participants to have switched method vs aged 2544 years 117 compared with white participants black participants were more likely to have switched their usual method vs 118 and to have stopped using contraceptives vs 37 reporting depression was associated with p value p0013 some 246 respondents answered not applicable as they were already pregnant planning to get pregnant or unable to get pregnant these responses are excluded from the table more effective method includes intrauterine device intrauterine system implant contraceptive pill injection and transdermal patch less effective method includes condoms spermicides rhythm method withdrawal and other methods participants who used no contraceptives or only emergency contraceptives are classed as no method used p values were calculated from f values generated from pearson χ 2 statistics using the secondorder correction of rao and scott 45 in a casual relationship in a new relationship in more than one relationship recently ended a relationship or other relationship status ci confidence interval gad2 generalised anxiety disorder2 phq2 patient health questionnaire2 p value p096 some 631 participants reported only or usually using a more effective method of contraception in the year before the first lockdown users of emergency contraception only were classed as stopped using contraceptives p values were calculated from f values generated from pearson χ 2 statistics using the secondorder correction of rao and scott 45 in a casual relationship in a new relationship in more than one relationship recently ended a relationship or other relationship status ci confidence interval gad2 generalised anxiety disorder2 phq2 patient health questionnaire2 original research switching method vs 100 table 2 unmet needs for contraceptive services varied by sexual identity and markers of physical and mental health among all participants 293 reported trying to access a contraceptive service between march 2020 and april 2021 74 of those who tried to access reported being unable to do so at least once many of those also reported at least one successful access attempt only 24 were unable to access a contraceptive service at all young participants were most likely to report an unmet need compared with those aged 3544 years 29 figure 1 as were those from minoritised sexual identities compared with heterosexuals 45 after adjustment for age anxiety 198 and depression were both associated with unmet need current smokers were also at higher risk of unmet need vs nonsmokers of barriers cited by those with unmet need most related to clinic closures and appointment cancellations or unavailability among all participants 136 reported a current pregnancy or pregnancy in the past year the mean lmup score for these pregnancies was 92 30 with scores 9 classed as planned and 66 were scored as an unplanned pregnancy while 333 of pregnancies scored as ambivalent and 601 scored as planned by comparison among the 285 participants who reported a pregnancy between 1 and 5 years ago the mean lmup score was 86 and 123 were scored as unplanned 307 as ambivalent and 570 as planned eleven participants reported an abortion in the past year and six of these had a pregnancy that was scored as unplanned though none of these participants reported unsuccessful attempts to access contraceptive services pregnancies original research in older participants were more likely than those in younger participants to be planned compared with participants aged 1824 years table 3 cohabitation relationship status and social grade were associated with pregnancy and pregnancy planning scores pregnancies were less commonly reported by those in noncohabiting relationships compared with those living with partners vs 171 single participants were less likely to report being pregnant those who did were more likely to have an unplanned pregnancy compared with those in a noncohabiting relationship or a cohabiting relationship those working in lessskilled occupations receiving state benefit or who were unemployed had lower lmup scores smoking was associated with lower lmup scores discussion our study used a large quasirepresentative sample of the british population and emphasises the high level of need for contraceptive services that continued during the year following the first national covid19 lockdown one in six participants reported an unmet need in attempting to access contraceptive services with clinic closures suspension of facetoface appointments and disruptions to travel reported as the reasons however most participants were successful in accessing services and those reporting difficulties also often reported successful attempts suggesting that resilience and adaptability in service delivery mitigated some of the challenges overall 539 of participants reported using an effective method as their usual contraception during the pandemic and this proportion was similar to the 564 and 542 using effective methods found in the previous natsal2 and natsal3 surveys respectively 31 however we found that low proportions of participants from asian or asian british ethnic backgrounds or from a mixed or multiple or other ethnic background compared with participants from white ethnic backgrounds reported using effective methods though likely due at least partly to prepandemic differences 32 this suggests different levels of risk for unplanned pregnancy by ethnicity during this national period of high stress and uncertainty it was reassuring that most participants using effective contraception prepandemic reported not having to switch method or stop using contraception because of the pandemic and 102 reported switching but were able to use similarly or more effective methods however consistent with earlier research we found that younger participants while being at greater risk of unplanned pregnancy were more likely to have switched method because of the pandemic and to report barriers to accessing contraceptive services 16 routinely collected data indicate large reductions in contraception prescription and dispensing in england in 2020 compared with 2019 33 34 35 our data suggest that difficulties accessing services primarily due to closures and appointment cancellations may have contributed to this reduction 9 our analysis of pregnancies during the pandemic builds on and challenges previous research elsewhere we report that compared with natsal3 data collected a decade previously pregnancies and abortions in the first year of the pandemic were substantially lower 18 we also found that pregnancies during the pandemic were less likely to be scored as unplanned compared with a decade previously 18 these observations correspond with several proposed mechanisms 36 on the one hand ongoing improvements in service provision may have impacted on access to contraceptive methods especially larcs on the other hand less sexual contact during the pandemic might have led to lower pregnancy rates 37 38 reducing risk of unplanned pregnancy regardless of contraception and service access our finding that ec use was lower during the pandemic than in preceding year with a small but not significant increase in plannedness score of pregnancies is consistent with the hypothesised effects of reduced social contact on sexual behaviour leading to unplanned pregnancy other studies report both desires to postpone pregnancy most commonly citing fear or uncertainty over service access and bringing forward pregnancy plans due to changed circumstances 39 40 41 mechanisms potentially contributing to an overall increase in plannedness in contrast to our findings indicating a decrease in unplanned pregnancies during the pandemic a convenience sample cohort study of pregnant women in the uk found that conceptions in the year following the first lockdown were more likely to be unplanned than prelockdown conceptions 14 two study design factors might explain the different results the cohort study used online adverts to recruit participants which might introduce bias additionally it only included participants who were still pregnant at the time of recruitment thus excluding unplanned pregnancy terminations before the end of april 2020 the natsalcovid estimate recruiting a wider range of participants and using weighting to achieve representativeness seems less susceptible to bias in our quasirepresentative population sample several markers of vulnerability and health risk behaviours were associated with elevated reproductive health risks while patterns of risks during the pandemic may match existing inequalities pandemicinduced inequalities in access to contraceptive services may have exacerbated these participants with poor original research health and behavioural risk factors such as smoking and drinking alcohol reported higher rates of unmet need for contraceptive services and higher rates of switching or stopping contraceptives participants in lower social grades and who smoked were more likely to report unplanned pregnancies which is similar to patterns previously observed in the uk 7 42 while these findings suggest a greater risk of unplanned pregnancy in these groups we were unable to directly link the plannedness of each pregnancy to specific attempts to access contraceptive services in our study most people switching contraceptive method switched to a similarly or more effective method suggesting flexibility and adaptability in participants responses to changing service provision which might have been sufficient to meet contraceptive needs in many cases our findings are also consistent with conveniencesample evidence from the usa that a drop in the desire to be pregnant was associated with low income but not independently associated with decreased income due to the pandemic 40 natsalcovid benefited from a questionnaire design and approach developed by the team responsible for the decennial natsal survey to obtain rigorous data on potentially sensitive behaviours and experiences 19 natsalcovid included a large national sample and used quotabased sampling and weighting to improve representativeness unlike the decennial natsal survey natsalcovid was not a probability sample and is therefore not directly representative of the general population 43 44 our study informs adaptations to contraceptive services to meet patient needs and preferences including in the pandemic recovery phase regardless of differences in how health systems are structured financed or commissioned in other highincome countries our findings broadly indicate the likely impacts of the pandemic on contraceptive method and service use we highlight here inequalities across age ethnicity social disadvantage and mental health ongoing provision of contraceptive services and future crisis planning should ensure ease and equality of access to contraceptive services for all to address the impact on contraceptive method choice and availability original research competing interests none declared patient and public involvement patients andor the public were involved in the design or conduct or reporting or dissemination plans of this research refer to the methods section for further details 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 patient consent for publication not applicable ethics approval open access this is an open access article distributed in accordance with the creative commons attribution 40 unported license which permits others to copy redistribute remix transform and build upon this work for any purpose provided the original work is properly cited a link to the licence is given and indication of whether changes were made see

background contraceptive services were significantly disrupted during the covid19 pandemic in britain we investigated contraceptionrelated health inequalities in the first year of the pandemic methods natsalcovid wave 2 surveyed 6658 adults aged 1859 years between march and april 2021 using quotas and weighting to achieve quasirepresentativeness our analysis included sexually active participants aged 1844 years described as female at birth we analysed contraception use contraceptive switching due to the pandemic contraceptive service access and pregnancy plannedness results of 1488 participants 1619 were at risk of unplanned pregnancy of whom 541 510 571 reported routinely using effective contraception in the past year among all participants 143 125 163 reported switching or stopping contraception due to the pandemic 32 20 51 of those using effective methods prepandemic switched to less effective methods while 38 25 59 stopped 293 269 318 of atrisk participants reported seeking contraceptive services of whom 164 130 204 reported difficulty accessing services clinic closures and cancelled appointments were commonly reported pandemicrelated reasons for difficulty accessing services this unmet need was associated with younger age diverse sexual identities and anxiety symptoms of 199⇒ the covid19 pandemic likely impacted reproductive outcomes in diverse ways such impacts may have been unequally distributed ⇒ previous studies reported adaptations to health service delivery and difficulties experienced in accessing reproductive health services with switching and stopping of contraceptive methods and potentially greater risk of unplanned pregnancy⇒ we examined differences in contraceptive use and pregnancy planning in a sample of women trans and nonbinary people able to become pregnant who were quasirepresentative of the british general population ⇒ we found that key markers of inequality and vulnerability related to age ethnicity social disadvantage and mental health were associated with increased contraceptive method switching unmet need of contraceptive services and lessplanned pregnancies

recommended diabetes care than those in metropolitan areas aas and latinos are more likely to be hospitalized for diabetes complications than nonhispanic whites and those with higher incomes african american women are more likely to have the diabetesrelated conditions of obesity and high blood pressure and are more likely than aa men to develop complications of heart disease and stroke recent findings revealed that for the years of 2011 2012 361 of american women were obese and of these 444 of latino and 566 of aa women were obese a significant risk factor for diabetes similarly 29 of aa women are more likely to die of cardiovascular diseases when compared with nonhispanic white women and hispanic women culturally relevant diabetes prevention and selfmanagement education are an essential component of improvement in selfcare behaviors successful dsme which is dependent upon several factors including patient health literacy levels understanding of oral and written educational materials and delivery of culturally tailored programs has a direct effect on health outcomes thus the capacity to understand educational information verbal or print about diabetes is a critical component in diabetes prevention and selfcare several factors are related to diabetes health disparities including health literacy diabetes selfcare is an essential component of diabetes selfmanagement however selfmanagement is dependent upon patient education thus understanding information about preventing early onset or consequences of diabetes risk and disease process has a direct effect on health outcomes often these materials are written at levels that lowliterate patients cannot understand one approach to prevention and diabetes care is patient centered and individualized care to meet patient values and needs community health workers providing individualized care focused on prevention and diabetes care have shown to improve patients health literacy and as a result improve patients understanding of diabetes diabetes selfmanagement and clinical outcomes health literacy the patient protection and affordable care act of 2010 defines health literacy as the degree to which an individual has the capacity to obtain communicate process and understand basic health information and services to make appropriate health decisions previous health literacy definitions have not included the term communicate yet a persons ability to communicate as part of making appropriate health decisions is essential according to the national center for education statistics in the past decade approximately 41 of hispanics 24 of african americans and 9 of nonhispanic whites were reported to have below basic health literacy skills health literacy and illness low health literacy has been linked to greater risk of death and an increased number of emergency room visits and hospitalizations health literacy has been shown to be related to age educational level raceethnicity income and nutritional intake several authors reported knowledge and awareness of heart disease and hypertension were lower among hispanics than african americans but both minority groups were lower than nonhispanic whites in addition younger age lower education and lower income were related to a lack of awareness of heart disease prevalence and symptoms in both african american and hispanic women low health literacy related to chronic disease symptoms and risk have been documented in aas hispanics and women one study showed that the level of health literacy may affect ability to carry out selfcare and treatment however patient health literacy levels are not often assessed by health care providers further some authors are not convinced that health literacy should be measured or is related to diabetes prevention or care outcomes the joint commission and the agency for health care research and quality urge health care providers practitioners and administrators to consider health literacy as an important part of communicating and understanding patient interactions care and outcomes determining health literacy among minority groups of women and the relation to diabetes risks may assist in developing culturally specific interventions and best practices for chronic illnesses such as diabetes care to meet the womens cultural health needs and match their lifestyles coxs interaction model of client health behavior was used to guide the study conceptual framework the imchm focuses on the relationship between individual client characteristics and providers behaviors that can influence health outcomes use of the imchb allows for addressing the relationships between client characteristics and health outcomes such as diabetes risk as well as client characteristics health literacy and health outcomes the model emphasizes the process by which clients and providers achieve health outcomes the model includes three constructs client singularity clientprofessional interaction and health outcomes elements of client singularity include demographic characteristics social influences environmental resources and previous health care experiences the clientprofessional interaction refers to the relationship between health care professionals and clients and in this study was operationalized as health literacy health outcomes are impacted by client singularity and client professional interactions the health outcome in this study was health status defined as the specific type and total number of diabetes risks this framework has been used to examine health behavior and other outcomes more recently the framework has been used to examine patient satisfaction with nursing care advanced practice nursing and latina womens health purpose the purpose of this study was to assess diabetes risk in a sample of african american and latina women the difference in diabetes risk between the minority groups and to examine the relation of personal characteristics and health literacy to diabetes risk the following research questions were addressed 1 what is methods a cross sectional survey design with face to face data collection was used the convenience sample of 90 african american and latino women were recruited from community and health care settings in counties with high proportion of aas and latinos all areas were medically underserved areas or had medically underserved populations north carolina is in the buckle of the stroke belt and was designated a diabetes hot spot in 2012 in fact in nc diabetes is ranked seventh as the leading cause of death if diabetes remains unchecked it is predicted that annual health care costs in nc will exceed 17 billion by 2025 sample and recruitment in the community settings bilingual flyers and announcements were made available in churches workplaces and tables or booths set up at grocery stores women enrolled in the study met the following inclusion criteria 1 age 25 years and older 2 selfidentification as african american or hispaniclatina 3 orientated in time place and person 4 english or spanish speaking reading and understanding women were excluded if they had a new mental health diagnosis in the past 3 months were known to be pregnant or had been institutionalized or incarcerated team members scheduled appointments to obtain written informed consent and collect data data collection was held in private rooms at churches trailer parks workplaces community centers homes homeless clinics and a subsidized retirement apartment complex sessions for data collection lasted 3060 minutes women were provided a 25 gift card to a local store as an incentive irb approval for this study was received from the university of north carolina at greensboro measures a demographic and health status form was used to collect data on client singularity social influences included marital status and number of years of formal education environmental resources were income level presence of health insurance and income adequacy income adequacy was a selfreport of difficulty paying their monthly bills previous health care experiences included seeing a health provider in the past twelve months perceived health status and perceived health experiences blood pressure was measured in a sitting position using standard protocols hba1c was collected by finger stick using a bayer a1c now instrument standard calibrated medical equipment was used to measure height and weight for bmi calculation the principle investigator and community registered nurses supervised and participated in all data measurement diabetes risk health outcome information was collected by asking the women if a doctor or nurse had ever told them that they had high blood pressure high cholesterol heart disease obesity or diabetes diabetes risk was defined as the total of the number of risks which included a history of hypertension diabetes bmi greater than 25 kgm 2 high cholesterol and cvd disease using national diabetes information clearinghouse guidelines to avoid any reading literacy concerns or embarrassment related to illiteracy the surveys were read to participants by bilingual trained research assistants investigators or community health workers the interview and surveys were available in english or spanish by client choice with all aa women choosing english and all latino women choosing spanish an identifier code for paper and computer stored data was assigned for all study participants to provide anonymity of responses data analysis data were doubled entered and assessed for accuracy client singularity and health status were tabulated with measures of central tendency appropriate to the level of measurement the client professional interaction variable was computed a significance level of 05 alpha was used for statistical tests spsspc and sas were used to manage data and compute statistics results the mean age of women was 48 years of age with a range from 25 to 89 years fifty two percent of the women were aa more than half of the women had a high school education or greater the majority of women were married and had incomes of 29999 or less fortysix percent of the sample reported no health insurance thirtyseven percent of participants considered their health to be either fair or poor the majority of the women had seen a physician within the last 12 months when asked about their health care experiences 56 rated previous health care experiences as excellent while 578 rated it as good twentythree percent of the women were told that they had diabetes and 90 were considered obese by the bmi calculations and diastolic bp averaged 7976 mmhg three month blood sugar management by hba1c averaged 652 sd177 range 48130 indicating multiple women may have undiagnosed diabetes the average number of diabetes risks for the sample numbered more than two and a half african american women had more diabetes risk factors than latino women there was a significant difference in the number of diabetes risks 416 p 000 indicating that aa women had a significantly higher number of diabetes risk factors seventyseven percent of the women had two or more risk factors for diabetes obesity hypertension and high cholesterol were the most frequent risks with consideration of all variables in question two client singularity variables were predictors of diabetes risks the regression model was statistically significant in predicting total number of diabetes risks accounting for 52 of the variance in the outcome further examination showed that when regressing the number of diabetes risks on race ethnicity age marital status education and difficulty paying bills only age was significant indicating that older women had more diabetes risks for research question three twentynine items were used to measure health literacy with a higher number indicating a higher level of health literacy the difference in the level of health literacy between aa and latino women was not significant 106 p 292 however latino women were slightly more health literate than aa women for research question four pearson correlations were first reviewed women not married had higher health literacy and older women had higher literacy health literacy was regressed on the sociodemographic variables of raceethnicity age marital status having a high school education and difficulty paying bills the equation was not significant for any predictors of health literacy df 5 p ≤ 701 in research question five number of diabetes risks were regressed on raceethnicity age marital status education difficulty paying bills and health literacy the model was predictive of the number of diabetes risks however only age was independently significant indicating that older women had more diabetes risks discussion seventyseven percent of these minority women were found to have two or more diabetes health risks ninety percent had risk with just the presence of obesity this is consistent with findings of the cdc and office of minority health aa women were found to have more diabetes risk factors than latino women in addition older africanamerican and latino women were found to have more diabetes health risks than younger women which is consistent with statistics of the american diabetes association and other researchers the high level and combination of risks in this sample are concerning the most prevalent risk factor are preventable through patient and provider action and obesity is linked to many of the other risk factors for diabetes and cardiovascular disease although health literacy for both groups was low there were no significant differences between the groups women who had more diabetes risks were found to have lower health literacy which is consistent with previous findings however the client provider interaction variable in this study was not a predictor of the total number of diabetes risks perhaps because all women were high risk and low in health literacy women had high numbers of diabetes risks and require cultural and literate appropriate interventions to increase understanding and ability to prevent diabetes related risk factors the consequences of those factors and to manage diabetes health literacy has been related to selfcare and treatment and low health literacy is consistently associated with less diabetes knowledge and with poor health care access and outcomes schillinger and colleagues found that interventions that included health literacy had positive health outcomes in addition older women were found to be less health literate and to have sociodemographic factors that significantly impacted their diabetes risks for example the majority of women in this study had incomes below 29999 which puts them at high risk for diabetes related factors previous authors have reported that health literacy was related to age educational level raceethnicity and income these findings point to the need for diabetes risk interventions inclusive of health literacy focused on older minority women by multiple levels of providers and professionals limitations this study was limited to volunteer women who may or not be representative of all minorities regardless the findings provide important insight into the most vulnerable women who may experience multiple morbidities and consequences of diabetes during their lifetimes conclusions findings of this study validate that disparities in morbidity mortality and care delivery persist although cdc officials have reported improvements in 29 health care categories disparities in the areas of race and gender continue prevention and selfcare are essential components of preventing the onset and controlling or alleviating the consequences of diabetes however prevention and selfmanagement is dependent upon patient involvement and interaction with the provider often this interaction and sharing of information is provided at levels that culturally diverse or lowliterate patients cannot understand studies have shown that patient understanding of information is an important factor in preventing diabetes risk factors and in diabetes selfcare prevention and selfmanagement written materials should integrate and include the literacy level of disparate groups and the age context of the recipients in this study older women were found to have more diabetes risks these older women may benefit from preventive interventions for diabetes risk especially those risks that are highly prevalent in minority women the patient protection and affordable care act discusses new patient care models such as accountable care organizations which will be focused on cost and quality of care received by patients and best practices by health care providers diabetes prevention including exercise healthy eating stress management and weight management is required in addition health literacy attention by providers practitioners systems and new models of care such as will be important to deliver quality and cost effective care to minority groups in an effort to decrease the current disparities in care future research is needed that focuses on diabetes risk and the role of health literacy among various age groups of minority and ethnicallydiverse women and men to better understand how best to improve health outcomes for these groups

minority women experience health disparities especially related to diabetes the purpose of the paper is to examine diabetes risk in minority women a survey design was used to recruit 52 african americans aa and 48 latina women participants described their health health behaviors and health literacy blood pressure and bmi were measured aa women had more diabetes risks than latinas and older women had more risks than younger women all of the women had low health literacy women with higher numbers of diabetes risks had lower health literacy findings can be used to develop diabetes prevention and education programs african americans aa and hispaniclatinos suffer disproportionately from chronic disease such as diabetes and related risk factors including overweight obesity increased waist circumference high cholesterol high blood pressure and high blood sugar agency for health research and quality ahrq 2012 minority women in particular have a high incidence and prevalence of diabetes and diabetes related risks diabetes affects 171 of aa women and 187 of hispanic women 45 64 years of age compared to 10 of nonhispanic white women among women 6574 years of age 314 of black women and 326 of hispanic women have been diagnosed with diabetes compared to 184 of nonhispanic white women center for disease control and prevention cdc 2012 additionally hispanic women and african american women born in 2000 have a 525 and 49 risk respectively of developing diabetes in their lifetime which far exceeds the 312 risk for nonhispanic white females cdc 2011 once diagnosed with diabetes aas and latinos are less likely than nonhispanic whites to receive a1c tests national diabetes fact sheet 2011 african americans and latino americans are more prone to complications in part because of failure to monitor blood glucose and have their cholesterol checked gavin fox grandy 2011 also the poor near poor and those with lower educational levels mcclearyjones 2011 receive less diabetes recommended care and persons in nonmetropolitan areas receive less

introduction mental health is defined as a state of wellbeing in which the person realizes his or her own skills can deal with the normal stresses of life can work effectively and fruitfully and is able to make a contribution to his or her community 1 mental health is essential to human life however many countries prioritize physical health over mental health this may be due to mental health stigma 2 peoples awareness of mental health issues is limited to those that are more severe or manifest later in the diseases progression its possible that this is due to the prevalence of common symptoms such as hopelessness and anxiety or that people are merely ignorant of their existence 3 4 5 6 suicide is widespread among those suffering from mental illnesses and among those aged 15 to 29 it is the fourth leading cause of death people with serious mental health disorders are expected to die up to 20 years sooner than the normal population for curable physical reasons 7 it is generally acknowledged that informing the public about major bodily illness prevention early intervention and treatment will benefit them many individuals know that safe sexual behavior reduces hiv risk smoking causes many diseases and a balanced diet is essential people usually recognize the early indications of cancer heart attacks and strokes and may have taken a firstaid course to learn how to treat these and other medical emergencies early intervention needs this information in contrast many people dont know what they can do to avoid mental illnesses are distrustful of suggested treatments and dont know how they can help those who are suffering 8 most people in the community would avoid talking to someone with a history of mental illness and even fewer would consider befriending them 9 many studies have shown that people who are labeled as mentally ill are seen in a less positive light and are more likely to be rejected no matter what they do 10 it is important to enhance community awareness of mental health issues the availability of effective treatments for mental illness and how to detect and treat these illnesses 6 the study of the communitys awareness attitude and healthseeking behaviors in relation to mental illness may help in the provision of mental healthcare services 8 the purpose of this study is to assess the levels of mental health awareness and practices in rural communities as well as the variables associated with them this article was previously presented as a poster at the 5th amrita international public health conference in december 2022 at the amrita institute of medical sciences in kochi materials and methods study design and settings a crosssectional method was used for this study which was done in the rural regions of devarayasamudra in the kolar district of karnataka india the study was conducted by visiting from house to house study population about 350 study participants were selected from the village of devarayasamudra using a convenient sampling technique 350 households were selected and interviews with household members were conducted participants older than 18 were included in the study and despite two visits the locked household was excluded study tools and measurements to assess the sociodemographic profile semistructured questionnaires were used and the adapted version of the mental health knowledge schedule 2 with a yes or no response was used to measure the communitys knowledge of mental health problems during the calculation of the median score for knowledgebased queries a cutoff point below and above the median score was considered in order to determine the proportion of community members with abundant and insufficient knowledge data analysis the collected data were cleansed coded entered in microsoft excel and exported to spss statistics version 22 for analysis to summarize the dependent and independent variables descriptive statistics were conducted using the logistic regression analysis model the factors associated with the outcome variable were identified ethical clearance institutional ethical committee approval was obtained results sociodemographic characteristics a total of 350 study participants were successfully interviewed the respondents mean age was 4436 the majority of participants in the study were men married and from nuclear families furthermore according to the modified bg prasad classification the majority of the study participants belonged to the class 1 socioeconomic classification and 309 of the participants were hindu by religion furthermore 30 of the participants only had a high school education frequency sex table 1 sociodemographic characteristics of participants respondents mental health awareness nearly threequarters of respondents know that mental illness is a type of medical disease and nearly twothirds know that mental health problems can be managed in contrast 317 of those surveyed believed mental illnesses were infectious and 417 recommended isolation as a therapeutic option in addition over half of those polled disagreed that men and women experience the same kind of mental health issues participants listed aggression or violence and hearing or seeing objects that arent there as major symptoms of mental illness characteristics frequency percentage mental illness is due to discussion more than 50 of the participants in the present study held only a fundamental understanding of mental health and mental illness ganesh reported a similar kind of outcome in new delhi india in 2011 by performing a crosssectional study to measure the knowledge attitude and behavior surrounding mental disease and showing that general public awareness of mental illness was relatively inadequate 11 similarly in nigeria gureje et al found that negative perceptions about mental illness were prevalent with as many as 965 feeling that people with mental illnesses are hazardous due to their aggressive behaviors most people would not accept even basic social relations with a mentally ill person 827 would be scared to talk to one and only 169 would contemplate marrying one 12 the present study observed that education level and occupation were statistically significant determinants of mental health knowledge and the participants who were illiterate had 176 times the odds of having insufficient knowledge compared to professionals this was similar to another nigerian study conducted by kabir et al among 250 adults that observed that literate respondents were seven times more likely to exhibit positive emotions toward the mentally ill as compared to nonliterate subjects and they also found that the most common symptoms proffered by respondents as manifestations of mental illness included aggression or destructiveness and loquaciousness about 46 of respondents favor standard medical care for the mentally ill while 34 are more inclined toward spiritual healing 13 in 2019 abolfotouh et al conducted a crosssectional survey on 650 saudi adults and they found that the majority of the saudi public reported a lack of knowledge about the nature of mental illness negative perception negative attitudes to mental illness and negative attitudes to professional helpseeking 14 although there is a significant prevalence of mental health disorders that affect every society in every region of the world less focus and attention have been placed on finding effective solutions to close the knowledge gap as evidenced by the general lack of information present across all research this study suggests that the development of mental illness involves a complex interaction between biological psychological and cultural factors in northern ethiopia abbay et al found that the level of mental health knowledge among the participants was low they additionally found that factors such as being male having a higher level of education and having strong levels of social support were independent predictors of good mental health and community mental health knowledge with both studies using the same questionnaire to assess the knowledge 15 furthermore south african research uncovered religious and cultural explanations for the causes of mental illness 16 the representation of the causes of mental illness in different countries may be different for a variety of reasons including socioeconomic status illiteracy rates and the urbanrural study context respondents to the study almost unanimously agreed that chatting or laughing to oneself as well as acting in a strange or unusual manner are symptoms of mental illness 17 the findings of research carried out in india are in agreement with this most of the people who answered this poll said they treated mental illness with a mix of medical religious and traditional methods this is similar to the research done in saudi arabia 2 comparable to research conducted in new zealand nearly 80 of the participants in this study reported that mental illness is treatable 18 the limitations of the study are that the crosssectional structure of the data does not enable a rigorous causal interpretation of the findings the present study assessed knowledge of mental illness by employing maks questionnaires which were sensitive to memory bias although the study was representative of the general population nonresponses may have had levels of knowledge and attitudes around mental illness and mental health helpseeking that were different from those of responders it is possible albeit difficult to forecast how this may have impacted the results conclusions the present study concluded that more than 50 of the participants had inadequate awareness of mental health and mental illness this highlights the need to spread awareness about mental health education among the general community early identification of mental disorders improved mental health outcomes and increased use of health services may result from increased knowledge about mental health and mental disorders better awareness of how to seek help and treatment and reduced stigma against mental illness at the individual community and institutional levels additional information disclosures human subjects consent was obtained or waived by all participants in this study institutional ethics committee issued approval dmcklriec392202223 animal subjects all authors have confirmed that this study did not involve animal subjects or tissue conflicts of interest in compliance with the icmje uniform disclosure form all authors declare the following paymentservices 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

introduction mental health is defined as a state of wellbeing in which the person realizes his or her own skills can deal with the normal stresses of life can work effectively and fruitfully and is able to make a contribution to his or her community although mental health is essential to human survival it is often given less attention than physical health in many parts of the world objectives the aim of this study is to evaluate the rural communitys awareness regarding mental health issues and the factors that contribute to them materials and methods a crosssectional study was undertaken in the rural community 350 study subjects were selected from the village of devarayasamudra by using convenient sampling 350 households were selected and householdlevel interviews were done using the mental health knowledge schedule questionnaire participants aged more than 18 were included in the study and locked households even after two visits were excluded from the study results the median aggregate knowledge score was 31 sd 71 with the minimum and maximum values being 11 and 44 out of 45 knowledge items respectively the total knowledge score found that 178 508 respondents had insufficient mental health knowledge based on the percentage of the study population with a cutoff score below and above the median score a multivariate logistic regression analysis confirmed that participants who were illiterate had 176 115226 times the chances of having insufficient knowledge compared to professionals and this remained true even after adjusting for other variables as wellthe present study concluded that more than 50 508 of the participants had inadequate awareness of mental health and mental illness this highlights the need to spread awareness about mental health education among the general community

introduction activity limitations are difficulties an individual may experience performing physical tasks they are considered negative aspects of functionality and constitute an important part of an individuals disability status 12 which is defined within the context of health as the persons feature directly caused by disease trauma or other health condition that requires medical care provided in the form of individual treatment by professionals 2 however a persons disability is also affected by the environmental characteristics of his her surroundings 3 it is now argued that as life expectancy continues to increase around the world life will mean on average a longer period wasted by suffering due to frailty disability and agerelated illness 4 5 6 in brazil the population pyramid is in the process of contraction resulting from a constant decrease of fertility rates from 63 children per woman in 1960 to 19 children per woman in 2010 this is already below the replacement level set as 21 children per woman 7 at the same time the epidemiological transition occurs differently from the model experienced by industrialized countries and even by other nearby locations such as chile cuba and costa rica in brazil there is coexistence of old and new health problems in which despite the predominance of chronic and degenerative diseases the communicable ones still play an important role 8 resumo objetivos estimar a magnitude das diferenças de gênero na incapacidade entre adultos com 60 anos ou mais e avaliar se elas podem estar associadas à desigualdade social de gênero e aos fatores contextuais socioeconômicos no nível das unidades federativas brasileiras métodos estudo multinível que utilizou dados de 23575 adultos mais velhos das 27 unidades federativas que participaram da pesquisa nacional de saúde de 2013 o índice de limitação de atividades foi desenvolvido a partir da teoria de resposta ao item utilizandose variáveis de atividades básicas e instrumentais da vida diária foram estimadas as associações das variáveis individuais e contextuais com a incapacidade avaliandose a magnitude das diferenças entre os gêneros ao utilizar efeitos de interação de nível cruzado em modelos lineares generalizados multiníveis incluindose apenas as variáveis que foram estatisticamente significantes no modelo final resultados a prevalência de incapacidade foi mais elevada entre as mulheres do que entre os homens totalizando 327 dos adultos mais velhos na análise multinível ajustada a incapacidade foi influenciada pela desigualdade de renda entre as unidades federativas além disso as diferenças de gênero na incapacidade foram associadas com as desigualdades sociais de gênero conclusões as mulheres tiveram desvantagens maiores de incapacidade quando comparadas aos homens e estas diferenças foram associadas às desigualdades sociais de gênero entre unidades federativas brasileiras influenciadas pelas desigualdades de renda in brazil social inequalities are prevalent in older adults due to the continuing inequitable distribution of resources among groups living under different socioeconomic conditions 9 social inequality plays an important role in the prevalence of disability among older adults 10 especially among women 11 it is likely that individuals living in areas with better socioeconomic conditions have greater access to medical goods and services and consequently are capable of maintaining good health conditions and functional capacity over time 12 those cumulative disadvantages mean that women are more likely than men to become poor and suffer from disabilities at an old age 13 palavraschave in a previous study 33 of older brazilian adults had limitations to perform activities of daily living in the northeast this prevalence affected 39 followed by the north and midwest with 35 each the south with 32 and the southeast with 29 14 the prevalence of disability is significantly higher among users of the public system than those of the private health system 15 the older adults who lived in federative units with higher gini index were more likely to present higher level of disabilities compared to the older adults who lived in states with lower economic disadvantages 1216 many important studies provide an overview of the disabilities in brazilian older adults including gender differences and their determinants 17 18 19 20 21 other previous studies have measured the functionality of older adults in brazil where disabilities were associated with demographic socioeconomic and health factors 122223 differently of those previous investigations this study uses the item response theory to aggregate two dimensions of functionality ie adl and instrumental adl in a latent trait and estimate crosslevel interaction analysis using multilevel modelling we can therefore estimate the contextual effect of an ecological exposure on individual risk the aims of this study were to estimate the magnitude of gender differences in disability among older adults aged 60 and older in brazil in 2013 and to examine whether those differences could be associated with social gender inequalities and socioeconomic contextual factors at the level of federative units methods sample and data collection this was a crosssectional study based on data from the brazilian health survey 2013 23 the bnhs selected 81187 households randomly and individuals aged 18 years or older were interviewed one individual from each household was selected in a complex sampling plan thus 64348 interviews were collected in the households resulting in a nonresponse rate of 81 24 in total 60202 people participated in individual interviews 25 in which 23815 were older adults 15 a selected population of the rev bras epidemiol 2020 23 e200002 study was composed by 23575 older adults aged 60 or older living in 27 brazilian federative units calibrated individual weights were established in order to address participants nonresponse and sample attrition 26 response rates ranged from 84 in pará to 96 in bahia a small number of individuals was excluded from the study due to lack of data for individual variables or because they were born with physical hearing cognitive or visual impairments considering that the data used in this study are anonymous and available in the public domain submission to the ethics committee was not required in accordance with the recommendations of the national research ethics committee of brazil 27 the national health survey is a householdbased nationwide survey carried out by the brazilian department of health in partnership with the brazilian institute of geography and statistics the scope of the survey is to establish the health status and lifestyles of the population as well as how they look after their health with regard to access and use of services preventive actions continuity of care and health care financing ethical approval this study was exempted from submission to an ethics committee in accordance with the recommendations of the brazilian national committee for ethics in research as the data used in this study are anonymous and available in the public domain dependent variable the construct of the activity limitation index which is used as a proxy to measure disability was based on 12 questions in the bnhs they were divided into two functionality dimensions adl 14 and iadl 14 but they were united in a single latent trait the selfreported response categories in adl were • 0 no difficulty • 1 has little difficulty • 2 has great difficulty • 3 cannot perform the activities the items related to the iadl were transformed into a dichotomous scale due to the scarce number of responses in some categories rev bras epidemiol 2020 23 e200002 individual independent variables the main individual independent variable was sex the following individual variables were also included in the analysis age in years restriction of usual activities during the last two weeks as a result of health problems selfperceived health medical health insurance plan participation in organized social activities educational level brazilian economic classification criteria adapted and based in the sum of scores educational level and housekeeper as proposed by cceb 28 thus the social classes were categorized as follows 013 1450 contextual independent variables the following contextual factors at federative unit level were used as additional independent variables • the multidimensional gender inequality index for 2010 which is based on six dimensions education income work politics reproductive health and protective factors the methodological strategy used in the construction of the mgii reproduces the same mathematical procedure adopted by the united nations development programme 29 the mgii ranges from 0 to 1 the closer a score is to 1 the greater the level of social gender inequality 30 • the per capita gini coefficient for 2013 measures the per capita household income distribution the measure varies between 0 and 1 where 0 corresponds to perfect equality and 1 to perfect inequality 31 • gross domestic product per capita for 2013 is a proxy for living standards indicating the levels of economic production of the territory 33 • life expectancy for 2013 reflects the average number of years a newborn can be expected to live it is a summary measure of mortality as a proxy for improvement in living conditions and population health 32 statistical analysis this study used a hybrid model of item response theory gpcm irt to construct the ali for each individual respondent despite the fact that the θ scale ranged from ∞ to ∞ it was transformed and restricted in continuous values between 0 and 1 for practical purposes and thus allowing regression for nonnegative positively skewed dependent variable the second level of multilevel analysis considered those variables related to federative units and the evaluation of ali behavior at first level was seen as a function of the predictor variables for both levels the coefficients of ali and gender differences therein as well as the 95 confidence intervals were estimated for each federative unit to estimate the association between contextual variables and gender differences in disability crosslevel interaction effects were used in multilevel generalized linear models for nonnormal and zeroinflated with robust variance responses model i included activity limitation by sex and there was no control for other individual variables model ii level 1 included all the individual and contextual variables model iii comprised all variables that were statistically significant in the multivariate analysis in model ii intercept and sex factor were considered to be random effects on all models fitted using gllamm command using a statistical significance level of 005 the statistical analysis was performed using stata 141 ic statistical software results gender differences in disability among the 23575 participants in the sample 327 presented some difficulty in performing the evaluated activities with a prevalence of 159 for adl and 297 for iadl the prevalence of disability was significantly higher among women than in men similarly to the case with the average ali in addition older women presented disadvantages in terms of disability in the evaluated variables more details on the characteristics of the survey participants can be found in table 1 gender differences in disability were observed in most of the federative units figure 1 shows the extent of gender differences in disability for each one the differences and severity of the disability among women are greater in the north and northeast regions the closer the results are to the diagonal line which represents gender equality the fewer the differences in disability between men and women despite the fact that maranhão amapá pará and são paulo had the smallest differences between men and women ap and pa had worse results than sp but better than ma however alagoas presented the greatest difference in disability between men and women while maintaining a high level of it among the older adults in this regard we can extract two extreme models al and sp each of them representing the negative and positive aspects of disability in brazil rev bras epidemiol 2020 23 e200002 gender differences in disability and contextual variables in the first model disability was significantly higher among women aged 60 or older when compared to men as shown in table 2 in an adjusted multilevel analysis more advanced age activity restrictions in the last two weeks prior to the survey a healthselfperceived as fair poor or very poor and being illiterate or having primary studies are factors associated with greater disability among older adults on the other hand social activity participation was associated with lower disability those functional disabilities were shown to be significantly influenced by income inequality in all federative units thus income inequality has a negative impact on disability in older adults the best model in the end was able to explain 61 of the differences between the federative units with the social gender inequalities the differences in disability between men and women were increased when adjusted for the other variables discussion results showed that the limitations in iadl were more prevalent than the adl among older adults this can be explained because the ability to perform the iadl is primarily affected especially because it requires greater motor and cognitive skills which tend to be lost early in the aging process 33 34 35 of change in variability was calculated using this formula initial variability x100 statistically significant variables in the response categories in brackets the parameter is set to zero because it is redundant the participation of older adults in community activities and the restriction in the performance of activities in the last two weeks have a direct relationship with one another pointing out an evaluation of the quality of social life among older adults towards the disability consequences the participation in community activities is related to the control of the physical and social environment reflecting better functioning and cognitive skills of older adults 36 model the disabilities associated with selfperceived health status among older adults were consistent with other findings in previous research 1216 hence it has been suggested that poor selfperceived health among women is a reflection of the higher burden of diseases they suffer however when this burden of diseases was compensated the gender gap disappeared 37 another finding was that the subscription to a health insurance was not associated with disability it is likely that in line with the theory of lack of information asymmetry there is little significance in health condition variables that explain the private ownership status among older adults 38 39 40 however a brazilian study showed that older adults who were enrolled in a health insurance had lower probability of high level of difficulty in accomplishing the adl compared to those who did not have a health insurance 12 regarding education and income as the levels increase the probability of the older adults to be able to perform adl increase 12 low educational level has a direct association with greater disabilities among the older adults compromising access to health education which is a strategy that allows the adoption of healthy behaviors and social mobilization to improve living conditions 41 among older women education seems to be associated with better functional capacity 42 gender differences in disability similar to other studies 101216 disability was found to be worse among women in all the federative units the high prevalence of disability in women is due to a combination of high incidence and long duration of disability resulting from lower rates of rehabilitation and mortality among women with functional disability 43 gender may be a risk factor for explaining a worse physical function among women but moving to equity could attenuate gender gaps in the physical function with advanced age 1344 according to bnhs data all brazilian regions showed similar levels of disability to the national average with no differences between men and women 34 two models of gender differences in disability can be highlighted al with a high level of disability among older adults and a large disadvantage of women versus men which is above the national average in both cases and sp with a low level of disability among older adults and a few differences between men and women which is below the national average for both alagoas and são paulo represent the socioeconomic extremes among the brazilian federative units in addition to the low level of human development al cannot meet the rev bras epidemiol 2020 23 e200002 needs of the current generations without compromising the capacity of reaching the needs of future generations due to the low sustainability therefore urgent state interventions are demanded 4546 it is noteworthy that sp besides the socioeconomic advantages that it presents ahead of many other federative units is considered an older adults friendly state in practical terms sp adapts its structures and services to be accessible and inclusive to the older adults with varying needs and capacities 47 therefore sp is an example in which intersectoriality happens in policies directed towards older adults the other federative units should see sp as a positive model although not ideal and replicate intersectoral policies with the aim of improving the older adult populations life 48 thus it is necessary to provide active and healthy aging applying and implementing health information and education strategies focusing on the prevention of disabilities and their determinants going beyond prescriptive methodologies and placing older adults as transforming subjects of their reality gender differences in disability and contextual factors social gender inequalities in brazil the highest rates of social gender inequality were associated with higher gender differences in disability with women at a greater disadvantage 16 a previous study found that the greatest social gender inequalities in federative units seem to be associated with high incidence of longterm disability among older women 43 in fact gender differences in disability may be related to broader social gender inequalities raising questions on how health socioeconomic and cultural factors influence gender patterns of seeking and using health care in later life in the country 4950 socioeconomic contextual factors income inequality is a main contextual factor in the social environment and it affects directly health increasing the probability of older adults presenting functional disability 12 therefore income inequality deepens gender inequality and disadvantages for older women that have a history of low participation in the labor market have minimal retirement benefits and depend on the public health system 41 with lower incomes than men women have less access to health and education that can ensure an improvement in their health quality since highly educated women were more than 10 times as likely to age successfully as were women with low levels of education 1042 in addition it is noteworthy that disability is strongly associated with chronic disease and functional disability relates to the performance of physical activities and social participation 51 therefore prevention policies rev bras epidemiol 2020 23 e200002 can help to delay the processes that lead to disability in older adults 52 as in this study other manuscripts did not find the gdp effect of disability on older adults in brazil 1216 as for life expectancy there was no effect either even though it is an important indicator of the populations quality of life it has also demonstrated the negative impact of disability on the health of older adults and its differential effects on women considering their higher disabled life expectancy 18 other studies could be conducted by adding new individual and contextual variables including the disabilityfree life expectancy and making a comparison with other countries strengths and limitations this study provides a representative approach to selfreported functional performance of older brazilians and contributes to the analysis of the health situation in brazil allowing researchers to trace the disability profile in brazil it also reinforces the importance of policies that reduce social inequalities in disability despite this this study has some limitations the response rates were lower in some federative units compared to others although sample weights have been used to correct this another limitation is derived from the nature of the sample information was only collected from older adults living in the community and excluded other living situations such as nursing homes convents and hospitals 34 moreover the database that represents the general population has limitations particularly because it addressed selfreported diagnosis data 53 older adults at a disadvantaged socioeconomic level might not have understood the questions asked during the bnhs or might be unaware of certain problems assessed in their locality underestimating the prevalence furthermore the study consisted of 27 samples in the second level of analysis which could limit the ability to detect statistically significant differences between groups conclusions women had higher disability disadvantages compared to men and those differences were associated with social gender inequalities among the brazilian federative units influenced by income inequality however it is important to consider that more studies are needed to elucidate other dimensions of functionality within and between the federative units considering other social determinants of health

objectives to estimate the magnitude of gender differences in disability among adults aged 60 and older and to evaluate whether they can be associated with social gender inequality and socioeconomic contextual factors at the level of brazilian federative units methods this is a multilevel study that used data from 23575 older adults of 27 federative units who participated in the 2013 brazilian health survey the activity limitation index was developed from the item response theory using activities of daily living and instrumental activities of daily living variables the association of individual and contextual variables with disability was estimated by assessing the magnitude of differences between genders using crosslevel interaction effects in multilevel generalized linear models including only the variables that were statistically significant in the final model results the prevalence of disability was higher among women 376 than among men 265 totaling 327 of the older adults in the adjusted multilevel analysis disability was influenced by income inequality γ gini 0022 p 0001 among federative units in addition gender differences in disability were associated with social gender inequalities γ mgiixsex 0020 p 0004 conclusion women had higher disability disadvantages compared to men and those differences were associated with social gender inequalities among the brazilian federative units influenced by income inequality

to the editor the prodigious greek philosopher aristotle with other renowned classical and contemporary thinkers plausibly observed that the human person is by nature a social being 1 or in the aristotelian term a political animal as a social being or a political animal mans sense of purpose is always intrinsically connected with the nature of socialization in other words the way a person deals with other human beings in the process of socialization defines how an individual creates meaning in relation to his own existence hence socialization is important not only in the search of the human person for existential meaning but also for keeping himself psychologically lucid departure from this natural tendency of the human person to socialize and to participate in the existential discourse of society would tragically result into a certain feeling of dejection and anxiety 2 in the case of the present situation that the society in general is currently facing in the midst of the covid19 pandemic this tendency to express oneself in the process of socialization has been pacified different governments across nations had implemented various forms of community quarantine just to prevent the widespread of the disease and the deleterious effect of the virus to different sectors of society 3 the preventive measures of the government in controlling the spread of the virus while good in itself pose a danger not only on the mental health of individuals but also their socioeconomic condition these aspectsthe mental health of individuals relational aspect of the human person and the socioeconomic condition of individuals are interrelated with each other simply because one aspect respectively affects the condition of the other two aspects in the case of the social condition brought by the pandemic many people across countries have lost their jobs when various businesses needed to be shut down because of the mandated quarantine or because of the lack of resources in funding their operation if these businesses would not shut their operation they would consequently end up minimizing their overall operation cost by reducing employed personnel and shortened their production hour just to cope up with their monetary lost which resulting to a sense of depression and anxiety on the part of those who are heavily affected the ones who lost their jobs this condition has left those people who have lost their jobs to spend their hardearned savings to provide the basic needs of their families and think of practical ways to survive given the absence of a suitable job the withdrawal from communal life and participation in social affairs certainly poses a threat to the socioeconomic condition of an individual which in return would affect his own mental health this proposition is true especially in the case of the most deprived ones in the social stratum 4 leaving them more deprived and utterly vulnerable however in the midst of the catastrophic phenomenon that the general populace is currently experiencing the natural tendency of the human person to socialize is still apparent the pandemic or any forms of restrictions could not stop the human persons participation in the process of socialization but instead makes his yearning for the other person even stronger the human nature to socialize could not be stopped by the pandemic simply because it is imbedded in his nature and it is this same social setting that the pandemic brings gives sufficient reason for the human person to be connected to others especially the suffering ones many people were moved into action in helping those who are deeply affected by the pandemic the silent yet obvious cry of those afflicted by the pandemic serves as a force that enable many people to socializes in the spirit of fraternal charity with a profound hope to alleviate the suffering and replace it with a deep sense of hope for a better tomorrow a hope that shines through the feeling of hopelessness that the pandemic brings fraternal charity seen in the process of socialization is a proactive advocacy and response to the anguish of the vulnerable 5 while people suffer in this time of global crisis the ray of hope coming from the natural tendency of the human person to socialize done in the spirit of fraternal charity is an assurance that humanity could withstand the disaster that threatens its very own existence who would have thought that the covid19 pandemic could bring out the best in many people to be a neighbor toward the other even if the situation requires corporal isolation who would have thought that the pandemic could result in a social paradox

government across all nations had promulgated precautionary measures in controlling the wide spread of the disease one that takes precedence is the practice of community quarantine where people are mandated to stay at home and avoid going outside if is not utterly necessary this mandate caused a lot of catastrophic outcomes in the socioeconomic condition and mental health of many many people are in psychological and existential despair for the loss of their jobs and the isolation that they are experiencing however in the midst of this undesirable condition the natural tendency of the human person to socialize is still present done in the spirit of fraternal charity an individuals way of socialization gives hope to those who are in despair the covid19 pandemic does not deter the human person to exercise his fraternal instinct but gives him sufficient reason to employ it all the more creating the social paradox of human presence

introduction inequality is a bit like cinnamonyou definitely want to have a little of it to spice life up a bit but too much of it can be very dangerous and make no mistake we are at cinnamondangerous levels right now 1 this simile for the gap between rich and poor in americaaccompanied by youtube clips which had gone viral of people spewing cinnamon at the camera while doing the cinnamon challengefeatured on hbos satirical show last week tonight with john oliver in july 2014 there can be little doubt that since the global financial crisis of 2008 criticism of the detrimental effects of capitalism has become a staple of american popular culture especially when directed towards a millennial audience the vehemence with which perceptions of social inequality as a highpriority political problem have moved from the left into the political middle only highlights the lack of effective government policies to address this issue the political relevance of social inequality has gained further momentum due to the spread of covid19 around the world the pandemic has highlighted dividing lines within modern societies many of which are the result of or at least exacerbated by an unequal distribution of income and wealth gaps between those who have sufficient access to the internet as crucial metaresource for remote learning and communication and those who do not as well as between those who can work from home and those who have little choice but to take increased health risks in order to earn a living to name just two examples that received much less attention before 2020 against the backdrop of these developments and the resulting political relevance multidiscipline research into social inequality has spiked and received a high level of public attention the most prominent example might be thomas pikettys capital in the twentyfirst century whichwhen published in english in 2014turned a regular academic economist into the global inequality guru pikettys work offered a plausible welldocumented and readable explanation of the explosive increase in social inequality we have witnessed since the 1970s and suggests how this could be countered through a global capital gains tax 2 along with british economist tony atkinson he also facilitated and encouraged further research by making his data freely available on the world inequality database as well as attracting much praise and publicity pikettys work has also become the target for some sharp methodological criticism 3 at least part of the criticism is directed at the fact that piketty tries to bridge history and economicstwo disciplines with widely differing conventions historians take exception to how economists use historical data without carefully reconstructing the circumstances of data production in favour of seemingly coherent time series the following article provides a review of research literature on inequality which crosses the borders of academic disciplines the literature covered here mainly focusses on the development of western societies between 1970 and 2010 and is organised in terms of research concepts despite methodological and cultural differences between history on the one hand and economics sociology and political science on the other maintaining a dialogue and paying more attention to each others research would enhance our knowledge of complex topics like social inequality toothless nationstates the limits and inefficiencies of policies of redistribution since the 1950s the scope of government intervention has expanded significantly in all western democracies welfare states in particular found new policy targets covered additional life risksalbeit at different rates of replacementand claimed an increasing proportion of growing public finances 4 this period of state expansion is usually seen as a golden age with little regard for its brevity or disparate developments 5 during the 1970s increasing societal complexity and mass unemployment put a strain on this new breadth and depth in state intervention giving momentum to crisis discourses from both the political right and left 6 by the mid1980s scholars and political commentators doubted the states capacity to redistribute income and wealth effectively under the pressures of globalisation 7 historian walter scheidel even argues that in the long run only wars revolutions failing states and medical catastrophes like the bubonic plague have interrupted the tendency towards evergrowing inequality due to their shock effect 8 in his book capital and ideology piketty offers a less deterministic interpretation of post1970s developments that is still a narrative of interrupted progress 9 he identifies three causes for the retreat of social democracy in western countries the abandonment of public ownership in the economy the failure to consistently tax wealth with progressive rates and the failure to provide egalitarian educational systems poornima paidipaty and pedro pinto have argued that pikettys argument is strong in description but does not identify factors that actually explain the failure of progressive politics or the public support for marketoriented policies 10 the following section explores two concepts that have been put forward as reasons for the decreasing efficacy of government redistribution first tax competition and other factors that discouraged states from taxing high incomes and second unintended changes in behaviour like opportunity hoarding in public education tax competition and tax havens since the 1990s there has been an ongoing debate about whether states are in a global competition for tax revenue which forces them to levy lower and lower taxes 11 several factors have combined to make the issue of tax competition relevant again the deregulation of financial flows freefloating exchange rates and relatively low tariffs allowed it to extract value from national tax regimes while taxes were high enough to make tax evasion financially attractive and worth the low risk of detection 12 the debate on tax competition in part describes the phenomenon in almost universal terms as if it is a strategy relevant to all income groups and exerts pressure on all kinds of tax revenues the empirical literature demonstrates however that when average or belowaverage income earners cross borders by far the main reason is for higher wages and not to avoid or lower their tax burden 13 the situation is different for financial services and capital income which strongly react to taxation rates the relative fluidity of capital gives small countries the opportunity to establish themselves as tax havens especially for anonymous shell companies from the major advanced economies 14 relative to their small budgets even a low capital or corporation tax rate generates significant revenue and makes this strategy worthwhile for switzerland luxembourg the channel islands and several caribbean islands to name the most significant tax havens 15 the scale of tax evasion is difficult to assess 10 paidipaty poornimapinto pedro ramos revisiting the great levelling the limits of piketty k not least because the business model of tax havens has at its core a strict observance of bank secrecy gabriel zucman estimates the global loss of tax revenue at around us 190 billion per year french public finances in 2014 alone lost around a third of their potential wealth tax revenue due to tax havens 16 much of the current literature on tax competition contains moral judgements that are somewhat unusual in the writing of academic economists gabriel zucman conceptualises tax havens as thieves who steal tax revenues that are the rightful property of other states joel slemrod and john d wilson go so far as to call tax havens parasites 17 apart from the states which benefit from tax evasion another focal point of the rapidly growing literature on tax evasion is individual tax evaders the new superrich several trade books with a strong popular appeal have attributed their behaviour to a changed relationship between individual and state in this interpretation billionaires become detached from specific societies and no longer feel any sense of responsibility for their development unlike the rich of earlier times who presumably paid their taxes out of a sense of duty this atomisation frees the new superrich to maximise their financial interests by utilising every loophole and playing national governments against each other 18 critics of both variations of the perpetratorvictimnarrative have argued that the states affected by tax evasion have not fully pursued strategies of international and supranational cooperation that could put a stop to tax evasion and money laundering practices according to andrea binder large economies like the us publicly complain about tax evasion while undermining efforts for more transparency like tax data exchange among oecd countries by refusing to comply themselves 19 big economies have also shown themselves reluctant to use access to their markets via licencing import and travel restrictions as bargaining chips to ensure compliance with national or supranational fiscal regulations in many cases they have also failed to prosecute financial crimes to the full extent allowed by existing laws 20 k economies might have in the continued existence of tax havens 21 research on fiscal competition inside federal states indicates that governments which do not want to draw public attention to a de facto lower corporate tax rate or lack the autonomy to change tax rates accept tax evasion as a strategy to attract business 22 there is a consensus in the research literature that tax competition and tax evasion place limits on the ability of national governments to redistribute income and wealth both have incentivised governments to shift the burden on to labour and consumption to make up for lost or forgone revenue to increase the public debt or to cut welfare payments most governments have applied all three strategies 23 however there is a dispute among economists over whether a highly progressive tax regime is the best way to redistribute income james poterba argues that tax progressivity is not as effective as politically assumed as it gives middleclass and workingclass taxpayers a high incentive to avoid tax by changing their behaviour and increases pretax inequality 24 other economists such as stefan svallfors and eiji yamamura demonstrate that tax compliance is not just a onedimensional reaction to taxation levels rather they argue the acceptance of taxation is directly connected to the degree of trust that social groups have in the government and in state institutions and how they assess the quality of governance 25 comparing the impact of redistribution in the us and european countries philipp doerrenberg and andreas peichl theorise that the best government strategy would be to focus on a strong welfare state and view taxation as a means of financing it rather than as an instrument of redistribution 26 educational inequalities and opportunity hoarding after world war ii numerous sociological studies drew attention to the lack of financial logistical and other resources that hindered children from workingclass and farming families from pursuing their education beyond the compulsory minimum in most western societies public debate treated such unequal educational opportunities as an issue of both social justice and economic development k disadvantaged backgrounds the chance to fulfil their intellectual potential was meant to increase economic productivity by avoiding educational wastage and providing emerging industries with the required higherskilled workforce 27 a common strategy to equalise educational opportunities was to open additional schools as well as universities and reduce or cut attendance fees together with the decreasing average number of children per family these measures reduced the relative cost of prolonged education for parents according to oecdfigures the growing uptake of secondary and tertiary education caused the state expenditure on public education among member states to rise from 43 per cent in 1960 to 52 per cent of gdp in 1975 within this general trend of educational expansion significant national differences in public spending on schools and universities remained varying from under 2 per cent in greece to over 7 per cent in denmark 28 aside from a usually strong crosspartisan consensus for increasing public spending education policy caused frequent conflicts between politicians of different ideologies and interest groups like parents organisations teachers unions and employers 29 in much of europe the debate focussed on the merits of selective versus comprehensive school models and their respective effects on educational equality and quality the founding of comprehensive schools was the most important strategy to equalise the abilities of children from different social backgrounds by exposing them to shared learning conditions for longer 30 the decision to go comprehensive was often linked to the broader egalitarian reforms of social democratic governments during the 1960s and 1970s most prominently scandinavian countries implemented the comprehensive model to the fullest extent while also spending the highest proportion of gpd on public education however the development of education systems does not in all cases concur with the classic typology of welfare systems the us the prime example of a liberal market economy also embraced a system of comprehensive schools and ranked close to the oecd mean in her spending on public education between 1960 and 2002 while public comprehensives accompanied by a strong tradition of private often religious schools and the legality of homeschooling were relatively uncontroversial in the us conflicts about public education here primarily concerned practices of racist segregation during the mid1960s the american high school system provided 63 per cent of workingclass children with a complete secondary education and at least theoretically the possibility to go to university at the same time only 3 per cent of english workingclass 27 k children and only 1 per cent of their peers in western germany succeeded this far in their education 31 both west germany and the uk exemplify how public education became one of the policy areas with the most first secondand thirdorder policy changes 32 both countries introduced comprehensive schools during the late 1960s and 1970s as a model for public schools and provided financial incentives for local authorities to implement it the concept was altered significantly or abandoned during the 1980s by conservative governments they also demonstrate a general trend of regional disparity since scotland wales as well as several german federal states kept comprehensive schools while england and other parts of germany retained or went back to a tripartite selective school system during the 1990s a controversy ensued among educational sociologists about the effects of educational expansion and reforms on educational inequalities 33 a muchregarded metaanalysis of 13 european countries by yossi shavit and hanspeter blossfeld and their controversial diagnosis of persistent inequality formed a critical reference point for this debate according to shavitblossfeld the level of education had risen significantly across all classes but childrens social background still determined the extent of their educational opportunities in most countries only sweden and the netherlands had managed to level the playing field for children from lowincome families 34 the reaction to shavitblossfelds study within the field of educational sociology has been mixed the model of regression analysis that shavit blossfeld use to measure education transitions was challenged on methodological grounds as both simplistic and lacking statistical power 35 several singlecountry studies also refuted the hypothesis of persistent inequality k however other studies defended shavitblossfelds findings based on national data and comparative analysis 37 a relatively rare but exemplary case the shavitblossfeld study has also been challenged by two replication studies with improved data sets the first one of 2009 by richard breen and others reassessed the persistencehypothesis based on more recent data and a larger sample from eight european countries 38 they used the ordered logit model to measure class inequalities via the classspecific odds of attaining five educational levels breens study covers five cohorts born between 1908 and 1964 contrary to shavitblossfeld their findings substantiate the notion that democracies strove and mostly succeeded to close the classbased attainment gap children from workingclass and farming families born between 1935 and 1954 benefitted the most from increased public spending on education however there are some notable exceptions to this general trend of equalisation even though breens study only covers children whose educational career mainly occurred during times of high economic growth and expanding educational opportunities in western germany the classbased attainment gap continued to narrow for men born between 1925 and 1954 but stalled for the last cohort born between 1955 and 1964 this age group was first to pass through an expanded more egalitarian education system but the proportion of workingclass children who received universityentrance qualifications only rose very slowly and stalled at around 10 per cent from the mid1970s onwards 39 in britain the longterm trend of improvement for the sons of small business owners and skilled workers nearly ceased for the cohorts born after 1935 some groups such as sons of whitecollar workers in france did not experience any advancement over the entire postwar period in italy class inequalities within the cohort born between 1955 and 1964 even grew more robust again 40 the second replication of shavitblossfelds persistent inequalitystudy by carlo barone and lucia ruggera of 2018 covered an additional cohort born between 1965 and 1980 and educational careers between the 1940s and the 2000s their study is hence able to track the impact that numerous socioeconomic and political changes had on educational inequalities since the 1970s 41 baroneruggera enlarge the cohort design regarding the number of countries and the 37 respective sample sizes unlike breens study they also examine both male and female educational careers baroneruggeras findings confirm breens refutation of the persistent inequalityhypothesis while addressing several methodological objections to the first replication study they show a general longterm trend of statistically significant equalisation across five country clusters that proves robust for several calculation models despite having different education systems and spending levels most countries reduced their kappa index which measures the association between paternal social class and childrens educational attainment between 40 and 50 per cent outliers are sweden with 67 per cent and germany as well as great britain with 17 per cent 42 barone ruggeras findings show that equalisation slowed or stalled for the last cohort born between 1965 and 1980 in most country clusters russia romania hungary and bulgaria even display a curvilinear development an initial flattening of educational inequality already started to reverse for students born after 1955 and hence significantly too early to be explained by the regime change in eastern europe baroneruggeras findings contribute to a surveybased narrative of how inequalities developed in europe during and especially after the trentes glorieuses however the authors themselves point out that their approach is descriptive and cannot identify causal factors since the expansion of education systems and the reduction of monetary barriers to further education were necessary conditions for postwar equalisation the most verisimilar explanation for its stalling would be the retrenchment of state financing during the late 1970s lack of economic growth and mass unemployment increasingly put pressure on public expenditure among oecdmember states the mean proportion of gdp spent on education decreased from 59 per cent to 54 per cent behind this overall retrenchment lay two different trajectories that led to a general trend of convergence countries that had spent the most on education between 1945 and 1975 also scaled back the most the retrenchment group with all anglophone countries as well as the netherlands norway finland and germany comprises examples from all three types of welfare systems which again speaks to the particular policy dynamics of public education manfred g schmidt has hypothesised a surprising link between spending on welfare and education in as much as countries like the netherlands and germany cut education budgets to maintain the structure of their welfare states under the pressures of mass unemployment 43 unlike the highspending retrenchment group countries at the low end of the educational investment spectrum upped their spending on public education considerably after the mid1970s this trend was most robust in spain portugal and greece where the idea of better educational opportunities for all merged with and was reinforced by the end of dictatorship and democratisation 44 these southern european countries also displayed a continuous reduction of educational inequalities from the 1940s to the 2000s without the stalling 42 ibid figure 1 on p 12 43 schmidt retrenchment p 174 44 ibid pp 168170 k effect common in other countries 45 equalisation in this case occurred from an exceptionally high level of educational inequality which responded strongly to the expansion of public education lower levels of educational inequality proved more resistant to state intervention even before education spending decreased relative to gpd a differential approach such as that of erzsébet bukodi and john h goldthorpe provides a valid explanation for the relative resistance of midlevel educational inequalities they argue that much of the research on educational attainment only analyse one of the three components of social originsocial class social status and parental educationleading to misinterpretations since they can develop incongruently 46 according to robert eriksonbukodi goldthorpes subsequent comparative study on cohorts born in sweden and the uk between the mid1940s and the late 1960s the effect of family finances on educational attainment remained stable at the same time the influence of parental social status declined and that of parental education even increased 47 baroneruggera disagree with their conclusions by arguing that parental education and social status combined proved the strongest predictors for educational attainment in the next generation according to them social class becomes statistically insignificant when controlled for these factors with one intriguing exception students from farming families 48 while the weighting between the components of social origin is in dispute there is consensus that the importance of parental education relative to that of economic barriers increased over the postwar period a comparative study into university education in france and england by cécile deer shows a similar persistence of inequalities despite a very different trajectory of public spending 49 since the mid1970s england cut spending on education incrementally replaced maintenance grants for university students with loans and introduced upfront tuition fees in 1998 45 baroneruggeras data does not cover the period after the financial crisis of 2008 which hit greece especially hard causing the greek economy to shrink by no less than a third and leading to drastic cuts in education spending of over 40 per cent between 2009 and 2015 see dassiou xeni greece in economic crisis the case of health and education in vierteljahrshefte zur wirtschaftsforschung 84 no 3 pp 145164 such a perfect storm of grave economic depression spiralling unemployment and severe retrenchment of public spending makes greece an idealtypical case study for future research on the development of educational inequalities 46 k in contrast france maintained her spending level and erected no such monetary barriers to higher education however access to university degreesespecially from highly prestigious institutionsremained primarily determined by social origin in both countries the following will briefly introduce two concepts from sociological and economic literature that together can further explain the stalling of equalisation educational assortative mating and opportunity hoarding starting with the social upheavals caused by world war i alternative visions of companionate marriage emerged alongside traditional ideas of marriage and started to grow mainstream in western societies during the 1960s and 1970s 50 part of the companionate ideal was a similarity in age and education between marriage partners as a social phenomenon educational homogamy rose between 1940 and 1970 when women started to close the educational attainment gap to men 51 during the 1960s wives of high earners still earned less than the average woman but the relationship between spouses earnings became positive from the 1970s onwards 52 when becoming parents middleclass couples with dual university degrees often were willing to invest a significant amount of time and other resources into optimising their childrens education they also were much more efficient at acquiring publicly financed educational resources for their children than parents with a smaller income and less education dawn lykensegosebe and serena e hinz have conceptualised such strategies as opportunity hoarding that often counteracted government policies intended to lower inequality 53 most of the literature suggests that hoarding strategies are motivated by the idea that their childrens future social status is threatened by an increasing competitionwhether real or imagined k lykensegosebehinz differentiate between withinschool hoarding and betweenschool hoarding betweenschool hoarding aims at securing a place at the best possible local state school either via official school choice or other means until the 1980s and 1990s state schools in most countries recruited their students from a set catchment area with parents officially having little or no choice by the late nineteenth century most cities had developed classbased and in many cases also ethnicityor racebased neighbourhoods often segregated by occupation or religion 55 which school catchment areas replicated 56 during the twentieth century many such spaces of inequality were modified or reinforced by middleclass parents prioritising residences in the catchment areas of state schools that had a good reputation in their peer group 57 contrary to what the predominantly sociological literature suggests this was not a novel phenomenon of the 1980s for the us such strategies are welldocumented ever since the interwar period and among other reasons motivated the middleclass flight from the us inner cities to the suburbs a study by john l rury and argun saatcioglu analyses the divide between the suburbs and inner cities based on the census and other serial data over a relatively long period from 1940 to 1980 58 the clustering of the affluent classes in the suburbs had multiple repercussions local taxes in the suburbs had to support fewer welfare recipients so that more resources could go to the local schools at the same time ethnic minorities and workingclass families who remained in the inner cities or moved there for the lower rents faced rising unemployment as well as poverty and sent their children to schools with much lower perpupil budgets 59 discriminatory zoning laws combined with high housing prices kept nonwhite workingclass families out of the suburbs this process of socioeconomic segregation between us suburbs and inner cities 55 k disrupted and reversed the slow narrowing of the racial attainment gap 60 rury saatcioglus findings support the matthew principle that advantages accumulate for predominantly white middleclass students in suburbia affluence combined with relatively stable family life a high degree of parental involvement and a large proportion of successful state schools by 1980 the suburbia effect accounted for almost half of the higher attainment levels compared to pupils from innercity schools while concentration effects are a wellknown phenomenon in poverty and deprivation 61 relatively little attention has been paid to their role in creating and reproducing wealthy milieus the relevance of such evasion strategies depended among other factors on the fluidity of the housing market which was high in the us case in european cities like athens where residential segregation and housing market mobility were low middleclass parents tended to optout of the state school system altogether by going private or tried to monopolise a local state school for children from their ingroup 62 selective state schools offered middleclass parents an alternative hoarding strategy without having to compete on the property market during the 1980s and 1990s the demand for freedom of choice in education gained momentum in most western countries 63 proponents of parental choice argued that this policy change created greater fairness by giving workingclass parents an option that affluent parents had possessed all along 64 in many countries catchment areas were abolished and parents officially gained the right to choose schools for their children in some cases the educational choice debate also resulted in the provision of state funding for private schools 65 the change was particularly pronounced when combined with standardised testing and much public attention paid to rankings for schools and universities as in the uk and the us some studies claim that middleclass and upperclass parents primarily aim to avoid social and ethnic heterogeneity when choosing their childrens school even above considerations of educational quality 66 however in many countries the market logic in public education remained limited and school choice did not prove as averse to social equality as many social scientists had predicted 67 the new possibility to choose was also not universally welcomed by middleclass parents since it turned a high level of parental involvement from an option into a duty and the acceptance of state allocation into a form of neglect 68 at least for some european countries such as germany and finland there is evidence that a segment of middleclass parents deliberately chose to send their children to the regular local school this decision depended on their assessment that their children did not risk being left behind 69 the education expansion had several unintended consequences which reinforced the perception of middleclass parents that their childrens future social status was under threat even though they proved highly effective in securing it the slowdown of economic growth meant that the job market did not keep up pace with the uptake of higher education this combination influenced the transition from the education system to the labour market on all levels not only did apprenticeships that used to be filled with applicants with mandatory minimum schooling increasingly attract students with universityentry qualifications the relative inflation of credentials also meant that competition among college graduates increased especially in the creative sectors of the economy middleclass parents often provided financial support so their children could meet new requirements like unpaid internships extracurricular activities and studies abroad 70 workingclass parents not only assessed the riskbenefit ratio of higher education differently than parents who were themselves college graduates but they also had less insight into the rules of postgraduate labour markets and often lacked the resources invested by middleand upperclass families 71 the concept of opportunity hoarding contributes to our understanding of how societies respond to attempts at social engineering and why universal welfare policies like public education can have unintended consequences that sometimes counteract policy goals however it remains unclear to what degree practising opportunity hoarding implies exclusionary intentions towards the groups that miss out on publicly financed resources as a result 68 k 3 societal impacts of social inequality over the last twenty years a vast amount of research has examined the societal effects of economic inequality much of this debate was initiated and influenced by the work of social epidemiologists kate pickett and richard g wilkinson their book the spirit level declared social inequality to be the determining factor in a long list of social problems according to pickettwilkinson unequal societies were significantly more violent and unstable with people suffering higher rates of illness and drug addiction their reasoning in both the spirit level and their followup book the inner level was mainly socialpsychological the primary effect of inequality was to create anxiety and to disrupt trust in relationships and this had multiple repercussions for both individual behaviour and societal cohesion similar to the strain theory pickettwilkinson saw social inequality as a structure that in creating unachievable expectations for almost everyone except the rich eroded their sense of selfworth 72 published in 2009 when most countries were suffering the full impact of the financial crisis the spirit level hit a nerve especially with the british and us public and became a bestseller despite its extensiveand controversialuse of statistics 73 pickettwilkinson offered an apparently easy fix for almost everything that was wrong with contemporary society and also provided a potential reason for the rich to act contrary to their own economic interests if redistributive policies could make society more peaceful and everyone happier the rich too would benefit directly from a higher quality of life and not just in a common good or altruistic sense the following section will examine how the spiritlevel hypothesis stands up to the research literature on three important societal impacts of growing social inequality crime happiness and openness crime the effects of social structure on a societys crime levels are a longstanding research focus of both sociology and criminology the theory of social disorganisation which has mostly dominated this field of research since the 1920s attributes crime to a combination of poverty and a lack of social interconnectedness since both impede a communitys ability to enforce shared values it signified a fundamental shift in the mainstream interpretation of deviant behaviour moving from individualor racebased causation to an environmentally based explanation following the chicago school approach most studies focused on the neighbourhood level of big cities and compared the crime rates of areas with different income levels current literature in the field of social criminology considers both poverty and deprivation relative to adjacent neighbourhoods it has shown inequality to be the more powerful 72 k explanatory variable for rising crime rates 74 a longstanding and contested issue in this literature concerns the different effects an increase in income inequality has on property crimes and on violent crimes against people 75 current research also examines the effect of rising income inequality in different countries from a comparative perspective the hypothesis of a positive causal link between inequality and crime rates has long been considered a western theory that only applies to industrialised countries however research on china shows that inequality in income employment and consumption positively correlates with different levels of crime between chinese regions 76 crosscountry comparisons face several methodological issues not all of which are reflected in the criminological and sociological literature most of these comparisons use highly aggregated time series data to test the robustness of correlations between some variant of giniindex and violent crime rates relative to population size versus other influences 77 time series data are more reliable than sampling individual years as a basis of comparison however they must be analysed as source material that is a product of changing circumstances and perceptions since the 1960s definitions of crimes and types of prosecution have changed significantly in many countries these changes are most apparent when it comes to crimes against an individuals sexual selfdetermination and domestic violence 78 similar problems apply to synchronic comparison because of differences in legal systems on the whole the hypothesis that societies with comparatively high inequality are also more violent is broadly accepted in the fields of both criminology and sociology however the example of crime also shows that attempts to use this insight as a basis for social engineering have produced unintended consequences during the late 1990s and early 2000s several countries added analytical tools to their legal procedures that automatically factored socioeconomic deprivation into sentencing procedures remarkably the outcomes of such attempts were similar in countries with different levels of social inequality these analytical tools turned economic deprivation into a highrisk factor for re offending behaviour such coding resulted in longer sentencing and lower chances for indigent defendants to be released on probation instead of going to prison when compared with their more affluent counterparts rather than making justice systems more equal the automated consideration of social inequality reinforced existing similarity bias in favour of middleand upperclass defendants 79 happiness while the spiritlevel hypothesis by and large holds up in relation to crime the research literature on the link between inequality and happiness is much more ambiguous mostly due to methodological differences there is currently no consensus in the research fields of sociology economics and social psychology on the question of whether unequal societies are more unhappy or prone to depression than those with less discrepancies in income distribution 80 similar disagreement exists about the capacity of government interventions like redistributive taxation and welfare payments to alter a societys happiness level 81 most research literature conceptualises happiness as one component of individual wellbeing and relies on selfassessments to measure it 82 since the 1970s happiness economics has aimed to answer the question of how the growing prosperity that industrialised countries experienced after the second world war affected the mood of their citizens the socalled easterlin paradox has dominated this fieldand popular perceptions of happiness economicsas the result of a pioneering study based on us data from 1974 onwards at the core of this paradox is the finding that in the longterm happiness does not increase in line with disposable income beyond a point of satiation 83 the 79 van eijk gwen socioeconomic marginality in sentencing the builtin bias in risk assessment tools and the reproduction of social inequality in punishment society 19 no 4 pp 463481 80 for an overview of these methodological controversies see schneider simone m income inequality and subjective wellbeing trends challenges and research directions in journal of happiness studies 17 no 4 pp 17191739 81 cheung felix income redistribution predicts greater life satisfaction across individual national and cultural characteristics in journal of personality and social psychology 115 no 5 p 867882 argues on the basis of german as well as crosscountry comparative data that lowering social inequality by 10 per cent increases overall happiness as much as a 37 per cent increase in overall prosperity similarly amendola adalgisodellanno robertoparisi lavinia happiness and inequality in european countries is it a matter of peer group comparisons in economia politica 36 no 2 pp 473508 point out that people who live in countries with strong welfare states experience less adverse effects of inequality on their wellbeing contrary to these proredistribution arguments cullis johnhudson johnjones philip a different rationale for redistribution pursuit of happiness in the european union in journal of happiness studies 12 no 2 pp 323341 claim the impact of income redistribution on average national happiness in eu countries to be marginal 82 psychologists have a different approach to happiness than social scientists who are working in this field while psychologists also acknowledge the impact of objective life circumstances on individual wellbeing they stress that emotional happiness is more independent from material influences like income than a cognitive assessment of their lifesatisfaction see decancq koenfleurbaey marcschokkaert erik chapter 2 inequality income and wellbeing in k easterlin paradox has been challenged on the basis of comparative data but still provides a focal point for debate within the field of happiness economics since the easterlin paradox seems to refute the idea that gdp is an explanatory factor for aggregate happiness a wide range of studies have considered the unequal distribution of growing prosperity to be decisive 84 apart from aggregated happiness levels some studies in the field of happiness economics utilise the concept of happiness inequality measuring the level of happiness across and within different social and ethnic groups one of the best sources for the development of happiness inequality is the us general social survey it has been asking a representative sample of americans to rate their happiness from low to moderate to high continuously since 1972 most research on happiness inequality does not refute the easterlin paradox but complements it with two valuable insights first there was an overall trend towards moderate happiness during the 1970s and 1980s while the share of americans who reported that they were not too happy fell from 14 per cent in 1972 to its lowest level of under 8 per cent in 1990 while the proportion of participants claiming a high degree of happiness has been on a downward trend since the early 1970s they still outnumber those with low happiness by 3 to 1 85 the rapid growth in social inequality has not led to greater happiness inequality among the us population overall second the general social survey data demonstrates a general trend towards crossgroup convergence since the 1970s the gap between men and women has almost disappeared with women reporting decreasing levels of happiness while men feel significantly better about their lives a similar trend towards convergence has occurred between whites and nonwhites but the gap was much bigger than the gender gap in the 1970s and was still more pronounced during the 2010s one exception to this general narrative of convergence is notable the happiness gap between university graduates and individuals without a completed secondary education has widened presumably because of an increased risk of unemployment for high school dropouts and the increasing financial return on higher education over the life cycle 86 several studies have confirmed the detrimental effect of unemployment on happiness levels a study comparing europe and the us argues that unemployment and not income inequality is the socioeconomic factor that determines happiness 87 several us surveys show that the effects of income inequality on happiness depend not only on objective circumstances but also on individual psychological factors like personality respondents from all income groups who attached great importance to how their income compared to that of others were less satisfied with their life than social peers who did not 88 this research literature also demonstrates the role of local social comparisons people tend to judge their economic status against that of facetoface contacts instead of abstract concepts such as national averages family members of the same gender with whom there is a climate of competition are of crucial importance corroborating h l menckens quip that for a man being wealthy means earning significantly more than his brotherinlaw 89 a 2019 study based on data from the european quality of life survey demonstrates that social comparisons have specific group effects in addition to the individual coping with social inequality this european data confirms the importance of close social contacts as a reference point since ingroup inequality decreases happiness at all levels of income while growing inequality between groups shows no effect in addition to such group effects the study also traces the adverse effect of inequality on all income groups 90 the research literature on happiness economics on the whole shows little or no reflection on how social and cultural contexts shape individual assessments of happiness a historicalcritical secondary analysis of the extensive survey data that is available for the post1970s period could enrich this field by pointing out the influence both of socioeconomic changes as well as perceptions and expectations within social spaces like milieus 91 societal openness the politics of resentment and welfare chauvinism the rise of a new rightwing populism since the 1990s has sparked a debate about whether growing social inequality made societies more exclusionary or even resentful towards those considered alien to a polity defined in racist or nativist terms ironically it was political scientist francis fukuyama who has made one of the most influential contributions to this debate on the crisis of liberalism and universalism 92 in his book identity fukuyama argues that the social inequality brought about by globalisation was a necessary condition for the rise of populism and aggressive identity politics but cannot explain it in and of itself instead he suggests socioeconomic changes like deindustrialisation triggered feelings of being disrespected and ignored by the media and political decisionmakers alike that turned the loss of income and status into longlasting grievances selfstyled antiestablishment elites used these resentments to mobilise voters against a variety of targets including minorities fukuyama is arguing against the simplistic idea of humans as rational maximisers of economic interests which he claims dominates public discourse and for the importance of emotions in politics 93 his book certainly offers some interesting insights into how the politics of resentment might work it appeals especially to politicians and political commentators who perpetuate the narrative that recent triumphs of populism were the revenge of those left behind in economic terms however fukuyamas argument lacks both empirical evidence and analytical clarity an analysis of emotions must amount to more than speculating that everyone who expresses resentment towards minorities or multiculturalism does so because of presumed experiences of economic loss and humiliation 94 empirical studies offer little support for the assumption that rightwing populist parties are especially appealing for voters in precarious economic situations or represent their interests the new rrps did not define themselves as prowelfare or proredistribution parties at least in their early phase in the late 1980s and 1990s most took a neoliberal approach to economic and social policy 95 the concept of welfare chauvinism which was adopted by almost all european rrps during the 1990s demanded that only ingroup members should be entitled to welfare payments and only under certain conditions by racialising the old idea of the deserving poor similar to the nazi volksgemeinschaft welfare chauvinism offered rrps the opportunity to reject or even demonise the universal welfare state and still claim to represent those who had lost out due to globalisation and other globalist elite projects 96 a frequently cited article by sociologist daniel oesch looks at classrelated differences in rightwing attitudes in france belgium switzerland austria and norway in all five cases workingclass voters were more likely than middleclass voters to choose rrps this gap varied between 300 per cent in belgiumfrance and 130 per cent in the netherlands oesch operationalises economic reasons such as insecure employment and fear of wage pressures to explain this voting behaviour along the lines of the ethnic competition hypothesis differential nativism and disenchantment with the political system could coincide with economic deprivation or the perceived risk of it however most workingclass supporters of rrps were insiders skilled 93 fukuyama francis identity the demand for dignity and the politics of resentment farrar straus giroux new york 2018 pp 611 94 for an integrated approach to a history of emotions and its methodological implications see lang johannes new histories of emotion in history theory 57 no 1 pp 104120 95 workers with steady jobs 97 oesch argues that cultural fears about immigration as a threat to national identity offer the most robust explanation for their support of rrps oeschs assumption that workers might reject multiculturalism because they have fewer cognitive skills smacks of classism 98 a historical perspective on the development and decline of an original workingclass identity accompanied by the universalisation of a middleclass lifestyle that was financially unachievable for most manual workers offers a better explanation for cultural anxieties among this group 99 according to the current political science literature the differing attitudes to multiculturalism of workingclass and middleclass voters are part of the dilemma that social democratic parties have faced over recent decades along with differing demands of welfare reform this electoral cleavage has restrained many european centreleft parties from turning rising social inequality into an electionwinning issue 100 german survey data from the 1980s and 1990s suggests that nativism among the unemployed and those with precarious jobsthe people most likely to be affected by ethnic competitiondid not equal a permanent resentment of immigration rather marcel coenders and peer scheepers argue their exclusionist attitudes were a temporary reaction to recent increases in unemployment and immigration neither of these disadvantaged groups displayed a lasting orientation towards rightwing populism 101 studies with a comparative european approach reach a similar conclusion neither the level of unemployment nor the proportion of precarious employment could explain the differing prevalence of nativism and racist attitudes 102 the acrimonious brexit campaign and the electorates narrow decision to leave the european union has startled many commentators and resulted in a major political victory for rightwing populist strategies of mobilisation in a particularly intriguing paper of 2020 economists maria abreu and özge öner have analysed how different socioeconomic political and cultural factors impacted the likelihood of constituencies to vote to leave the european union 103 one of abreu öners findings points to a particularity of the brexit campaign constituencies with a low voter turnout in previous elections were more likely to vote leave than others this success for the leave campaign is likely down to a novel type of microtargeted advertising on social media that used a combination of psychographics and big data to influence or nudge previous nonvoters with an alleged antiestablishment message to participate in a protest vote 104 abreuöners analysis supports the hypothesis that valuesbased cultural grievance were more influential in the brexit vote than socioeconomic circumstances like inequality amongst economic variables only low wage growth was more prevalent in probrexitthan in proremainconstituencies given that brexit has mostly been interpreted as a workingclass vote against globalisation this difference with 18 percentage points is much less significant than expected as jim tomlinson argues in his fascinating book managing the economy managing the people narratives of economic life in britain from beveridge to brexit of 2017 seeing brexit as an antiglobalisation revolt accords with a dominant public discourse by politicians and journalists that depicted globalisation as both inevitable and ubiquitous while giving little to no mention to benefits like cheap imported consumer goods there is little doubt that wage stagnation and wage polarisation increased social inequality in the uk and drove resentment against the economic status quo which many voters identified with the eu however most of the british wage development is due to longstanding processes of deindustrialisation in which globalisation only played a relatively recent cumulative role 105 tomlinson also points out that immigration and a europeanised labour market turned out the most problematic topic for the remain campaign 106 abreuöners data supports this argument antiimmigration attitudes with seven percentage points were a much more decisive factor than low wage growth to tip the majority against a continued eu membership and the freedom of movement that goes along with it of particular interest is that abreu and öner can show the difference between how immigration is perceived and how it is experienced in everyday life in the local community contrary to the hypothesis of ethnic competition economically successful constituencies with low immigration levels were more likely to reject european immigration than economically slowgrowing areas with high levels of immigration 107 the leave campaigns strategy of suggesting that turkey would join the eu imminently with millions of turkish citizens coming to the uk proved an effective mobilisation tool 108 there are several similarities and entanglements between the brexit vote and the other recent major success for rightwing populism the victory of republican candidate donald trump over democratic candidate hillary rodham clinton in the 2016 us presidential election much of the political commentary has reproduced the claim of selfstyled bluecollar billionaire donald trump to represent a revolt of downwardly mobile workers and middleclass voters in difficult financial situations the research literature is more mixed with some scholars pointing to the low education level of the average trump voter and reviving lipsets idea of workingclass authoritarianism while others dispute the notion 109 trump won around 62 per cent of the white workingclass vote which is a level similar to richard nixons election of 1972 110 when looking at a voter breakdown along income groups instead of class categorisations it becomes clear that trump especially appealed to voters with midlevel and higher incomes hillary clinton received an absolute majority among voters with very low and very high incomes 111 the median annual income of trump voters surpassed the statewide median income in every state and the national median income by more than 10000 112 data from the american national election studiesa survey that has been continuously conducted on presidential elections since 1948again demonstrates how crucial cultural grievances are for the electoral appeal of rightwing populism negative attitudes towards minorities and feminism combined with preferences for authoritarian leaders were the best predictor of who would vote for trump 113 trumps electoral success was mostly due to his ability to mobilise more radical nativist voters and simultaneously maintain the support of traditional conservatives while clinton failed to motivate the socalled obama coalition to turn out in sufficient numbers for her especially in the midwest 114 much of the cited research pits socioeconomic explanations of electoral behaviour against theories that focus on cultural interpretations of belonging and resentment in their thoughtprovoking article three worlds of welfare chauvinism jeroen van der waal willem de koster and wim van oorschot argue that neither cultural nor economic theories alone can explain why exclusionary tendencies between countries differ their analysis of data from the european social survey for 2008 combined with countrylevel census data points to the importance of institutional settings and path dependency der waalde kostervan show that countries with strong welfare statesthe socialdemocratic type in gøsta espingandersens wellknown modeldisplay the lowest level of welfare chauvinism the authors hypothesise that the resulting lower social inequality led to less divergent lifestyles between different income groups they argue that relative similarity fostered an understanding towards lowincome groups and prevented stigmatisationan effect that extended to welfare recipients and immigrants 115 an article by jonas edlund and arvid lindh also confirms the welfare state inequality hypothesis by a comparative analysis of data from the international social survey program for 20 countries and additional data however their reasoning is somewhat different unlike van der waalde kostervan oorschot who emphasise crossclass harmony edlundlindh link the lower level of welfare chauvinism in countries with effective redistributional policies to walter korpis theory of class conflict 116 this interpretation suggests that strong welfare states channel social conflicts into political conflicts that are expressed and regulated through institutions 117 while both articles present convincing arguments for the welfare stateinequalityhypothesis they also demonstrate the need for further research a longerterm comparative perspective that links the development of welfare states and social inequality with an analysis of exclusionary attitudes and resentment towards minorities would help determine the role of individualised live risks in societal processes of inclusion and exclusion china india chile sweden and england in a longterm perspective from the middle ages to the twentyfirst century following the socioeconomic status of families with unusualand hence traceablesurnames the apparent differences between these societies their historical circumstances cultures and level of government intervention make clarks hypothesis of a uniformly level of social mobility even more astonishing unlike studies that take into account only how individuals fare relative to their parents clark applies a multigenerational approach and he credits this as part of the reason why their estimates of social mobility are much higher than his families with norman surnames for example provide impressive evidence for the longterm preservation of social status their huge overrepresentation among oxbridge graduates during the twelfth century declined gradually over time but was still visible in the late twentieth century clarks argument for a multigenerational research design is convincing but it is not as unique as the author claims given that the socalled grandparents effect is well documented in the literature on social inequality 119 grandparents tend to play a significant role in reproducing their socioeconomic status in their grandchildrens employment history 120 this seems especially plausible for the us and western european cohort that was born during the 1930s they reached their maximum earning capacity during an economic boom phase bought houses in record numbers and paid off their mortgages during the 1980s 121 being free of this debt released economic capital just at the time when their grandchildren were reaching school age allowing for intergenerational investment and adding to several other dynamics that increased social inequality during the 1980s 122 while clarks idea of following families with lowprobability surnames over a long period is a considerable innovation there are several grounds for serious critique the first is methodological the categories he uses to describe socioeconomic positions are elite and underclass which lack a clear definition based on income property and other forms of capital a longterm perspective intensifies the analytical weaknesses of such vague categories the suggestion that graduating from prestigious universities like oxford in the thirteenth century or harvard in the seventeenth transferred the same kind of elite position as in the twentieth century makes this research design practicable 123 however the lack of historical context diminishes its explanatory power especially since the declared goal is not to examine elites in and of themselves but to compare the development of relational positions k within specific societies another methodological issue concerns how clark arrives at his universal constant as sociologist ineke maas has pointed out clarks data does not necessarily lead to his conclusion of crosscase and crosstemporal uniformity to do so requires substantial corrections for migration flows for example that are applied in some case studies but not in others 124 the second ground for critique relates to the farreaching conclusions clark draws from his findings especially his contribution to the naturenurture debate he takes a position close to genetic determinism on the spectrum of this debate arguing that some families are successful in the long term because they pass on superior abilities to their offspring via their genes there are several objections to equating status and genetic inheritance as clark does families as documented by surnames are primarily defined by law via the presumption of paternity not necessarily by genetics and their gene pool is increasingly diversified with every generation clark goes even further by claiming that social inequalities are fair and natural the result of unequally distributed innate talent that is mostly resistant to intervention 125 this conclusion seems like a dusty souvenir of the highly ideological naturenurture debate of the 1980s and 1990s in the us in particular this debate was conducted by both social scientists and natural scientists and quite openly formed part of a political argument about the role of government in changing unequal access to resources without much support from scientific evidence for such a simplistic interpretation the political nature advocates questioned the prudence of investing in policies designed to produce more social mobility if genetics had already determined an individuals abilities this discourse culminated in the book the bell curve published in 1994 126 and the social darwinistand in some cases openly racistpositions that drew legitimacy from it these interpretations of social inequality helped to move the us political mainstream away from the new deal consensus and enabled the fundamental changes to the welfare state during the clinton presidency 127 both herrnsteinmurrays bell curve and clarks the son also rises demonstrate the often complex interdependence between scientific output and dominant interpretations of social realities within the political field future research on social inequality will benefit from the political relevance attributed to its subject in terms of visibility and access to additional funding however this role poses additional challenges to reflect not only on how societal interests and expectations shape research scientific communities also need to agree on bestpractice strategies to prevent cherry picking 124 maas ineke review of the book the son also rises surnames and the history of social mobility by gregory clark in economic history review 68 no 4 pp 1481f 125 the only exception clark allows are policies that influence the marriage rate between social groups with different levels of abilities see clark son p 14 126 herrnstein richard jmurray charles the bell curve intelligence and class structure in american life free press new york et al 1994 considering its political importance the bell curve debate has received relatively little attention from historians 127 at the heart of this reform was the personal responsibility and work opportunity act of 1996 which ended entitlement to welfare payments implemented workfare principles and enabled states to privatise social services see graebner william the end of liberalism narrating welfares decline from the moynihan report oversimplification and instrumentalization when transferring their results into public debate conclusion this article aims to provide an interdisciplinary review of research literature on social inequality it focuses on three main issues that have inspired much debate in economics sociology political science and history the first concerns the ability of governments to redistribute income and wealth under the pressures of globalisation and the tendency of modern societies to resist governance this part of the article follows the debates about two research concepts tax competition and opportunity hoarding the literature demonstrates numerous limitations and unintended consequences of government intervention but also points to a lack of political will to implement redistributional policies effectively the second issue under review is the impact that growing social inequality had on the development of western societies from the 1970s taking pickettwilkinsons spirit level hypothesis as a point of departure the article reviews the literature on crime happiness and societal openness while growing social inequality on the whole corresponds to increasing crime levels in most societies the effects on happiness are less clear finally exclusionary tendencies showed a robust correlation both with social inequality and the redistributional aims of the welfare state the third issue concerns the influence of genetics on longterm trends in social mobility this part of the article reviews clarks hypothesis that social mobility follows a universal constant because of the natural distribution of abilities within societies and points out several methodological issues with his approach k funding open access funding enabled and organized by projekt deal open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit 0 jenny pleinen

this article reviews research literature on inequality from economics sociology and political science from a historiographic perspective the literature covered here mainly focusses on the development of western societies between 1970 and 2010 and is organised in terms of research concepts such as tax competition educational attainment gaps educational assortative mating opportunity hoarding happiness inequality politics of resentment welfare chauvinism and nature versus nurture

background mass psychogenic illness or mass hysteria has been defined as a group of physical signs and symptoms which suggest the presence of organic illness but with no any clinical and laboratory evidence of disease and as disease that affects more than one person who share a conviction of having a similar illness 1 it is also defined as the rapid spread of illness signs and symptoms affecting members of a cohesive group originating from a nervous system disturbance involving excitation loss or alteration of function whereby physical complaints that are exhibited unconsciously have no corresponding organic aetiology 2 the outbreak usually follows an environmental trigger or illness in an index case and spreads rapidly by audiovisual cues and is often aggravated by an exaggerated emergency or media response 3 4 5 6 it commonly affects people who live in groups such as nunneries boardinghouses schools prisons and religious institutions 78 various studies in the past have shown that 50 of reported outbreaks of mpi cases came from schools followed by factories villages and families and other institutions 579 mpi can be manifested in two forms mass anxiety hysteria and mass motor hysteria the former consists of episodes of acute anxiety occurring mainly in school children prior tension is absent and the rapid spread is mainly due to visual contact with a person affected by the illness and many of the victims recover within 24 h but the latter case consists of abnormalities in motor behavior prior tension is usually present and any age group can be affected by it moreover index cases can be identified the spread is gradual and outbreaks may be prolonged from weeks to months 10 symptoms of mpi reported in more than onethird of individuals include headache dizziness or lightheadedness nausea abdominal cramps or pain cough fatigue drowsiness or weakness sore or burning throat whereas hyperventilation or difficulty of breathing was reported in onefifth of individuals 11 these symptoms together with other symptoms such as shaking twitching trouble walking fainting vomiting palpitation anxiety itching watery eyes chest pain communication difficulties uncontrollable laughing and trance states have also been commonly reported in african settings 5 12 13 14 15 in africa evil spirit witchcraft satanism or failure to perform cultural and religious rituals as needed have been mentioned as the causes of their illnesses 5121316 when it comes to western setting however the effects of toxic chemicals and environmental pollution have been replacing previous beliefs similar to those in africa 6 because of these attribution styles in africa many victims of mpi commonly seek treatment from religious and traditional healing sites 51213 though there is no conclusive evidence about the causes of mpi the following are postulated causes psychological factors environmental factors different stressors conflicts lower level of education lower socioeconomic status minority race and history of abuse or trauma 17 18 19 since the year 1374 outbreaks of mass hysteria have been documented in various cultural 20 21 22 ethnic 23 24 25 and religious 25 26 27 groups throughout the world such outbreaks were also reported in different african settings including ethiopia 1214 28 29 30 31 despite the difference in culture religion and age range the clinical presentation of the victims of epidemic hysteria are somehow similar in all of these incidents the illness was mainly attributed to evildevil force management was provided in fragmented ways and it brought intense public terror to the extent of compromising school and occupational activities though there is an increase in awareness among health professionals mass psychogenic illness is still underappreciated under reported and still causing significant health and social problems in our country since the beginning of 2012 following the death of a 43 year old socially recognized woman several women were reporting of having a breast cancer in derashe woreda segen area peoples zone of snnpr the index patient died of metastatic breast cancer a few months after having mastectomy done on one of her breast following her death the number of women who reported similar complaints increased to 120 within 3 years among these women half of them had reported the complaints to nearby health institutions a year before this study was carried out fragmented medical treatments and psychoeducation services were provided here and there by nearby health institutions however the interventions and explanations forwarded by health professionals could not satisfy the victims and their families as a result the victims started visiting traditional and religious healing sites as treatment options the traditional healers used hot metallic rode to cauterize the affected area as a treatment in addition these traditional healers also advised the affected individuals to apply herbs and to drink herbal juices which they provided later when the issue got a huge public attention the regional health bureau deployed an emergency team consisting of public health officers general practitioners gynecologists and different other stakeholders to the area the team examined 92 women who reported of having breast cancer among these women 87 of them did not have any objective finding which suggested the presence of breast cancer except breast scars which were noted in some of them for the remaining five women bilateral breast lump in 2 axillary lymphadenopathy in 2 and breast ulcer in 1 were found finally the team concluded that there was no breast cancer but there could be psychological explanation for the womens complaints so this study was designed to document the nature and impact of the illness to assess the interventions and come up with recommendations and management formulations for dealing with such kinds of outbreaks in the future methods a community based crosssectional study was conducted in derashe woreda segen area peoples zone of snnpr in june 2015 woreda is a district administrative structure of about 100000 peoples derashe has ten kebeles with different ethnic groups among these ethnic groups derashe gawwada mossiya kusumie mashole konso gamo and amhara comprise the majority only the two kebeles were affected by the outbreak for quantitative data ninetyseven women with complaints of breast cancer but without objective physical and laboratory findings were included two focus group discussions and four key informant interviews were conducted as part of the qualitative study a semistructured questionnaire containing the sociodemographic variables symptom complex onset and duration of illness for quantitative data gathering was prepared by the investigators in addition participants were asked about illness attribution information source presence of recent psychosocial stress their perceptions towards measure taken by officials presence of similar illness in the past and presence of substance use or mental illness at present or in the past focus group discussions and key informant interviews were facilitated by using a guiding questionnaire developed by the investigators home to home interviews with affected patients were conducted using line list of patients and local guides from the community participants were interviewed alone to secure confidentiality and to avoid information bias formal physical assessments were done at the end of each interview in order to rule out recent underlying medical illnesses quantitative data was collected using four bsc degree holder public health officers who can speak the local language while qualitative data was gathered by two investigators in addition one supervisor was assigned to organize facilitate and control the whole process of the data collection filled questionnaires were checked for completeness and consistency of the information on daily basis quantitative data was entered and analyzed using spss for windows version 200 fgds and kiis were facilitated by using guiding questionnaire developed by the investigators the developed guides were reviewed by research team and program experts for reducing ambiguity leading questions emotive questions and stressful questions thereby to address trustworthiness guiding questionnaires were prepared in english and translated into local language by investigators two investigators at a time conducted interviews and discussions verbatim transcription of fgds and kiis was done and transcriptions were translated to english we used framework analysis as it is tailored for policy research and allows for inclusion of a priori and emerging concepts 32 33 34 even though framework analysis is inductive in its approach studies suggest that it can be used with deductive 34 and descriptive 35 approaches so we used deductive and descriptive approaches to summarize data transcriptions were read multiple times to validate transcription and familiarize with content preliminary themes were prepared by categorizing data into groupings key phrases and quotes were coded classified and categorized repeatedly for deeper understanding preliminary themes were refined subsequently and finally groups of related data were clustered to similar themes quotes that best described main themes were chosen and presented though we noticed response overlap in the majority of the qualitative and quantitative data finding we have not done triangulation in the analysis process so this should be taken into consideration when you read the finding of this study ethical clearance was obtained from the ethical review committee of regional health bureau all participants gave verbal consent to participate after through explanation of benefits of study and all the information obtained was anonymous and kept confidential results sociodemographic characteristics of the participant for quantitative investigation a total of 97 women were assessed the ages of the respondents ranged from 17 to 56 years with a mean of 328 years sixtynine of them were from bussa bassa kebele while the rest were from bussa killa kebele ninetytwo of the participants were followers of protestant religion eightyeight of the study participants were married moreover seventyfive of the participants were house wives by occupation more than threefourth of participants did not attend formal education from which 763 were unable to read and write while 41 were able to read and write from the skills they got from informal educational setting like church family member and friends except for one participant the rest were from mossiya ethnicity symptom profile in addition to the complaints of having breast cancer a majority of the study participants were complaining about the following symptoms breast pain back pain dizziness chest tightness headache fatigue or weakness tingling sensation drowsiness numbness or paralysis and anxiety or nervousness despite these and other complaints nothing was objectively found by the emergency medical team which evaluated these participants during and prior to the data collection periods exceptions were the presence of dry scar in the breasts of some of the study participants bilateral breast lump in 2 axillary lymphadenopathy in 2 a breast ulcer in 1 women the dry scar and breast ulcer happened to the study participants due to being cauterized by hot metallicrode as a treatment by a traditional healer following the perceived unsatisfactory explanation and intervention by nearby health institutions onset and duration of illness the community members started to report symptoms from the beginning of 2012 up to the end of the data collection period that is june 2015 eighty of the women developed the symptoms in the years 2014 and 2015 among these 50 developed the symptoms in the year 2015 while the rest developed the illness between 2012 and 2014 the duration of illness a woman suffered from the start of complaints ranged from 1 to 48 months with a mean of 186 months information sources about the spread of cancer eightyseven of the study participants said that they initially heard about the illness from indirect conversation or gossip on the other hand 42 of them reported that they had observed the illness directly from affected persons in addition to the gossip they had heard only 7 of the women said that they had heard the information either from health professionals or they couldnt remember exactly from where they had heard the information first illness attribution and treatment sought by the victims fiftyone of the participants replied that they did not know the cause of the illness while 38 said it may be due to punishment by god twelve of the study participants reported that it may be due to the presence of toxic chemicals polluted environment cold air using family planning injection or pills influence of witchcrafts and the curse of dead ancestor or evil spirits threefourth of the participants had sought treatment from modern health services and 62 had visited traditional healing services while 42 had sought treatment from both modern and traditional healing services eight women had sought treatment from religious services and 5 of the victims visited all the three treatment sites namely traditional healers religious healers and health institutions traditional healers either used hot metallicrode to cauterize findings from qualitative responses two focus group discussions were conducted one with affected women and the other with nonaffected women in each focus group discussion seven women were involved the ages of the participants ranged from 23 to 40 years in addition to focus group discussions four key informant interviews were undertaken the key informants involved consisted of a health extension worker a community leader a woreda health office head and a head of disease prevention and control officer the information gathered during these discussions was grouped into the following three themes onset of the illness understanding the nature of the problem and its possible transmission and commonly reported symptoms and psychosocial impacts of the illness attempts were made to preserve participants phrases experiences and meanings theme 1 onset of the illness on the discussion made among participants about the onset of illness a majority agreed that the onset of illness could be traced back to the year 2012 following the death of a 43 year old protestant socially active and recognized woman she was from bussa bassa kebele the woman was said to have had breast cancer and mastectomy was done in one of the government hospitals in the region but after few months of the operation the woman developed respiratory distress loss of appetite and experienced generalized body weakness finally she died of cancer related complications in the second half of 2012 before her death she had been showing the wound and the mastectomy site to woman closer to her though few women were complaining of having similar problems while the index case was alive following her death many women started complaining about breast swelling breast and back pain according to the majority of respondents most of the affected groups were women closest to the index case by place of residence and blood theme 2 understanding the nature of the problem and its possible transmission in both focus group discussions and key informant interviews the theme did not specifically point at a single possible cause of attack and means of transmission however a majority of the participants said that their source of illness could be punishment by god caused by not obeying his commandments some of them believed they might have acquired the illness from contaminated water pesticides and polluted air one mother said it could be secondary to using family planning injection or pills as means of transmission a majority believed it could be airborne or transmitted through sitting with and drinking together with the affected person or else by taking toxic chemicals from contaminated water food andor air a limited number of mothers said carrying heavy load being overloaded with many duties at home and outside having financial crisis and quarreling with close family could precipitate the illness but they did not believe that these were the main contributors to the outbreak of the illness a majority of the respondents used to believe the cause of their suffering to be breast cancer but through the repeated health education given since the beginning of 2015 their understanding has changed through time they have heard from different health professionals that the ailments they are suffering from might not be cancer but they did not find adequate explanations from health professionals for their worry the findings also indicated that during kiis also suggested the communities were suffering from a serious illness but the root cause was still not clear to them a 38 years old woman expressing her belief and experience regarding the cause and means of transmission said i dont know why we are suffering from this illness it is the duty of god people are suffering in mass i dont know its means of transmission maybe we are getting it from contaminated water food and air or it may be from the pesticides we use i have visited different health institutions and traditional healers the health professionals used to give some medication and the traditional healer cauterized the affected site using hot metallic rode but both of them did not help me a 32 years old mother who expressed her deep concern also said our communities including me are suffering from a deadly ailment previously we were sure the cause of our suffering was breast cancer but now because of the different information we have got we become confused about the possible cause of our suffering we urge the government to tell us the exact cause of our suffering before we lose many lives theme 3 commonly reported symptoms and psychosocial impacts of the illness the symptoms and signs revealed by fgds and kiis were almost similar to those reported by the afflicted participants symptoms centered on the breast manifestations were characterized by breast swelling breast pain back pain squeezing sensation over the breast and chest some also complained of having numbness tingling sensation and weakness in their upper extremity a majority reported that the pain usually started on their back near their shoulder and then migrated to their breast because the illness was perceived to be contagious this resulted in rejection by husband family and neighbors the stigma and discrimination were strong to the extent of not drinking and gathering together with the affected individuals for many years the communities have had the tradition of drinking a local drink called cheka by sharing the same drinking cup but after the epidemic nobody was willing to drink together in particular with the affected individuals a majority of the participants feared risk of being divorced there was mass terror among the community for fear of having the illness fgd with nonaffected women showed that they were also worried about the situation some of them said that they will follow traditional treatment as their friends did because they believed there was no possible solution other than this however some of them reported that they will seek modern treatment if problems arise as they were getting health education at the time of rapid response a 28 years old nonaffected woman expressing the degree of her fear about being affected by this illness said these days i and my neighbors have been on a great terror personally i have been trying my best not to create contact with the affected person but it is also difficult to distance oneself from the affected person because we have lived together with them for long in addition some of them are our blood and family women who participated in the fgds said that the affected women had been reporting a constellation of signs and symptoms that looked like the presence of breast cancer like the woman who died with a complication of breast cancer a 30 years old woman said i dont know what we can do this disease is affecting our population i am also one of the affected women i heard the signs and symptoms of the disease from my colleagues but mine is not at that stage and i fear in the near future i will develop these signs and symptoms the above fgd findings were also supported by the kii findings during key informant interviews with individuals about the impact of disease in the public one person said because of the communitys fear of being affected by the illness schools were closed for few weeks on the other hand the communitys limited medical facilities were overwhelmed moreover primary health workers and woreda health officials were baffled by the condition the affected women were given different antipain and first line antibiotics but a few days later they started complaining about the symptoms again the other problems reported by kiis were the physical health impacts secondary to cauterization of the affected area with hot metallicrode locally called astae during indepth interviews with a traditional healer woreda health office head and health extension workers they reported that a majority of the affected women usually visited traditional healers the traditional healers in addition to cauterizing the affected area they were giving them herbal juice to drink and order them to apply herbs on the affected area because of these interventions some women developed massive infected wound over their breasts discussion one hundred and twenty women were affected by the mass hysteria since 2012 from these 104 women were involved in the study 97 for quantitative study and 7 for qualitative study the age of respondents who participated in the quantitative study ranged from 17 to 56 years with a mean of 328 years the majority 69 were from bussa bassa kebele the rest were from bussa killa kebele ninetytwo of them were followers of protestant religion like other previous studies 91324 mass hysteria in this woreda affected mainly females in addition like the previous studies 9133637 the commonly reported symptoms were having some sort of physical pain dizziness chest tightnesspain headache fatigue tingling sensation breast swelling drowsiness and numbness or paralysis of the limbs significant numbers of women also reported having anxietynervousness inability to concentrate trouble thinking hyperventilationdifficulty of breathing nausea lightheadedness cough abdominal cramps and faintingloss of consciousness the only difference from the majority of previous studies is the complaint of having breast cancer this suggests to us that the other associated symptoms in this community follows illness anxiety which can be defined as preoccupation of having or acquiring a serious illness without objectively having organic bases for the complaints 38 moreover based on this finding we can say the community was suffering from chronic mass psychogenic illness for the following reasons symptoms with no plausible organic basis occurrence of symptoms in a segregated group presence of chronic and acute anxiety symptoms had been spread via sight and indirect conversation preponderance of female patients and symptoms were similar with other studies 53940 the illness seems to have started at the beginning of 2012 following the death of a 43 year old protestant socially active and publically recognized woman after being sick with breast cancer for long the majority of the affected women were from dubayisho got where the index case had lived the outbreak spread to the other adjacent areas as time passed though typically mpi affect the groups for limited periods 2512 in this case it stayed for about three and half years this might be because of the fragmented interventions and inadequate explanations given about causes and transmission of the presumed illness as to the causes of the illness a majority were confused and perplexed before massive health education had been given they used to believe they were suffering from breast cancer but after health education they become confused as to what might be the cause however a majority said that their source of illness could be punishment by god for not obeying his commandments unlike our studies in many other studies this outbreak was attributed by the community to the work of evil spirits 10113741 or the spirits of dead ancestors 23 in africa many attribute mpi to supernatural causes such as witchcraft satanism or any element which makes up their cultural beliefs 42 like the western study 43 significant numbers of women in our study believed they might have acquired the illness either from contaminated water pesticides and polluted air as to means of possible transmission a majority of them believed it could be airborne from sitting and drinking together with affected person or else by taking toxic chemicals from contaminated water food and inhaled air a limited number of mothers said that carrying heavy load being overloaded with many duties at home and outside having financial crisis and quarreling with close family members could precipitate the illness but they do not believe that these are the main contributors for the outbreak of the illness as a result ordinary public activities were disrupted because of these beliefs for example many started to refuse to eat and drink with the affected women and schools were closed for few weeks searching for treatments and adequate explanations many were moving here and there from traditional to modern treatment sites unnecessary financial loss and iatrogenic illness were the major risks for these kinds of public behaviors people working at all levels of the health sector in the woreda were also confused and worried of the situation and lacked appropriate answers to the people complaining about the pain they simply forwarded the peoples complaints to higher levels rather than teaching the community about the truths of cancer this went on until an emergency response team from regional health bureau tried to clear community tension by doing massive psychoeducation early identification and labeling of the condition is found helpful to control the spread of mpi among the crucial steps in managing mpi are avoiding extensive investigation without letting down the victims complaints being authoritative and firmly explaining that the outbreak is related to psychological conditions controlling the outbreak can be farreaching if doctors continued extensive testing since it strengthens the victims beliefs that their cause of suffering was either physiological or toxic agents moreover telling the victims and their families that the condition has no relation to demonic possession or any organic illness could also bring huge reassurance and decrease the intense anxiety affecting the public 544 so in our population groups if early intervention and adequate explanation had been given from the outset of the illness the outbreak could be easily contained within short period of time it would have been also good if we include mpi as a training package in one of continuous professional development going on in the country so that health professionals can be equipped with the necessary knowledge and skills to handle these kinds of outbreaks in the future awareness creation about these kinds of outbreaks to the community and people working in various media is also helpful unrealistic and exaggerated rumors and radio talk can be minimized by creating awareness to this group of the population the emergency teams at different level in the health systems have to be as responsive as possible before this collective obsessional behavior reach out to other nearby communities and bring mass terror conclusion unrealistic and exaggerated rumors nonorganized and late intervention inability to get adequate explanation about the causes and modes of transmission of the illness were the main contributing factors to the spread of the outbreak proper communication strategy can contain mpi within short period of time before they affect many individuals and bring about many psychosocial impacts on the community group anxiety could be reduced by providing proper psychoeducation timely and endowing convincing explanations abbreviations mpi mass psychogenic illness snnpr southern nations nationalities and peoples region spss statistical package for the social sciences fgds focus group discussions kiis key informant interviews cpd continuous professional development competing interests all authors declares that they have no competing interests and that this is an article from an original study

background outbreaks of mass psychogenic illness mpi which are a constellation of physical signs and symptoms suggestive of organic illness with no identifiable causes mpi has been documented in numerous cultural ethnic and religious groups throughout the world the aims of this study were to document the nature and impacts of the illness to assess interventions and to come up with recommendations and management formulations for dealing with such kinds of outbreaks in the future methods community based crosssectional study was conducted in june 2015 in derashe woreda segen area people zone of the southern nations nationalities and peoples region women with complaints of breast cancer but with no objective findings were the subjects of the study ninetyseven women were investigated using a semistructured questionnaire for quantitative study two focus group discussions with seven affected and seven nonaffected women and four key informant interviews were conducted using guiding questionnaires quantitative data was analyzed using spss version 20 software packages while qualitative data was analyzed manually going through thematic areasthe ages of the ninetyseven study participants ranged from 17 to 56 years with a mean sd of 328 87 years onset of illness was dated back to the year 2012 following the death of a 43 year old socially active woman with complications of breast cancer following her death many women started to report multiple vague physical complaints similar to those of the deceased woman even though the responses from the study participants did not specifically point to a single possible cause and means of transmission high numbers of women believed the source of their illness could be punishment from god while some said that the cause of their suffering could be environmental pollution since the illness was taken to be contagious affected women faced stigma and discrimination moreover school activities and social gatherings were limited significantlyunrealistic and exaggerated rumors and inadequate explanations about the nature and spread of the illness were the main contributing factors for the spread and prolongation of the outbreak an organized intervention clear and adequate explanations about the nature and transmission of the illness can contain mpi within a short period of time

introduction since the early 1980s the structures of public sectors in nations like denmark and the uk have been critiqued for being too bureaucratic privatization outsourcing marketization and other buzzwords arose as solutions to this perceived problem of structural inflexibility as new public management became the dominant discourse the attack on the public sector was nuanced to open the closed distinction between public and private all institutionsinhierarchy should become partly independent organizations with their own budget responsive to the demands and opportunities of their own environment new tools of selfmanagement were introduced such as benchmarking which encourages the single organization to have a sidegaze to other comparable organizations and to become aware of the contingency of their own way of organizing since 2000 new public management itself has been critiqued under the umbrella of postnpm many new concepts have emerged like public value interprofessional management and cocreation though critical of public sector marketization postnpm has continued and even radicalized the antistructural tendency that is the focus of this article now not only are organizational structures attacked but also professional knowledge and professional structures and even law as such antistructure has come to include antilaw law is seen as an obstacle to agile solutions to emotional and motivational engagement to potentializing interprofessional cocreation and above all to processes open for the unexpected future this desired unexpected future can be called the future of the future since it is precisely not the future of the current present but that of a present to come this new skepticism about law as a force of unwelcome closure with negative implications for the future future can be observed more generally extreme examples include putins disdain for ukrainian legal sovereignty and trumps ambition to make america great again which involved viewing not just various international legal agreements but also their own administrative apparatus as hostile obstacles to this great returning future a comparable disdain for law justified by appeal to a future future was evident in the uk brexit movements aspiration of freedom from eu law and bureaucracy the then government chief special advisor dominic cummings was held in contempt of parliament after refusing to answer questions about electoral fraud during his direction of the vote leave campaign according to cummings own public judgement the illegal funds were spent on targeting 15 billion ads at voters identified as persuadable on social media in the crucial last few days before the referendum his blogs informed his public that powerful insiders planned to use law to gain a second referendum they will do absolutely anything to keep their grip on power and money they will do anything to stop you normal voters from taking back control of them postbrexit within a matter of months the uk government revised the legally binding northern ireland protocol prompting the european commission to take legal action against the uk in june 2022 a tendency to stress the constant change needed in readiness for an unknown future was already apparent before the phase inaugurated by trump and johnson but without the radical extension to law in his farewell speech on 11th of january 2017 for example obama addressed young americans proclaiming that americas future is safe in their hands because …you know that constant change has been americas hallmark something not to fear but to embrace this matches tony blairs famous description of a world fast forwarding to the future at unprecedented speed the change or die reality of the global economy he insisted rewards those who are open to it but is indifferent to tradition… no respecter of past reputations… has no custom and practice the future of the past is death but the future future scary though it may be is replete with opportunities for those fast and flexible enough to exploit them unless we own the… reality now upon us and the next about to hit us we will fail in this article we will suggest that more is at stake in this development than a strong pendulum swing to the right within the political system in our reading the above cases are symptomatic of evolutionary changes in the form of state which challenge the structural couplings between state and law and maybe even involve a change in the function of law in social systems and later in law as a social system niklas luhmann suggests that the legal system functions as the immune system of society conflict and contradiction serve as the immune mechanism for this immune system this is because conflict and contradiction sound an alarm that alerts to threats to the system in luhmanns sociology communications are the basic operations that form social systems on this premise he defines conflict as the communication of the contradiction of a communication as societys immune system law does not prevent conflicts but creates conditions which contain its more harmful effects by reconstructing it as an immune mechanism as an antibody seeks an antigen so law invites conflict and transforms it by means of legal decision making the recruitment of conflict as an immune mechanism is therefore not a matter of protecting the system against external threats rather it protects the system from structures created by itself over time that it now observes thanks to the alarm mechanism of conflict as compromising its own capacity to continue into the future law is a selfgenerating recursive network that creates conditions for the production recruitment regulation and dissemination of conflict qua immune mechanisms what concerns us here however is that the immune system of law is itself increasingly becoming observed as an inappropriate structure law itself is being observed and placed under attack by a new mechanism of immunity andersen and stenner suggest that certain antistructural technologiesthose they call potentialization technologies have emerged as a new form of social immune mechanism familiar and innocuous seeming examples include innovation games future workshops cocreation trustbased partnerships managerial laboratories and cross professional speeddating they share the goal of potentialization in that they aim to create new possibilities for what welfare education care and treatment can be the premise of potentialization technologies is not just to expect change but to facilitate it by changing fixed expectations andersen and stenner draw upon barels definition of potentialization as the recovery of possibilities provisionally excluded by structure they point to its role in the emergence of novelty potentialization is about the exploration of new horizons rather than realizing options within the given horizon in short potentialization is about creating conditions for the future future an innovation game for example is designed to enable participants to think the unthinkable or expect the unexpected it is antistructural in that it dissolves the likelihood that the present will give rise to its expected future freeing the possibility of a different future during the game participants can work towards enabling a future future by entertaining possibilities that exist beyond the horizon of the present future building on luhmanns theory in which laws mechanism of immunity is its response to conflict andersen and stenner argue that potentialization is now also functioning as an immune mechanism via these technologies here we take forward the observation that law where it produces structures perceived to limit expectations of open change is being targeted by immune mechanisms of potentialization conflicts may arise spontaneously but potentialization technologies by contrast are devised occasions they are carefully designed to defend welfare operations against any established structures in the welfare system however they put basic premises at stake since they indiscriminately attack structures in general including those established through professionalization through daily routines and through legalization in this sense they dissolve security around any and every expectation structure hindering the formation and institutionalization of professional routines and even undermining the legal certainty afforded by rights this article makes a case that the immune mechanism of potentialization is now working in an autoimmune way by attacking the traditional immune system of the welfare state law and legal right this broad frame adds a new perspective to recent debates in critical legal theory that recognize the centrality of temporality as a preliminary step it is necessary to further clarify what a social immune system is and how it can be theorized toward a social immunologic luhmann is not the first or only scholar to apply immunologic to the social and psychological domains freuds defense mechanisms protect the psyche from integrity threatening interruptions and bergson explained the evolution of traditional static religion as a defensive reaction of nature against the dissolvent power of intelligence for bergson the evolution of the human intellect endangered social solidarity because intelligent thought challenges customary authority religion protects society against these dissolvent sideeffects and shores up the points of attachment between individuals and society through the mechanism of a mythmaking faculty more recently girard offered a comparable thesis concerning the quasiimmunological function of religion this centers on the capacity of the scapegoat mechanism to neutralize escalating violent conflict giving rise to institutions respected as sacred from this perspective law takes over from sacrificial ritual as the principle immune system for managing conflict in more complex literate societies donna haraway jacques derrida peter sloterdijk androberto esposito have each developed the immunological theories in their own distinctive ways and hannah richter and cary wolfe have offered valuable syntheses jacques derrida began working with the immune concept after 911 in 2001 he examined the war on terror as autoimmunological an autoimmunity process is the strange behavior where a living being in quasisuicidal fashion itself works to destroy its own protection to immunize itself against its own immunity derrida points out that the distinction between immunity and autoimmunity is imperfect and impossible since any immunity also involves autoimmunity without autoimmunity with absolute immunity nothing would ever happen or arrive we would no longer wait await or expect no longer expect one another or expect any event this derridian sensitivity to paradox echoes luhmanns premise that a system can be cognitively open to its environment only by means of its operational closure and hence selfreferentiality donna haraway highlighted the ways in which a misconceived vision of the purity of the immune system institutes and justifies exclusionary social norms and expectations directed against nonconformists espositos approach elaborates this insight noting the etymological resonances between the words community and immunity building on ideas from michel foucault and georgio agamben esposito is critical of a way of understanding politics which starts from the idea that community is something proper whose purity is guaranteed by immunity yet the politics and law of modern western society have typically been imagined as a project of community that operates under the banner of immunity just as an organisms immune system is supposed to protect it from external and internal pathogens so an immunized model of community imagines its citizens protected against improper internal and external threats for esposito the task at hand is to overturn in some way indeed in every way the balance of power between common and immune one important aspect of this is to conceptualize the function of immune systems in a different way making them into relational filters between inside and outside instead of exclusionary barriers we note that esposito begins his immunological theorizing with the old image of biological immunity and only then calls out for a new image that might put the picture right and help solve our political problems this account thus faces an historical problem because it is implausible that this theory of immunity influenced societys much older selfimage as sovereign more plausibly it was the selfimage of the sovereign state that fed into and infected the articulation of the much later scientific concept of biological immunity with concerns derived from the sociopolitical domain luhmann by contrast does not start with this flawed concept of immunity only to call out for a new one drawing inspiration from the autopoietic turn within biology he starts with a more scientifically sophisticated account of how immune systems actually work 1 on that basis he diagnoses the law as having an immunological function not because it attacks invaders but because it affords tolerance of conflicts by recruiting them into a system which creates expectable insecurities out of them 2 biologists informed by systems theory started an important debate around the immune concept in the 1980s a turning point was the work conducted from the mid1970s by the danish immunologist niels jerne jerne demonstrated how the bodys production of antibodies was organized into networks francisco varela in collaboration with humberto maturana reconstrued jernes network as an autopoietic system from this perspective it is not the antibodies and other agents that taken together constitute an immune system rather the immune system occurs only when these agents are recruited as immune mechanisms and linked together into the selfgenerating selfreferential and selflearning network of an immune system this autopoietic turn involved a changed view of the relationship between the immune system the environment and the organism varela describes this as a movement from a classical antigencentered immunology to an organismcentered immunology the function of the immune system from this new perspective is to increase the bodys flexibility and tolerance to antigens this theory has the advantage of explaining why the organism is rarely attacked by its immune system and it explains how the immune system continues to function without irritations from antigens the core principle of the immune system is its ability to connect to the foreign material whether that be the bodys own elements or the antigens it is positive creative and active before being defensive and reactive the immune system is flexibility in living and its unlimited flexibility creates connectivity to multiple antigens via a large diversity of antibodies luhmanns sociological imagination is captured by this notion of immunity as operating through the inwardly directed positive creation of flexibility within a selfreferential system the lifeblood of social systems is communication but that lifeblood flows thanks to structures of expectation that build up and are preserved and modified over time social structures are expectational structures this identification of social structure with expectation is crucial to luhmanns immunologic health communication for example has built up expecta1 luhmanns theory of social systems is part of a broader tradition of systems theory that includes mathematicians physicists biologists psychologists and sociologists in this tradition it is customary to distinguish between a universal or general systems theory and theories of specific system types luhmann implicitly claims that the term immune mechanism should be discussed as a general concept with homologous manifestations in multiple system types biological systems thus need not be given ontological priority as if they were the objective source domain of concepts which are thereafter applied only metaphorically to other system types 2 luhmann has since proposed that inflation and deflation serve as immune mechanisms in the economic function system and he has made a more comprehensive analysis of protest movements and social movements as important immune mechanisms at the societal level he also considered emotions as immune mechanisms in systems of consciousness where the continuation of the stream of consciousness is threatened emotions bridge the interruption so that autopoiesis can continue tion structures in the form of a division of roles between doctor and patients medical diagnoses treatments that respond to diagnoses and so on but the value of structures is doubleedged clear expectations allow for heightened predictability but structures can also become rigid and problematic more fundamental to a social system than its structures is the continuation of its communicative operations that new connections create new connectivity for new connections luhmann uses the term immune mechanism to identify resources communication can draw upon when the continuity of its communication is threatened immune mechanisms defend the continued operations of a social system against those of its structures that have become problematic as with varela immune mechanisms are autoimmune operations directed inwardly towards the system itself they immunize the system against its own immunity from this perspective social systems are autopoietic systems that create all their elements and structures through communication as with varelas theory the difference between system and environment is not a given but an internal construction of the system an observation the system makes of and for itself when a social system adapts itself to its environment it thus adapts to an internal construction of the system this makes it problematic to say that the social system defends itself against or even reacts to the environment furthermore it may be the way in which the social system has been constructed to be sensitive to its environment that ends up threatening its possibilities to continue the system has closed itself in relation to a specific internal construction of its environment which may no longer be adequate and the more the system adapts to this environment the more it reduces its capacity to continue in luhmanns account immune mechanisms are a matter of recruiting conflicts in the system of law there might be many conflicts in society some very small and some larger communication everywhere produces latent contradictions and these become social immune mechanisms when recruited by law how should we understand this communication is composed of recursive streams of selectionsconnections and each connection selects into a horizon of connectivity the connection could be different not all connections are possible and no connection is a necessity luhmann points out that the constant selection process produces latent contradictions between the actualized connection and the discarded possibilities these are latent in the sense that they are not articulated until they are explicitly communicated in the form of a no they exist as indeterminate and internal noise in the communication reproducing contingency a hand was waved for instance as no one waved back there could be latent contradictions between hello friendwaving and nonwave the latent contradictions are not in themselves immune mechanisms they become so only when nonacceptance of the communication is communicated that is when communication is answered with a no contrary to intuitive understanding we must therefore not understand no as a threat to communication but as an immune mechanism within it luhmann writes the system does not immunize itself against the no but with help of the no it does not protect itself against changes but with the help of changes against rigidifying into repeated but not environmentally adequate patterns of behaviour the immune system does not protect structure but autopoiesis the systems closed selfreproduction after the abusive finger communication we might communicate further but the gesture will have dissolved some structure ie security in the expectation of friendship of particular interest are those conditions of instability during which the continuation of a social system is so threatened that a fundamental reordering of its principle of organization is occasioned conflicts both latent and actual multiply during transitional periods such as the european shift from the middle ages to the modern era for luhmann this shift saw a societal form of functional differentiation replace the older feudal form of hierarchical differentiation this change represented a fundamental change in structures of expectation and this was mirrored by deep changes in law as societys immune system from this perspective the modern notion of basic rights which formed the foundational principle of the constitutions of the french and american revolutions during a subsequent phase of massive societal transition can be observed in its immunological function the semantics of basic rights as inalienable attributes of human beings functions immunologically both by dissolving structural expectations that supported the feudal order whilst bolstering the structures supporting the new functional differentiation rights in general might always have functioned immunologically in the sense that in the face of a conflict involving disappointed expectations they allow law to intervene and support the right bearers insistence that their expectations be honoured but the new grundrechte were a modification of this tool to support the new form of society with basic rights the state begins to distinguish between the interest of society and the interest of the individual and to expect disputes and conflict between them this constitutes a significant shift in how the state observes these conflicts they are no longer avoided but invited public and administrative law develops to recruit and handle conflicts between state and individual rather than simply suppressing them the challenges to law we are highlighting in this article may be part of a comparable episode of profound societal instability connected to the collapse of this modality of juridical power conflicts and law in the classic welfare state conflicts constitute an immune mechanism because they protect communication by transforming it in a manner that dissolves certainty in existing expectations communication thus continues but in the altered form of conflict communication which tends to draw the host system into conflict to the extent that the attention and all resources are claimed for the conflict conflict communication has a tendency to escalate because it inverts the form of double contingency at the basis of all communication the improbability of communication ever occurring is usually reduced by a structure of positive expectations but in cases of contradiction the positive expectation informing one communication is met with a no from another double contingency then takes a negative form i do not do what you want when you do not do what i want conflict continues when no is answered with a no and the autopoiesis of communication continues on the basis that everything that harms you benefits me conflicts can thus serve as immune reactions to perturbations within the circuit of communication itself and given the danger of not being able to continue communicating they tend to abandon structures and to rescue communications selfreproduction conflicts form continuously across the welfare state they can begin with something very small a client gets angry with the caseworker a teacher criticizes the school most conflicts lose their energy relatively quickly and die out other conflicts recruit new topics and connect to the wider societal communication a healthcare assistant who faces tight deadlines asks an elderly person to urinate in a diaper because he had no time to help he shares this unbearable experience with colleagues together they communicate nonacceptance of their present working conditions the manager of the elder care institution invites the employees to a dialogue about the case aiming to limit the conflict to the organization level the health care assistant writes in his public blog that a lack of resources at the institution forces him and his colleagues into undignified situations for elderly people it becomes a story in the national media the labour union connects to the conflict and makes it into a general conflict about the under resourced elderly care sector more and more communication resources are enrolled into conflict such conflicts can sometimes result in changes in the regulations of the welfare institutions in other cases the conflicts simply drain the organization of attention what the conflicts share is that they say no to specific existing structures and create uncertainty around these but how does law serve as an immune system by recruiting this immune mechanism the legal system serves as a societys immune system by regulating the formation of conflicts conflicts are elevated and cultivated through the differentiation and evolution of the legal system the court neither removes nor extinguishes conflicts since law does not serve to avoid conflicts it merely seeks to avoid the violent resolution of conflicts and make suitable forms of communication available for every conflict the legal system constructs its own image of society observing other systems as steered by norms understood as expectations of expectations when norms are disappointed or contradicted in other systems the legal system can normalize norms saying that this or that norm is either legally right or wrong according to legal programs in this way law offers the possibility of transforming conflict by moving it into law the court handles conflicts selfreferentially by making them internally comparable elements an immune system gets along without knowledge of its environment it only registers internal conflicts and develops case by case solutions for them which can be generalized that is providing surplus capacity for future conflicts instead of researching its environment the immune system generalizes experiences with itself but the law also contributes to the production of conflicts when legislation provides rules and assigns rights to individuals and collectives it simultaneously invites the conflict to resituate around these rules and rights for example in 1938 new legal regulation of psychiatric hospitals in denmark gave doctors new powers to use force with psychiatric patients leading to new conflicts about the limits of the doctors authority by inviting new conflicts about where doctors authority begins and ends law facilitated a controlled resituation of the original conflict in the latest amendment to the mental health act from 2006 psychiatric hospitals are obliged to prevent coercion opening new relationships between the various professions at work in the hospitals this illustrates how the law does not simply constrain conflicts but works formatively in relation to them immunizing the welfare state by allowing supporting and regulating the controlled production of conflicts in this specific sense conflict is order and community is immunity as argued by roberto esposito following this line of argument society needs conflicts and law is the means by which the noise they generate can be tolerated and converted into a form that can be put to use the basic challenge of law as immune system becomes how to produce enough contradictions to create a valid immune apparatus what if we look at the welfare state from the point of view of the immune system the development of the welfare state has accelerated processes of legalization individualization and universalization more and more areas of society have over time been legally regulated individuals have been separated from the state becoming legal subjects first with personal rights and later with social rights and these rights have become universalized ending up covering all legal subjects in this sense the welfare state has been working as an accelerator intensifying the function of law as the immune system of society whilst also applying law more extensively each time new individual and collective rights have been created the legal systems capacity to regulate the production of antigens in the form of conflicts has increased many welfare states have developed sophisticated law on social work health education pension regulation etc and in connection to this they have constituted a number of legal rights supported by special courts complaints rights and participatory rights and then there are also collective rights for example rights to organized special groups of citizens rights to be heard in policy processes and rights to be represented in commissions and council in this way law as immune system has come to include the neocorporativism and later network governance supplementing conflict on individual rights with collective conflicts luhmann emphasizes that the modern development of functional differentiation demands a more intensified immune system esposito likewise suggests that immunization has progressively extended itself from the legal sphere to politics economics and culture until assuming the role of system of system the general paradigm of modernity we now resume our argument that new immune mechanisms have emerged which attack the legal immune system and which work not through conflicts but through potentialization potentialization and law potentialization technologies deliberately stage an interruption designed to shift the present present to a past present and create room for a new present to emerge capable of imagining a future future to our knowledge it was gh mead who first put terms like the past past and the present future systematically to work in social theory of particular relevance to our thesis is his article how can a sense of citizenship be secured here mead raises the problem that legalistic solutions to social problems can only work by stating their problems in terms of institutional norms which are fixed in advance by definition the norms of the institution are not flexible provisional means of bringing out the social problem as it appears in the individuals experience in law for example an actual human situation complete with evaluative feelings must always be forced into a highly formalized evaluation whose rules and standards are already institutionally established any conflicts between the institutionalized system and the perspective of the judged individuals are not tolerated the individual is effectively negated and forced to obey mead is aware that this approach can be counterproductive it can hardly be expected to engender a positive sense of citizenship on the part of legal subjects and can backfire by fostering conflicts instilling rebellious feelings entrenching criminality etc mead observes signs of the development of alternatives to legal structures in the form of the juvenile courts and experimental schools in the former a more sympathetic approach to interrogation allows the ends of law to be stated in terms of the emotional interests of the juveniles legal decisions for example can be accounted for by spelling out their implications for the future future wellbeing of the juvenile instead of simply applying pregiven legal procedure the aim is to be on all fours with the estimates and standards of the child encouraged to grasp the application of the law in relation to their own concrete and affective situation the juvenile thus has the chance of actually identifying with the social system they are subject to mead observes this development as diagnostic we have not realized the full implications of the change from our perspective he is observing an initial phase in the development of modern technologies of potentialization juvenile courts emerged as a means to flexibilize personalize and emotionalize a legal system that would otherwise manage conflicts in a hyperstructuralized manner the fact that law can respond to the viewpoint and feelings of those involved only by forcing obedience and silencing other thematisations and perspectives on the situation means that law in turn generates unexpected conflicts the problematic nature of those conflicts is particularly evident in the case of young people whose lives can easily be observed to be still full of potential here we see an incipient critique of law which focuses on how to immunize against its unintended consequences how can courtroom communication be modified so that a potential future good citizen may be provided with a way out from the crushing motivational effects of the application of law the law of the welfare state is articulated from within as its own threat and a solution is offered which takes the form of communication which opens up towards a future future consider now a recent example from the denmark the government initiative of 2018 called one denmark with no parallel societies addresses the perceived problem of minority groups with values different from the danish mainstream this document articulates two levels of threats against the danish society at the first level the parallel society is problematized parallel society is a major burden on the cohesion of society and for the individual it is a threat to our modern society when freedom democracy and equality are not accepted as fundamental values and when rights and obligations are not adhered to at this first level where a selforganized ethnic or religious minority that might not respect danish law is contemplated fundamental rights are championed as inviolable at the second level however universal legal rights and universal welfare laws are observed as the true threat because these make it impossible for the welfare state to do what is presented as practically necessary to solve the problem of parallel society universal rights and welfare laws in areas such as public housing access to local schools social rights and duties as well as legal penalty rights are observed as obstacles blocking the ability to address particular groups and individuals with the necessary dispositions the government want to have possibilities available to make particularized decisions which are only valid for particular groups individuals and areas already in 2010 building upon the whitepaper bring the ghetto back to the society the ghetto became a legal category that opens up for the delegation of certain new rights to the local police to define special zones where criminals from the ghettos are no longer allowed to enter in 2018 this way of defining particular exceptions from general rules was taken to a new level there are three clear examples of such exceptions first all danish parents have a universal welfare right to a child cheque for each child no conditions are connected to this right but now the government have implemented a ruling that parents living in the ghettos can be denied this right if they do not live up to a requirement of parent responsibility a requirement which applies only to them if children of parents in ghettos miss 15 of their public schooling fail to attend a specially designed language test or do not take steps to learn danish then they lose the cheque the second example illustrates that it is not just universal individual rights that are seen as problematic the danish welfare state is based upon an extended autonomy of local municipalities that basically have responsibility for the welfare institutions the welfare institutions such as schools are in turn delegated a certain autonomy and are run by school managers in collaboration with a democratically elected board of parents the government initiative sees these institutional rights as a potential threat against doing what is needed the state gives itself the right to take over any school that shows poor results for three years in a row in worse case scenarios the state reserves the right to close a school thereby annulling its autonomy and that of its municipality but this option to cancel local autonomy is only to be used in exposed city areas the third example covers criminal law the government gives the police rights to define a socalled sharpened penalty zone in these zones penalties will be doubled or where the normal penalty is a fine the penalty can be increased to a prison sentence criminals will not be allowed to live in certain exposed city areas and municipalities will be given more efficient powers to evict them from their apartments in this case as in meads example a certain tension is set up between the structural inflexibility of law and the requirement to flexibly potentialize openness to a different future to the one that law with its backwards gaze onto the facts would insist on expecting into existence in both cases the potentialization thus immunizes against the iatrogenic effects of law and a new mechanism of immunity is layered upon the old it is in this sense that the welfare state is articulated from within as its own threat to laws closure potentialization technologies respond with the positive creation of new possibilities for the future they say no to structures but with a flexible agenda of innovation they function immunologically not through legal regulation of spontaneous conflict but through positive and selfconscious generation of radical alternatives but in doing so they remain systematically blind to their destructive side they dissolve security around any and every expectation structure including legal rights in the following section we offer a further case of the 2012 reform of early danish pension law to illustrate how these new immune mechanisms attack the classical legal immune system by observing legal structures as a threat for continuous communication potentialization as immune mechanisms observed through rehabilitation teams and resource trajectory in order to clarify the 2012reform a brief analysis of the original law on early pension is required the first danish law on public financial support for the elderly was passed in 1891 the law allowed the disadvantaged over 60yearold with a birth right and residence in denmark to apply for a modest benefit called old age support this law was replaced in 1956 when a danish national public pension was introduced as a universal welfare benefit for all citizens over a certain age in 1965 this law was supplemented by a law on early retirement making it possible for people below the pensionable age to receive benefits under certain conditions the 1965law had a very clear structure regarding the legal rights of the citizen and the decision criteria for applying them it makes clear that a citizen is entitled to receive pension if his or her work ability is reduced to a certain level early retirement pension is a service intended to provide compensation for the consequences of a reduction or cessation in the ability to work the law here is clearly structured by a conditional program in other words one based on ifthen sentences if ones ability to work is limited then one has a right to early retirement in this way citizens can know with relative certainty when they are entitled to a pension the challenge is of course to decide in a given case whether work ability is in fact sufficiently limited to make this decision the conceptual line illustrated in fig 1 must be put to work the other side of the concept of limitations here implied is possibility work ability is a line drawn within the unity of the difference limitations possibility early retirement pension is essentially a right or a positive entitlement based on the observation of limitations a positive decision compensates for the consequences of an incapacity or reduced capacity to work what a person cannot do possibility here refers to an assumption of the general work ability of a normal healthy citizen but how can the public administration through the medium of law observe work ability and draw the line needed to reach a conclusion when the citizen is observed in the medium of law the citizen emerges as a legal subject rather than a living body law thereby becomes dependent upon observations made by other social systems that are able to apply their own gestalts and treat the citizen as body this dependency could potentially lead to radical uncertainty but the law on early retirement structures this dependency upon nonlaw very carefully the law states that t he grounds for employability must be a morbid condition medical disability and it continues the medical component of the disability assessment consists of ascertaining whether there is an illness that has an effect on the persons ability to perform a job the law thus creates procedures regarding how the code of law and the code of medicine should be coupled and how the law communication should observe the medical observations of the citizen on the basis of the medical discretion an assessment is then made on whether the conditions of the law are fulfilled law installs procedures for how to interrupt law by inviting contributions formed in the medium of the health system by invoking the medium of medicine the public administration becomes able to observe the citizen not just as a legal subject but also as a patient whose health has been examined symmetrically within the medium of medicine observations of the patients health are possible but the patients rights and duties are removed as topics of observation the legal communication has procedures for interrupting its own selfinterruption thus returning to the medium of law though medical facts and legal facts are not the same the public administration can now observe in the medium of law the earlier medical observations and medical facts and make legal decisions regarding the legal facts within the medical facts in other words the public administration observes medical facts by productively misreading them as legal facts that can function as legal premises in ifthen decisions this welldefined structural coupling from law to medicine creates high expectation security regarding how to make a decision as well as high calculability for citizens to understand their rights from the year 2000 a discussion arose around the perceived economic and social problem of there being too much permanent early retirement amongst people too young calling for reform an official report states its about people who do not get the opportunity to realize their potential in an active working life it is about futureproofing our welfare and it is about our community and danish business growth and job creation and new jobs that do not benefit from the resources and skills of the many retired young people a contradiction is here articulated between the citizens clearly defined right to early retirement and their more diffusely understood right to realize their potential in the semantic of the citizens right to early retirement we have seen that communication operates with the distinction limitations of possibilities in the semantic of the citizens right to realize his or her potential limitations and possibilities are interchanged the semantic imperative is that we must stress potential despite limitations here communication operates with the distinction potentialization of possibilities from limitations work ability as the unity of the difference limitationspossibility is substituted by potentialization as the unity of the difference possibilitylimitations as a former social affairs minister henrik dam kristensen put it back in 2000 the main aim of the reform is to focus on peoples work abilities instead of how sick they are after the reform the principal of social work will be the resources and value of the single individual what counts is not the disabilities of an applicant but what he or she can do after the reform was fully implemented in 2014 minister of employment mette frederiksen articulated this as a right as follows the opportunity to work or educate yourself for a life that provides the best conditions for fulfilling and living the potential and the resources dreams and desires that each individual has it is a right that everyone has whether they are ill have limited working capacity get off to an early start in adulthood or have outdated skills observing potential amidst and despite limitations becomes the starting point for developing citizens resources and we end up with two almost antagonistic gazes at the citizen limitationspossibilities and possibilitieslimitations it is remarkable how both differences are built into the new law despite the fact that they are exactly antagonistic so the citizen is both given a right to early pension on the basis of limitations to hisher possibilities and at the same time given a right to develop and realize hisher potentiality based on the limitations however serious they are the reform of early retirement incorporates this antagonism into the law so that the citizens right to early retirement can be exercised only when her right to realize her potential has been exhaustively explored it is a condition for a case to be processed under the rules on early retirement that the case has been submitted to the municipalitys rehabilitation team we will explore further below how these rehabilitation teams function as potentialization technologies here we simply note the sequencing whereby first when all possibilities of potentializing the citizen have been exhaustively explored by observing by means of the difference possibilitylimitation only then is the citizen permitted to be observed with the difference limitationspossibility as written in the law text the local council decides that the case will be dealt with according to the rules on early retirement when it is documented or it is quite obvious that due to special circumstances the person cannot be improved by participating in resource trajectory or activation rehabilitation treatment or other measures the law gives a right to early pension and rejects it too the contradiction that this builds into law serves to protect the welfare state against the law we see two immune functions in this regard the first is to protect the process of finding possibilities and solutions against citizens that claim their rights the second is to protect an explorative process investigating how different function systems might contribute to the potentialization of the citizen against legal ifthen procedures and the search of legal closure of the case unrelating law from the process of potentialization here seems crucial regarding the first point it is very clear that citizens who claim their rights to early pension are observed not as active collaborative citizens but as a kind of countercitizen minister of social affairs and integration karen haekkerup states this very clearly in 2012 we cannot look passively on while we park young people on benefits for the rest of their lives and the danish agency for labour market and recruitment formulates the new expectation concerning the active citizen in 2014 in this way coownership means that the citizen is committed to the effort and takes responsibility for his own situation this means that the caseworker plays a more coaching motivating and recognizable role in relation to the citizen a trusting relationship must be established between the caseworker and the citizen where the citizen gets help to get an overview of his opportunities and help to use the opportunities the citizen should take ownership of the process of potentialization and not fall back on their rights to a final decision on a case in one case where a citizen insisted on her rights in formulating a legal complaint the national board of appeal concluded it is not excluded that your ability to work can be developed so that you could manage more than just a few hours of work per week retsinformation 2014a 2 there are almost always possibilities of potentialization left to explore no matter how much the citizens health has been weakened the following example is from a field study conducted by anne roland hoolbaum and karen maria jensen in 2015 observing how the rehabilitation teams work we are here seeing a piece of the communication between the client martine and her regional doctor doctor i can see what it is that affects your functioning it is especially adhd and i can see now and it is also described that you have psoriasis to a considerable extent so it is clear that there are some things that affect your ability to work and that is what you have to take into account in terms of how to find opportunities for you in the labour market perhaps reduced time etc this is what is the exercise when i look at you that you are 27 years old there are opportunities but where they are located i cant take care of that from a medical point of view we can take into account your special needs i think you are only 27 years old we should do our best to explore your possibilities martine the more i get pressured the more my illness will be and it has become doctor its early at 27 years old to have to park on an early retirement dont you think martine i need the calm i need to be allowed to have my life doctor i fully understand that i just think that there must be a balance between giving you some peace while also trying to have a future it is also important to have a future martine tries to argue that she really needs early pension because she needs a closure to her case she needs calculability and fixed structures that allow her to relax and to live with her limitations but the doctor points out that this attitude is an obstacle for her potentialization she is only 27 and has a long life to lead full of possibilities despite her limitations so the exercise is to explore what opportunities for work martine might have and how these can be adjusted to fit with her health limitations the rule requiring the construction of a resource trajectory to enable this adjustment protects the welfare state from its obligation to meet martines claim to early pension and does so in the name of potentializing martines future the potentialization says no to the right to early retirement to the extent that this right threatens the citizens potential to remain active but in saying no to the legal right of the citizen this type of potentialization also provides a technical alternative to the welldefined structural coupling between law and nonlaw the rehabilitation teams function as a technology for exploring the citizens possibilities by including them in a multidisciplinary conversation with a variety of stake holders rehabilitation teams and resource trajectory is constituted in the law in order to potentialize the citizens rtrt basically says no to legal conditional regulation of the coupling between legal concerns and nonlegal concerns like health care love and education the rehabilitation team is in the law constituted as a dialogue and coordination forum which shall give an assessment in all cases before decisions regarding resource trajectory and early retirement are taken based on the individual citizens overall situation the aim of the rehabilitation team is to ensure interdisciplinary coordination and a holistic effort across administrations and authorities focusing on employment and education so that the citizen as far as possible gets a connection to the labour market the rehabilitation team becomes a technology of potentialization examining the potential development of the citizen oscillating between many perspectives belonging to different administrations and functions systems the rehabilitation team is an interdisciplinary team consisting of doctors psychologists lawyers social workers and others who represent different administrative and social systems perspectives on the client before examining retirement rights the team must first explore possibilities to develop the client they can either devise a resource trajectory which practically articulates those possibilities or recommend a retirement decision in the first case the citizen is observed within the frame of possibilities from limitations the individual resource trajectory they are offered aims through provision of mentoring psychological counselling job training voluntary social work treatment of abuse exercise and so on to develop their resources to enable new or subsidized employment in the second case of a retirement decision the citizen is observed within the old frame of limitations upon possibilities we noted that in the early retirement law from 1965 the law has clear procedures for how to manage the structural coupling of law and medicine defining the main purpose as potentialization of the citizen the new law from 2013 makes itself dependent on numerous nonlaw social systems the regulation of the couplings between these many systems is delegated to the rehabilitation team who outlines a resource trajectory one might say that rtrt functions as an immune mechanism that protects the work of potentialization by intercepting structural decisions and creating a zone of uncertain expectations about how to observe the citizen in order to potentialize it is the rehabilitation teams duty to exhaust the possibilities for developing the citizens resources before arguing for early retirement a rehabilitation team can recommend a resource trajectory lasting up to five years and it can legally recommend yet another resource trajectory this effectively grants a bufferzone of immunity from the legal structure of rights meaning that citizens who have applied for early retirement have no opportunities for clear and unambiguous expectations regarding their legal possibilities for early retirement using this immune mechanism the many codes and perspectives offered by society can now be perceived as being an open reservoir through which the social work organization can experiment with itself here the question is not how to use available facts to reach legal closure in a case the questions are rather what are the possibilities of potentialization of this case this citizen and this communication when we choose to form this or that code and perspective what does this or that perspective open towards what does it make us discuss and see as interesting possibilities how does the citizen react if we invite himher into a dialogue coded by care in comparison with a dialogue coded by education or health does the motivation of the citizen increase mostly in the discourse of psychology pedagogy health promotion or money what discourses provoke citizen resistance and should therefore be avoided basically this experimental program dealing with a multiplicity of perspectives is only possible if the relations between the different perspectives are in principle open and loosely coupled which perspectives in a given case are relevant cannot be taken for granted all taken for granted relations between case and perspective have to be constantly unrelated to make the potentialization work the readiness to loosen up to disconnect or to unrelate specific formmedium relations becomes essential this is what pedersen calls creative cutting but creative cutting can only work on condition that the rtrt is able to render irrelevant the perspective of legal rights conclusion when the welfare state protects its operations against its own structures this article took off from the observation of a certain skepticism about law that is acquiring prominence law is perceived as a force of unwelcome closure with negative implications for the future of the future we have not offered a normatively based critique but rather a diagnosis of this aspect of the present we have done so by developing an immunological analytical strategy that involves observing with the guiding difference immune mechanismexpectation structure for as long as we have had a welfare state we have had immune mechanisms employing luhmanns account of law as societys immune system allowed us to identify some special types of welfare technology whose function is potentialization the creation of radically new possibilities for what welfare is and can be potentialization is not about realizing existing possibilities or meeting existing challenges with closure potentialization is about the hunt for a new horizon of possibilities on the other side of the existing one without this diagnostic approach the quest for potentialization might simply be championed as an unquestioned basis for normative critique the economic instrumentalizations often associated with neoliberalism for example might be challenged and countered by a call for the creation of alternative spaces with atmospheres suited to the entertainment of radical new possibilities our analytical strategy allowed us to address how potentialization technologies have emerged as an integral part of todays neoliberalized welfare states to address in part at least unintended sideeffects of law we have also observed that they are now coming to attack law potentialization can thus be observed as a distinctive type of social immune mechanism which is functionally equivalent to conflict but works in a different way in law as a social system luhmann refers to ross ashbys point about the function of variety in complex systems and argues that law as immune system compensates for the lack of requisite variety conflicts as elements of the immune system are in this regard important because they have a high degree of randomness and an extreme frequency potentialization technologies differ in a number of ways first they are devised rather than spontaneous they represent a more direct and managerially controlled solution to ashbys problem of requisite variety they are basically designed to create new requisite variety second potentialization technologies function virtually by use of imagination to conjure a steerable future that is to say by pointing out a not yet visible horizon of potentiality beyond the existing horizon and by using this new horizon to mobilize and communicate contradictions against the present future in short potentialization technologies operate with a future future third in this way potentialization technologies differ from conflict in that they can perform a paradoxical operation of saying no to the present future whilst at the same time saying no to the no of conflict conflict and contradiction is as it were unfolded and put to use within a carefully designed safespace of playful imagination which can present itself as positive as opposed to destructive critique fourth conflicts and potentialization represent different kinds of no that indicate structure differently conflicts communicate no to the specific structure that they highlight a school conflict might communicate no to a teachers unilateral authority for instance potentialization says no to structures as such given the widely perceived need for coordination on a global scale in the face of multiple systemic crises this antistructural feature of addressing all kinds of structures as problematic is likely to become the source of problems in whatever future replaces the future future open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit licensesby40 authors and affiliations niels åkerstrøm andersen

sociologist niklas luhmann argued that the law functions as societys immune system by regulating conflicts that threaten the certainty of expectation structures in this article we argue that law itself has become a target of new social immune mechanisms since the 1980s welfare states have increasingly seen their own structures as a threat today the ideal is a public sector consisting of organizations that constantly emerge anew by selecting the structures that fit each specific moment case and citizen to protect public sector organizations against their own structures potentialization now functions as a social autoimmune mechanism by initiating a constant search for new openings and possibilities this critique of structures includes a critique of legal structures like rights looking at the danish law of early retirement as our empirical case this paper analyzes how the tension between law and potentialization is built into the law itself while the law gives citizens certain rights to early retirement it simultaneously protects against the same rights by potentializing citizens potentialization here functions as a mechanism that protects the operations of a system against its legal structures it functions by unrelating those operations from the structures this means that when citizens claim their right to pensions the social workers can reject them on the grounds of a right to a future that is not foreclosed and parked on a pension the papers contribution is to show how potentialization works by dissolving even fundamental legal expectations this profoundly transforms the relationship between the citizen and the public sector

introduction it is well known that males and females differ in terms of their life expectancy and overall health males have a higher mortality than females in terms of both total mortality and for most causes of death mens higher mortality is due in part to gender differences in risktaking and healthrelated behaviour and gender differences in employment several biological hypothesis have also been proposed including more active female immune functioning the protective effect of estrogen compensatory effects of the second x chromosome reduction in the activity of growth hormone and the insulinlike growth factor 1 signaling cascade and the influence of oxidative stress on aging and disease there is a remarkable discrepancy between the health and the mortality of men and women despite the lower mortality at all ages compared to men womens longer lives are not necessarily healthy lives and men tend to report a better selfassessed health and fewer disabilities this phenomenon is called the malefemale healthsurvival paradox proposed explanations for this paradox are rooted in biological social and psychological interpretations in addition to the above mentioned factors there may be a reluctance or delay for men to seek and to comply with medical treatment it cannot be excluded that part of the differences in morbidity may be due to methodological challenges such as differential participation or underreporting of health problems by gender studying crosssectional differences in composite indicators such as health expectancies which combine both mortality and morbidity may contribute to the better understanding of the dynamics of population health and gender differences health expectancies predominantly disabilityfree life expectancies are available for over 50 countries worldwide including many european countries but crossnational comparisons have been difficult because of a lack of consistency of health measures and calculation methods both of these factors have been minimized with the healthy life years indicator in particular harmonisation at the point of data collection by the use of a single survey across the eu25 called the statistics of income and living conditions has aided comparability of the underlying measure of disability in most study reports on life and health expectancy the indicators are presented stratified by gender however few go beyond the mere description and explore the role of determinants on the gender difference the aim of this article is to describe the pattern of the gender difference in life expectancy the life expectancy with and without activity limitations at age 50 across 25 eu countries and to explore the association with macrolevel factors that may explain any diversity in gender difference in life expectancy with activity limitations between countries methods data life expectancy in a particular health state eg life expectancy without disability or life expectancy with disability is defined as the average number of years a person at a certain age is expected to live in the particular health state to assess these health expectancies two types of data are needed data on mortality enable the estimation of the total life expectancy data on the prevalence of different health states are applied to the life table to estimate the person time lived in the different health states full life and health expectancy tables were downloaded from the ehemu information system the disability data came from silc2005 survey the silc survey is a european wide survey the implementation of the silc survey by the european member states is based on a common framework regulation to enhance the betweencountries comparability the framework defines the survey design the use of common concepts and classifications the use of harmonized lists of target variables and common requirements a description of the methodological details can be found in the comparative quality report the participation of households was above 80 in nine member states and above 60 in all other countries with the exception of the netherlands participation rate did not differ by gender the silc contains the minimum european health module devised by the euroreves group the minimum european health module has three questions including a disability measure the global activity limitation index to ensure a maximum harmonization of the minimum european health module questions in the silc at the point of the data collections all member states received definitions of the concepts included in the gali and translation guidelines for the translation of the item to the underlying concepts checks were made on whether there were any cultural issues that were likely to impair understanding or reporting the gali instrument aims to capture longterm limitation in usual activities caused by illhealth with three severity levels none limited but not severely and severely limited the disabilityfree life expectancy based on the gali is called the hly the hly was selected in 2004 to be one of the structural indicators of the eu the hly at age 50 years is the average number of years a person of age 50 years is expected to live without activity limitations as no distinction is made by the severity level of the activity limitations the difference between the life expectancy and the life expectancy without limitations defines the life expectancy with activity limitations we obtained from the eurostat website the relevant macrolevel factors structural indicators for each country the indicators cover broad areas of wealth and expenditure labour force participation employment rate of older at age 5564 years longterm unemployment rate mean exit age from labour force and level of education lifelong learning low education attainment we defined four additional indicators as malefemale differences for each of the sexspecific indicators definitions of the indicators and their quality grade are given in table 1 most indicators chosen included all adult age groups those for the older population were chosen to reflect the countrys provision for older people specifically data on the macrolevel factors relates to 2005 with the exception of the expenditure on elderly care for which the most recent data was available for the year 2004 methods the life expectancy with and without activity limitations at age 50 years were calculated using the sullivan method which integrates agespecific disability prevalence with the life table variance estimation of the life expectancies was calculated from complete life tables variance estimates of the life expectancy with and without activity limitations were calculated from abridged life tables with an open ended last age group of 85 years and over as the variance due to mortality is negligible compared to the variance due to morbidity we ignored the variance due to the mortality data when estimating the variance of the health expectancies to investigate the relationships between either the gender differences at age 50 in the life expectancy or in life expectancy with activity limitations and countryspecific structural indicators metaregression models were fitted within the metaregression analysis the uncertainty around the country specific gender difference is accounted for graphical data exploration indicated possible differences in the association between the gender difference in life expectancy with activity limitations at age 50 and the structural indicators in the original and the more recent european member states in a first set of models each structural indicator was entered univariately fitting separate models for the original and more recent countries although no formal tests for outliers or influential data points were carried out gross domestic product gdp per capita in purchasing power standards a expenditure on elderly care the share of social protection expenditure devoted to old age care as a percentage of gdp not available poverty risk for 65 yrs persons aged 65 years and over with an equivalised disposable income below the riskofpoverty threshold which is set at 60 of the national median equivalised disposable income after social transfers as a percentage of all aged 65 years and over c inequality of income distribution the ratio of total income received by the 20 of the population with the highest income to that received by the 20 of the scatter plots of all relationships were assessed visually to ascertain if any relationships were the result of just one or two data points in a second set of models the member state specific level of life expectancy of males and females was additionally entered in a last model the statistical significance of the interaction between the structural indicator and the eu15eu10 countries was assessed results tables 2 and3 summarise the gender differences in life expectancy and expected years with and without activity limitations at age 50 in 2005 life expectancy was always larger in females the differences ranged between 32 and 82 years the gender differences were larger in the newer eu countries compared to the more established eu countries gender differences in life expectancy without activity limitations were also positive except in a few countries cyprus portugal and spain were the expectation of life in good health at age 50 is greater in men the gender difference in life expectancy without activity limitations ranged from 22 to 37 years and were in general larger in the newer eu countries compared to the more established eu countries gender differences in years with activity limitations were between 22 and 78 years with higher differences in the newer eu countries compared to the more established eu countries the gender gap in life expectancy and in years with activity limitations tended to be larger in countries with shorter life expectancy furthermore countries with large gender differences in life expectancy also tended to have larger gender differences in years with activity limitations for the older eu member states there was a greater estimated increase in the gender difference in years with activity limitation for a 1year increase in the gender difference in life expectancy than for the newer european member states the differences between genders in expected years with activity limitations were smaller as the expenditure on elderly care or the mean exit age from the labour force increased whereas the gender differences were larger as the inequality in income distribution increased the analysis was repeated after stratification eu15 eu10 the stratified analysis decreased the power if the association did not differ between the two groups of eu countries however the power increased when the associations were inconsistent the high coefficient of the expenditure on elderly care in the newer eu countries was related to the narrow range whereas the values within the older eu countries ranged up to 26 an opposite direction of the association was observed for low education attainment employment rate of older women and men unemployment rate women and men and the gender difference in the unemployment rate lifelong learning women and gender difference in lifelong learning because the size of the gender gap in years with activity limitations was associated with the gender difference in life expectancy the life expectancy of women and men were added to the model in a final model the statistical significance of the heterogeneity of the association between the more established and newer eu countries was tested using an indicator variable to identify eu15eu10 countries and interaction terms in contrast to the older eu countries within the newer eu countries the life expectancy of men and life expectancy of women was not significantly associated with the gender difference in expected years with activity limitations within the older eu countries the effect of the life expectancy of men was stronger compared to the life expectancy of women after the inclusion of the life expectancy in model the gender gap in years with activity limitations among the older eu countries increased with increasing income inequality with increasing proportion of the population with low education and with an increasing mean exit age from the labor force among men among the newer eu countries the gender gap in years with activity limitations increased with increasing poverty risk for the 65 years and older and with increasing employment rates among men and women the gender difference in years with activity limitations was negatively associated with the expenditure on elderly care indicating that the gender gap was larger in countries with a lower expenditure on elderly care there was evidence that the association between the structural indicators and the gender difference in years with activity limitations was significantly different for the more established eu countries compared to the newer eu countries in terms of gdp the expenditure on elderly care poverty risk for the 65 year and older and the employment rate of older women for the poverty risk for the 65 years and older and for the employment rate of older women the positive association was stronger in the newer eu countries the negative association between the gender difference in life expectancy with activity limitations and the expenditure on elderly care was larger in the newer eu countries for the gdp the association with the gender difference in life expectancy with activity limitations was negative in the older eu15 countries whereas it was positive in the newer eu10 countries discussion in this article we evaluated the association of the gender differences in life expectancy with activity limitations within the eu with macrolevel structural indicators the life expectancy with activity limitations was estimated using the gali the gali instrument has been validated both within countries by comparing subpopulations with different cultural backgrounds and between different european countries the gali appears to be reliable and to reflect levels of function and disability both across europe and in a similar way between countries given the focus of the article on gender difference within european countries in life and health expectancy at age 50 and its association with macrolevel structural indicators it is essential that the validity of the gali is homogeneous across gender this question has been addressed using data from the belgian health interview survey reporting no evidence of heterogeneity of the validity of the gali by gender we observed that the size of the gender differences in life expectancy with and without activity limitations at age 50 is larger in the newer eu countries compared to older eu member states that comprise the eu15 countries with a large gender difference in years with activity limitations tend to have a smaller life expectancy and a larger gender inequality in the life expectancy overall within the eu the gender gap in years with activity limitations decreased as the gdp the expenditure on elderly care and the lifelong learning among men increased while the gender inequality in years with activity limitations increased with an increasing inequality in the income distribution the association between the gender difference in years with activity limitations and some of the structural indicators was not the same comparing the new and old european countries for the gdp the effects were opposite for the other indicators with a significant interaction the effect in the newer eu countries was larger compared to the older eu countries international research on health expectancies is often hampered by imperfect harmonization of the health measures and the exclusion of the institutional population the focus of the article on gender differences helps reducing these effects as the same instruments applied to men and women in each country however studying gender differences cannot completely eliminate these effects due to countryspecific differences in male and female institutionalization rate health status and social roles for which men and women might feel restricted we first discuss the fact that the silc survey is limited to the community dwelling population and no information is available on the health status of the institutionalized population this limits the use of the assumption that all institutionalized people are disabled however ignoring the differences in health status between the people in the general population and in institutions probably leads to an overestimation of the expected years without activity limitations and an underestimation of the years with activity limitations it is unknown if this error occurred similarly in both genders in which case it would not affect the gender differences even so the overor underestimation may be larger in countries with a higher proportion of the population in institutions and this may have an influence on the observed associations with the macrolevel factors a second limitation is related to the fact that the harmonization at the point of data collection may not have been perfect this was eg the case with the instrument used in denmark and this may have resulted in an overestimation in the expected years without limitations and an underestimation of the expected years with activity limitations although the focus on gender differences could diminish this problem data analysis were repeated after exclusion of denmark to evaluate the possible effect of this methodological problem removing the information from denmark did not change the distribution of the gender differences in the expected years with activity limitations and the difference between the older and more recent eu countries remained similar the conclusion of the univariate analysis did not alter both at the level of all member states or when the analysis was limited to the older eu countries after exclusion of the danish data the analysis could also focus on the moderate andor severe activity limitations and evaluate the robustness of using different outcome levels countries with large gender differences in life expectancy also have large gender differences in the expected years with moderate or with severe activity limitations the gender gap in expected years with activity limitations was larger in the newer eu countries and this is a result of both the larger gender gap in expected years with moderate and with severe limitations one should always be cautious when interpreting ecological associations however the directions of the associations between the gender inequality in years with activity limitations and the structural indicators are as expected eg in countries with either a more extreme income inequality an increased risk of poverty at older ages a lower gdp or less expenditure on health care the inequality in years with activity limitations by gender tend to be larger there is increasing evidence of a reduced health and health expectancy in less privileged social populations the impact of social conditions seems to be more important for men next to methodological reasons eg social position measures such as occupational status and education are reflecting better the social situation of men when measured at the household level the greater negative health impact of the social position in men can also be a result of other mechanisms such as differences in type of industrial evolution resulting in more unhealthy work related exposures and outcomes negative life styles such as smoking alcohol and violence with a more extreme uptake among males in lower social groups this may however change due to the increasing participation of women in the labour force during recent decades and the evidences of the physically and psychologically health damaging impact of womens implication in both professional and domestic activities especially in the less privileged social groups on the other hand in countries where men take more opportunities for lifelong learning the health dynamics between males and females favour the catching up of males reducing the gender gap conclusion we have shown that the gender differences in life and health expectancy at age 50 diverge among the european countries with larger differences in the eu10 compared to the eu15 the fact that association between macrolevel structural indicators and the gender gap in years with activity limitations is not homogenous between the more established eu15 countries and the ten new eu countries indicates that there is room for improvement special attention should be given to the expenditure on elderly care poverty risk at older ages and inequalities in income distribution

women generally live longer than men but womens longer lives are not necessarily healthy lives the aim of this article is to describe the pattern of gender differences in expected years with and without activity limitations across 25 eu countries and to explore the association between gender differences and macrolevel factors we applied to the eurostat life tables data from the statistics of income and living conditions survey to estimate gender differences in life expectancy with and without activity limitations at age 50 for 2005 we studied the relationship between the gender differences and structural indicators using metaregression techniques differences in years with activity limitations between genders were associated with the life expectancy le and the size of the gender difference in le gender difference in years with activity limitations were larger as the gross domestic product the expenditure on elderly care and the indicator of lifelong learning decreased and as the inequality in income distribution increased there was evidence of disparity in the associations between the more established eu countries eu15 and the newer eu10 countries among the eu15 gender differences were positively associated with income inequality the proportion of the population with a low education and the mens mean exit age from labour force among the eu10 inequalities were smaller with increasing expenditure in elderly care with decreasing poverty risk and with decreasing employment rate of older people the association between structural indicators and the gender gap in years with activity limitations suggests that gender differences can be reduced

introduction sexually transmitted infections human immunodeficiency virus is not only a serious public health or social problem affecting the nigerian military but also a national security problem that requires a concerted effort to control the disease 1 with a population of approximately 1492 million people nigeria is said to be the second most affected country in subsaharan africa with the hiv disease 2 the adult hiv prevalence increased from 18 in 1991 to 58 in 2001 before dropping to 50 in 2003 and 44 in 2005 3 however the national prevalence seemed to stabilize between 2005 and 2010 with a reported prevalence of 46 in 2008 and 41 in 2010 4 based on the overall national prevalence of 41 it is estimated that 31 million people in nigeria are living with hiv aids in 2010 the vast majority of hiv transmission in the country is through heterosexual activity and women are disproportionately affected 3 like many other countries in africa hiv is most prevalent among the most productive members of society age 25 26 27 28 29 with young women particularly affected the epidemic also had a disproportionate impact on women and girls in their reproductive years with 49 of pregnant women age 2529 infected followed by women age 2024 with 47 a more alarming situation is the fact that about 36 of women age 1519 were reported to have been infected as well suggesting early sexual debut 5 while awareness of hiv is relatively high especially among urban populations in nigeria it appears that the high level of knowledge of hivaids has little impact on the myths and misconceptions about hiv transmission 6 and the attendant risktaking behaviors 78 evidence indicates that vast majority of nigerian women still indulge in risky sexual practices such as having multiple sexual partners unprotected sex alcohol and drug abuse with elevated rates of stis 7 8 9 the impact of hiv among african militaries have assumed alarming dimensions with prevalence rates of between 58 and 267 reported in selected countries 10 nigerian military personnel like other militaries in the world indulge in highrisk sexual behaviors which put them at high risk of contracting stis including hiv when compared to the general population the prevalence rates in the nigerian military have been estimated at 1020 11 the military is a highrisk population because of its demographic constitution social norms and occupational exposures apart from the fact that danger and risk taking are integral parts of most field operations in the military profession there are a number of other risk factors that increases the military personnel vulnerability to stishiv infection they are generally young mostly single and sexually active stay away from their families and home communities for extended periods of time and are more likely to be influenced by peer pressure rather than social convention freed from the strictures of their normal social environments many engage in high risk behaviors such as anonymous purchased or even coercive sex as a means of relieving the tension of loneliness 1213 including alcohol consumption use of drugs and unprotected sex with multiple partners and commercial sex workers 111214 the relationship between perception of risk and sexual behavior is complex and poorly understood studies conducted in different cultures countries and subpopulations have associated hiv risk perception with a wide range of variables including choice of partner choice of sex act and condom use 7 15 16 17 according to the aids risk reduction model knowledge of aids is a prerequisite to recognizing risky behavior and taking action to change it 18 but findings regarding the relationship between knowledge and behavior have so far been inconsistent in our earlier study 7 we noted that despite having a high degree of hivaids knowledge majority of the study participants were engaged in risktaking behaviors including having unprotected sex on the contrary accurate assessment of risk perception has been associated with increased condom use 15 many young people do not consider their behavior or that of their sexual partner to be risky and this lack of risk perception is more challenging when the negative outcomes are not immediately obvious for instance it has been reported that 36 of nigerian uniformed service personnel did not think of using condoms during sexual encounters with their casual partners 19 also in our recent study 7 we noted that female military personnel who were not consistent condom users were 65 less likely to encourage their casual partners to use condom thus suggesting that this group would be at elevated risk of stishiv infection while the trends in risky behaviors are likely to persist in the coming years in spite of a high level of public awareness about hivaids military women would be particularly susceptible to stishiv infection and its consequences this is because the existing sexual norms place them at a disadvantage in that they are unable to control the sexually risky behaviors of their spouses andor partners or take action that would limit their risk of exposure 20 the increasing participation of women in the military in nigeria also underscores the special vulnerability of this group to stishiv transmission it is also important to note that the walls of military bases constitute no barriers to the bidirectional transmission of stishiv between military and civilian populations these health risks apart from contributing to the hiv epidemic may serve a significant threat to the preparedness of the military to carry out its functions 114 already aids is now the leading cause of death in military and police forces in some african countries accounting for more than half of inservice mortality 21 therefore individual level risks for stishiv infection are at the core of these epidemics and are powerfully impacted by social structural and population level risks and protections 22 these observations suggest that hiv risk assessment should be based both on personal perceptions of risk and on the epidemiologic notions of risk 7 but weinstein 23 posit that perception of risk goes beyond the individual and that it is a social and cultural construct reflecting values symbols history and ideology although behavior changes may be indicative of ones perception of risk but recognizing ones current behaviors as risky is the first step toward behavior changes such as adopting condom use also an individuals risk perception could have direct influence on the reception of stishiv prevention messages especially as the choice of personal hivinfection prevention strategy has been associated with different risks and benefits 24 ideally effective choices are based on an accurate perception of the risks from different combinations of behaviors often however the perceived hierarchy of risks from different activities may not match the data from epidemiologic standpoint 25 accurate information on the magnitude of risks and benefits of each of these choices could substantially improve efforts to prevent stishiv infection among venerable population such as the military the main objective of this study therefore was to compare the correlates of selfperceived and epidemiologic notions of risk for acquiring stishiv infection among female military personnel in nigeria in addition we determined the measure of agreement between both risk assessment methods and the sociodemographic characteristics associated with accurate assessment of stishiv risk in the study population finally we modeled the predictors of participants risk levels based on selfperception and epidemiologic notions of risk for acquiring stishiv infection methods study participants and procedures using a crosssectional design 346 female military personnel were recruited from two military cantonments in the southwestern part of nigeria to participate in the study the number represented 90 of the initial sample population of 386 screened the two cantonments were chosen because they served as camps for recruitment training and entry points for returning military personnel deployed on peacekeeping operations and foreign missions and therefore offered an ideal environment for our study the participants formed the baseline population of an intervention study 26 in order to consider the participants at risk of potential stishiv infection this study required them to be sexually active and to meet certain criteria which include aged 18 years or older selfreported unprotected vaginal intercourse and having two or more different partners in the past six months or having been diagnosed and treated for a sexually transmitted disease in the last year residence at the study sites ability to communicate in english language and willingness to sign a consent form for study participation the study was conducted between 2006 and 2008 measures and operationalization the questionnaire used captured participants sociodemographic characteristics such as age marital status number of children raceethnicity religion level of education employment status annual income sexual relationships and personally knowing someone with hiv aids other measures assessed include hivaidsrelated knowledge sexual behaviors stishivrelated risks and alcohol and drugrelated risks using several items participants provided selfreport based on these measures selfperceived risk was measured on a 4point scale with the following questions based on your behavior in the past 3 months what do you think is your risk of getting sexually transmitted infections like herpes syphilis chlamydia or gonorrhea and what do you think is your risk of getting the aids virus participants who responded no risk at all or somewhat at risk were defined as perceiving themselves at nolow risk and participants who responded good deal at risk or extremely at risk were defined as perceiving themselves at moderatehigh risk a composite mean score for both items was used to represent participants stishiv risk levels which is herein operationalized as selfperceived stishiv risk the assessed stishiv risk of participants referred to as epidemiologic notions of stishiv risk in the current study was determined using selected risk indicators for stishiv infection such as having not used a condom at last sex having had a causal partner at last sex having had two or more cumulative partners in the last 6 months having a history of stis and having received money drug or gifts in exchange for sex having ever been tested for hiv duration since last hiv test drinking or using drug before last sexual encounter not knowing someone with hivaids sharing needle and having sex with a partner who used needle to inject drugs and not knowing the hiv status of last sex partner this measure assessed participants risks on a scale ranging from 05 depending on the number of answer options for each question with 0 representing no risk and 5 representing the highest risk level three investigators independently evaluated and scored each participants responses to variables of interest depending on the risk level the risk assessments were valid only when at least two of the investigators gave the same weight or score to a response a composite score that summarized the status of each participant response score was then created 242 the average score was used to categorize the study participants into two main risk groups as follows little or no risk and moderatehigh risk this assessed measure of risk which was used as proxies for confirmed risk status in the circumstance of the crosssectional design study also served as the gold standard for comparing the respondents perceived risk statuses human subjects protection and ethical considerations appropriate steps were taken to ensure the protection of participants given the possibility of coercion in a military establishment the research protocol was reviewed and approved by institutional review board of both the university of houston in the united states and institute for health research and development in nigeria the women were informed verbally and in writing that their participation was voluntary and that failure to complete the study questionnaire or refusal to participate would not jeopardize their eligibility for benefits to which they were otherwise eligible at the armed forces program on aids control or the collaborating communitybased organization statistical analysis chisquare statistic was used to assess the independent associations between sociodemographic characteristics hivaidsrelated knowledge sexual behaviors stishivrelated and alcoholdrugrelated factors and the risk assessment methods furthermore we used chisquare to test for differences in the proportional distribution of participants who were able to accurately assess their risk levels by sociodemographic characteristics using the epidemiologic notion of risk as the gold standard the fishers exact test was used where applicable to correct for small cell counts the measure of agreement between the two independent risk assessment methodsselfperceived risk and assessed risk by sociodemographic characteristics were measured using the cohens kappa statistics where 1 represents perfect agreement 0 represents no agreement beyond chance and negative values indicate agreement less than chance ie potential systematic disagreement between the two ratings the general formula for calculating cohens kappa is kappa where a obs is observed agreement between perceived and assessed risk levels a ch is total agreement expected by chance and n is the total sample size using the sociodemographic characteristics as independent factors we conducted a multivariate logistic regression analysis to determine the adjusted odds of accurate stishiv risk assessments by the study participants through selfperception based on epidemiologic notions of risk based on the outcome of the initial bivariate analyses the predictor variables were selected a priori to model the covariates of stishiv risks if they were significant at p≤010 or if they were epidemiologically important hivaids knowledge and educational level were considered epidemiologically important and therefore were forced into the models irrespective of their probability values a total of 14 and 17 variables met the criteria for selfperceived and assessed risk categories and were included in the multivariate logistic regression models to assess the independent contribution of each covariate in predicting participants risk based on selfperceived and epidemiologic assessment and to simultaneously adjust for the covariates and potential confounders in the models we applied the stepwise procedure with forward selection in the multivariate analyses because we were interested in the most parsimonious models with the minimum number of variables that will predict the outcome variables adjusted odds ratio with 95 confidence interval was computed for each association finally we conducted a model likelihood ratio test to determine the goodness of fit of the models the regression diagnostics yielded no evidence of multicolinearity or overly influential outliers in any of the models all tests were twotailed with probability value of 005 used as the statistical significance level data management and statistical analyses were performed using spss software version 160 study limitations this study has several limitations that should be considered when interpreting and generalizing the findings first because the study was based on a cross sectional design we were unable to examine the direction of causality between risk context and associated sexual behaviors this makes it difficult to interpret the reported relationship status in the models as concurrency is unknown due to the sensitive nature of the survey findings are subject to social desirability bias where individuals may not wish to report behaviors that may be deemed undesirable additionally retrospective recall of the number and nature of sexual activities may be less accurate after a long period and may have resulted in underreporting in developing epidemiologic risk scale we assigned weight or score to each participants response depending on the level of risk for which such response was assessed it is possible that the risk levels associated with certain sexual practices and behaviors may have been underestimated or overestimated and therefore given higher or lower weights leading to risk level misclassifications and selection bias however while potentially correlated response may have been anticipated between risk categorizations and behaviors further analysis indicated that each construct represented a distinct and measurable dimension that varies independently from each other given that the study used military cantonments from one of the six geopolitical zones in nigeria the findings may not be generalizable or representative of the female military personnel in nigeria each of the zones has different sociocultural characteristics and environmental settings that may have some influence on the type of sexual risk behaviors and practices that personnel serving in such areas engage in in spite of these limitations the findings from our study have several implications for the design and implementation of stishiv prevention interventions for female military population in nigeria in addition to providing an important extension to previous researches on stishiv risk assessment results sociodemographic characteristics the sociodemographic characteristics of the study population comprising of 346 participants and their association with stishiv risk assessment methods are presented in table 1 there were clear indications that participants generally tend to underrate their risks level based on selfperception overall majority of the participants significantly perceived themselves to be at no risklow risk than those who claimed to be at moderate high risk of contracting stishiv infection with selfperceived stishiv risk assessment except for employment status all the factors considered were significantly associated with the participants risk levels however when their epidemiologic stishiv risk levels were determined we noted a significant shift in the proportions with 193 of the participants who perceived themselves to be at no risklow risk actually being determined to be at moderatehigh risk of contracting stishiv infection based on actual risk assessment we noted the existence of significant independent associations in the risk levels by marital status number of children raceethnicity and annual income of the participants of interest was a significant increase observed in the proportion of legally married individuals who perceived themselves to be at little or no risklow risk becoming 618 at moderatehigh risk of contracting stishiv infections after epidemiologic assessment similarly following epidemiologic assessment more women of hausa yoruba and other tribes were at moderatehigh risk levels compared to their initial selfperceived assessment bivariate associations of risk indicators table 2 shows the bivariate association between hivaids knowledge sexual behavior stishivrelated and alcoholdrugrelated risks and risk assessment methods findings indicate that selfperception of risk by participants were significantly associated with the following risk factors cumulative number of partners type of partner at last sexual encounter condom use at last sexual encounter duration since last hiv test drinking before the last sexual encounter and drug use before last sexual encounter within these factors the proportion of participants that rated themselves as being at no low risk ranged from 500100 while those that rated their risk levels as moderatehigh ranged from 00500 in addition to the aforementioned variables six more risk factors were significantly associated with epidemiologic risk assessment method these include receiving money drugs or gift for sex hiv status of the last partner personally knowing someone with hivaids number of persons known with hivaids ever sharing needles to inject drugs and having sex partners who used needles to inject drugs the proportional distribution of participants assessed risk levels ranged from 00882 for nolow risk and from 118100 for moderatehigh risk category in general with selfperception majority of the participants tend to underrate their levels of risk for contracting stishiv infections by claiming to be at nolow risk but when assessed epidemiologically we noted a significant increase in the proportions of those at moderatehigh risk and a reduction in participants classified as being at nolow risk measure of agreement the measures of agreement between selfperceived and assessed stishiv risk by sociodemographic characteristics of participants are presented in table 3 the results indicate that majority of the kappa coefficients obtained were negative except for a few low positive values and ranged from 0021 to 0115 these figures generally denote very low agreement between both assessment methods and confirmed that majority of the women tended to underrate their stishiv risk levels through selfperceptions compared to the epidemiologically assessed risk levels consequently participants were more at risk of acquiring the diseases than they actually perceived themselves to be accurate assessment of stishiv risk percentage distribution and adjusted odds ratios of accurate assessment of stishiv risk levels of the study population by sociodemographic characteristics are shown in table 4 using the epidemiologic notions of risk as the gold standard we observed that overall 454 of the study participants were able to accurately perceive their risk levels however the proportions of accurate assessment of risk by participants differed significantly across and within the sociodemographic characteristics for example correct assessment of risk increased significantly with increase in age group educational level and annual income but showed no clear pattern based on number of children participants who were christians had 115 more accurate perception of their risk levels than muslims the highest accurate risk perception came from participants with annual salary of ₦501000 and above 1 us ₦150 followed by those who had four or more children and then those who were divorced widowed or separated from their partners risk estimates based on accurate assessment indicated that women who were 40 years and older were 5 times more likely than those in age group 1829 years to accurately assess their risk levels employment status and annual income of the participants were also associated with participants ability to accurately assess their risk of contracting stishiv women who earned ₦361000 ₦500000 were approximately 4 times more likely than those in the lowest income bracket to accurately perceive their risk levels active service female personnel were about 12 times more likely than trainees to accurately perceive their risk levels while our final model indicated that only 193 of actual stishiv risk could be predicted by the identified covariates the slightly wide confidence intervals associated with the aors may indicate a reduced precision of the estimates and call for caution in interpreting the results in attempt to determine if accurate risk assessment was associated with condom use at last sexual encounter we noted that among participants who accurately assessed their risk levels 727 of them used condom at their last sexual encounter compared to 273 who did not using multivariate analysis we further noted that only raceethnicity and number of children were significant predictors of condom use at last sexual encounter with participants from ibo and yoruba tribes being 10 and 7 times more likely than the hausas respectively to have used condom at their last sexual encounters covariates of selfperceived and epidemiologic notions of stishiv risk multivariable models analysis indicate that selfperceived risk by participants could be significantly predicted by educational level religion condom use at last sex and duration since last hiv test the adjusted odds ratios were generally protective except for religion where muslims were reported to be three times more likely than christians to be at moderatehigh risk of contracting stishiv results showed that the epidemiologic risk for acquiring stis hiv unlike selfperceived risk was significantly determined by the following covariates type of partner at last sex condom used at last sexual encounter cumulative number of partners duration since last hiv test drinking before last sexual encounter and personally knowing someone with hivaids with a model coefficient of determination of 70 women who did not use condom during their last sexual encounter were 4 times more likely than those who used condom to be at moderatehigh risk of contracting stishiv furthermore epidemiologic assessment of the participants risk showed that increased duration of last negative hiv test was significantly associated with moderatehigh risk of stishiv infection participants whose recent hiv tests were carried out during the last 412 months and more than 12 months were 8 times and 14 times respectively more likely than the reference group to be at moderatehigh risk of contracting the diseases similarly participants risk levels tend to increase with increasing cumulative number of partners with those having 3 or more partners being about 14 times more at moderatehigh risk of contracting stishiv infection than those with single partner women whose last sex partner or both of them were drinking before last sexual encounter were 4 times and 12 times more likely than those whose male partners and them were both drinking to be at moderatehigh risk of acquiring stishiv not personally knowing someone with hivaids was also significantly associated with increased risk for acquiring stis hiv participants in this group were 8 times more at risk than those who personally knew someone with hivaids disease comparatively only two of the covariates namely condom use at last sexual encounter and duration since last hiv test were significant and common predictors of the risk level of the study participants based on both assessment methods however the slightly wide confidence intervals associated with some aors may indicate a reduced precision of the estimates and call for caution in interpreting the results discussion accurate assessment of personal risk and making the connection between behavior and susceptibility to stishiv infection are important first steps in preventing the diseases in the current study we noted with significant sociodemographic variations that majority of the participants who perceived themselves to be at little or no risks were actually at moderatehigh risk of contracting stishiv infection following epidemiologic assessment this demonstrated systematic tendency of the participants to be overly optimistic about the outcome of planned actions which has been termed optimism bias 27 was similarly observed among college students in nigeria 28 and by other researchers elsewhere 15252930 in nigerian culture individuals with stishiv disease are highly stigmatized and often mistakenly believed to be associated only with certain individuals or highrisk groups such as commercial sex workers homosexuals intravenous drug users and immoral others therefore the fear of subjectification may be responsible for this unrealistic optimism which may make the women less likely to take protective action or be more likely to engage in high risk behaviors in addition the common patterns of risk perception shared by the women may be linked to the military community memberships shared experience culture norms or other forms of group selfidentity that in turn shape their risk behaviors consequently the choice of safe sex or abstinence may involve weighing the sexual fulfillment expected from a given behavior against the perceived health risks of that behavior this implies that sexual behavior and safer sex has a complex relationship that is determined by several factors such as context time and settings we noted that 454 of our study participants accurately assessed their actual risk levels based on selfperception this figure raises some concern about higher likelihood of stis hiv transmission among those who are less likely to correctly perceive their risk levels or aware of any recent changes in their serostatus while this observation may be implicated in the current epidemic dynamics in the nigerian military effective health education campaign among this population will depend to a large extent on getting participants to acknowledge the link between their behavior and actual risk level thus selfperception of risk may be the first step toward behavioral changes and adoption of protective actions such as condom use and has been reported to be powerfully influenced by social structural and populationlevel risks and protections 22 a typical nigerian military environment which tends to put the female military personnel at high risk of contracting and transmitting stishiv have been described in previous studies 6 7 8 9 analyzing the risk environment in which these women operate would help in developing prevention and coping strategies that emphasize both individual behavioral and environmental change the relationship between perception of risk and sexual behavior is complex and some studies in subsaharan africa have shown mixed results 1620293031353940 we recorded no significant association between hivaids knowledge and the risk assessment methods despite a high prevalence of hiv risk indicators in the population although the adult literacy rate in nigeria is considered high this observation corroborates with our earlier findings 6 7 and that of other researchers 31 32 where despite high degree of hivaids knowledge armed forces personnel were reported to have engaged in risktaking behaviors for instance approximately 604 of our study participants who did not use condom during their last sexual encounter were at moderatehigh risk of contracting stis hiv despite widespread knowledge that condoms offer protection against the diseases when used correctly and consistently as expected more of the behavioral variables were associated with epidemiologic risk than the selfperceived risk outcome however we noted significant independent associations between cumulative number of partners type of sex partner at last sex condom use at last sexual encounter duration since last hiv test drinking before last sexual encounter and the two risk assessment methods studies conducted in different cultures have similarly associated hiv risk with a wide range of variables 15 16 17 in subsaharan africa sociocultural norms and practices were identified as major determinants of sexual risktaking behavior 33 based on epidemiologic assessment personally knowing someone with hivaids significantly reduced the risk of contracting stishiv by 323 when compared to those who do not know someone with the diseases if participants are able to relate with those impacted by the disease it could help to create awareness about the consequences of hivaids disease thereby leading to safer sexual practices proximity to the disease has similarly been shown to be useful in educating others about the disease 3447 this finding confirms the wisdom of many community programs that utilize persons with hivaids to reach and motivate the community 6 also of interest was the highly significant moderatehigh risk associated with participants who were identified as receiving money drugs or gift for sex sharing needles to inject drugs those who had sex partner who used needles to inject drugs and where both partners were drinking before last sexual encounter this was not surprising because it is common to have restaurants and bars around military barracks in nigeria where alcohol and some time illicit drugs such as marijuana are sold such social environments also support the meeting of new partners with undisclosed hiv status and engagement in risky sexual behaviors such as unprotected sex which tend to increase their risk levels to maximum this scenario is also supported by earlier findings that alcohol and marijuana use are directly correlated with hiv risk perception among military personnel 911121435 such socioenvironmental characteristics have been associated with high hivaids prevalence rates 36 similarly mackellar et al 37 recorded in their study that participants who engaged in sexual and druguse behaviors and perceived themselves at moderatehigh lifetime risk were significantly more likely to have already acquired hiv this assertion may also apply to some participants that were at high risk of contracting stishiv in our study women in this group should therefore be encouraged to undertake a comprehensive stishiv tests to ascertain their serostatus we observed very low agreements between selfperceived risk and epidemiologic notion of risk in our study these further confirmed the optimism bias and gross mismatch noted between selfperceived and epidemiologic risk for contracting stishiv in our study population and support earlier researchers findings 25282930 therefore individuals perception of risk is not a reliable measure of the actual risk status among the female military personnel given that optimistic biases represent an underestimation of risk this may make the women less likely to take precautions to prevent the outcome from occurring in this instance any deviations from protective and health promoting behaviors are considered irrational and the product of the risk environment this may well be responsible for the long observed elevated risk of exposure to stishiv among nigerian military 6 7 8 9 11 in general the impact of hivaids among african militaries have assumed alarming dimensions with prevalence rates of between 58 and 267 reported in selected countries 10 the public health implications of the accuracy of individuals risk perception also highlight the importance of improving and expanding access to stishiv testing counseling and treatment among military personnel in nigeria and indeed in subsaharan africa militaries individuals knowledge of hiv transmission and accurate assessment of risk seems to be among the key factors in adoption of safer sexual practices 38 39 however this was not the case in our study as we noted highly significant variations by sociodemographic characteristics in the proportion of the participants who were able to accurately estimate their risk levels through selfperception inaccurate risk perception by participants was therefore considered a barrier to undertaking protective forms of behaviors and safer sex that could help them reduce the risk of contracting stis hiv the increasing trend in accurate assessment of risk with increased age in our study may be related to the fact that increased age brings about maturity in cognitive abilities coupled with sexual experiences and increased knowledge of stishiv risk behaviors leading to rational perception and ultimately to realistic risk assessments similarly our study revealed that educational levels played a significant role in accurate perception of risks and increased from 304 among women with primary school education to 570 among college graduates the level of education possibly increases response to prevention messages and increase knowledge and understanding of all forms of protection and barriers 4546 these could also enhance individuals sense of efficacy and control leading to a more accurate perception of risk for acquiring the disease our results further showed somewhat significant decreasing trends in selfperceived and epidemiologic risks with increased annual income of participants and conversely increasing trends in accurate risk assessments with increased annual income since income levels are often linked to educational attainments higher annual income would imply an improvement in the standard of living of participants leading to interest in ascertainment of hiv serostatus through testing acquisition of stishiv knowledge adoption of protective measures and accurate perception of risk in the current study while single women were able to closely perceive their risk levels only 382 of legally married women correctly perceived their actual risk levels these findings have great implication for prevention strategies in the subpopulation especially as this route is where majority of the hiv transmission takes place although unprotected sex among married couples is the cultural norm many married women and men in nigeria engage in unprotected extramarital sexual relations thus exposing their spouses to high risk of acquiring stishiv infections 633 it is therefore important for women to accurately assess the risk associated with their relationships and to encourage condom use in all types of sexual relationships including consensual and legal unions 15 although condom use may signal mistrust especially among married couples addressing these issues and encouraging testing for married and regular partners during information and education campaigns should be considered an important part of stishiv prevention efforts race ethnicity may also influence sexual behavior through cultural beliefs and practices our study demonstrated that participants who were of ibo tribe closely perceived their risk levels with 528 accuracy compared to the hausas similar racial and ethnic variation in risk perceptions have been reported among adolescents in south africa 29 furthermore the fact that participant of hausa tribe were less likely than theyorubas and ibos to have used condom during their last sexual encounter also underscore the fact that this group may be at elevated risk of contracting stishiv infection our results suggest that education and prevention programs should be knowledgebased driven and culturally sensitive and be specifically targeted at military women from the major races ethnic groups in nigeria especially those from hausa tribe we noted that different set of covariates tend to shape the risk landscape based on the two assessment methods except for condom use at last sexual encounter and duration since last hiv test which were significant contributors in both selfperceived and epidemiologic stis hiv risk models the low predictive value of selfperceived stishiv risk model compared to epidemiologic stishiv risk model implies that other confounding covariates not identified in the current study may be associated with selfperceived risk in the population we noted that women who were muslims were more at moderatehigh risk of acquiring stishiv infection than christians an observation that was further reenforced by the 115 improvement in accurate risk assessment by female personnel who were christians compared to their muslim counterparts our finding corroborates with those of bekele and nichols 44 who reported that muslims had higher risk of contracting hiv infection compared to christians among african immigrants living in new york city our result underscores two points first the need to take into account religious background when designing educational interventions for military women and secondly the need to intensify the involvement of religious authorities in stishiv prevention efforts at military community levels the general protective effects demonstrated by the selfperception model in our study may have a negative impact on the prevalence rates of the diseases among nigerian military this is because with sexual behavior being likely based upon subjective perceptions of risk rather than actual risk the women may continue to feel invulnerable to stishiv infection thereby treating such as distant possibility despite their continuous involvement in highly risky sexual behaviors the high predictive value of the epidemiologic notions of risk model indicates the importance of integrating the associated covariates in stishiv prevention intervention programs targeted at changing individual risk behaviors and perceptions as well as the social contexts in which risky behaviors occur in the military population for instance while condom use at last sexual encounter was protective under selfperceived stishiv risk model participants who did not use condom during their last sexual encounter under epidemiologic stishiv risk model were four times at moderatehigh risk of contracting stishiv than those who used condom it is a common practice among most nigerians to use condom on new or casual partners csws or at risk individuals than for regular partners 6719313339 this practice may be linked to our current finding that encounters with casual sexual partners were considered less riskier than those with noncasuals and resulted in protective odds effect this is because the women might be tempted to underestimate the risk posed by their spouses or regular partners based on their expectations of mutual fidelity while actual risk may be elevated among such women due to the risky sexual behavior of their partners 39 despite widespread awareness and availability of condoms several reasons have been reported to hinder its use 6161939 when used consistently and correctly condoms are highly effective in preventing the sexual transmission of hiv infection and reduce the risk of other stis 15163940 however it is important to mention that our study findings may be confounded by the fact that no distinction was made between condom use for pregnancy prevention and those for protection against stis including hiv thus warranting caution in interpretation at the personal level perceived risks and costs of hiv andor pregnancy should determine contraceptives use among married couples and sex partners therefore prevention programs have an important role to play in creating greater awareness of the risk of hiv infection within marital and cohabiting relationships among nigerian military population although at the initiation of the study participants claimed to be hiv negative we noted that epidemiologic risks of acquiring stishiv infection was significantly associated with increased duration since last hiv test from less than or equal to 3 months to greater than 12 months mackellar et al 37 similarly reported the tendency for their study participants to underestimate current or future hiv infection risks following their perceptions on prior negative hiv test results consequently it may be important to provide voluntary counseling services to the female military personnel and to emphasize to them that a negative test result offers no assurance that one will remain free from hiv infection we demonstrated that epidemiologic risk increased significantly with increasing number of partners from 368 with single partner to 833 for participants who had four or more partners participants with two and three or more partners were about 2 times and 14 times more at moderatehigh risk of contracting stishiv than those who had a single partner our study finding corroborates with earlier research studies where hiv risk perceptions have been reported to be strongly and significantly associated with multiple partnerships 3941 the use of alcohol or other drugs has been proposed as a contributing factor to sexual risktaking and may also be one of the most common and potentially modifiable hiv risk factors in our study population our finding supports this proposition with single and both sexual partners drinking being 4 and 12 times more likely than participants for which neither of them was drinking to be at moderatehigh risk of contracting stishiv respectively this is because alcohol and drugs are thought to interfere with judgment and decisionmaking other research studies 93541 have similarly demonstrated that alcohol and drugs use in conjunction with sexual activity increases the probability of occurrence of risky behaviors thereby inhibiting the practice of safe sex thus our finding in conjunction with those of others emphasizes the need to integrate alcohol abuse policy in hiv prevention efforts in the nigerian military and elsewhere another key finding of this study was that having knowledge of someone with hivaids had a significant positive influence on the military womens risk status it is possible that personal knowing someone infected with hivaids makes risk of the disease seem more real thereby causing participants to curtail their involvement in risky sexual behaviors for fear of being a victim our proposition is sustained by palekar et al 47 report of a positive behavioral change among south african youth following knowledge of someone who died of aids thus personally knowing someone with the hivaids disease may increase awareness about hiv risk to untested individuals leading to greater uptake of voluntary hiv testing and counseling and changes in hiv risk behaviors risk levels of participants who personally knew no one with hivaid significantly increased by eight times in our sample underscoring the impact that knowing someone with the disease may have in the study population therefore if the potential barriers and risk associated with disclosure 48 can be overcome knowledge of someone with the hivaids disease may constitute a powerful tool for an intervention program to change behaviors in the military social network as well as the community implications for stishiv prevention our study findings have several implications for stishiv prevention strategies in the nigerian military with special reference to female military personnel we found that the participants perception of risk was contradictory to their actual behaviors as indicated by their epidemiologic notion of risk with only 454 of the study population being able to accurately assess their stishiv risk status consequently prevention strategies aimed at individual behavior would only reduce partially the risk of acquiring and transmitting stis hiv and suggest that changing the contexts in which risky behaviors occurs may be more successful than attempting to change the way the women think about risk 42 many researchers agree that peoples perceptions of risk are based at least in part on factors that do not necessarily reflect objective reality or scientific fact 154243 however some researchers have identified structural realities as powerful drivers of the diseases spread and that these may substantially determine individuallevel risks for acquiring sexually transmitted infections including hiv 7264243 our results further demonstrate that correct assessment of risk is insufficient to guarantee the adoption of protective behaviors in the study population thus prevention campaigns should not only promote and foster changes in individual behaviors but should also address structural factors that encourage highrisk behaviors in the subpopulation the variation in correct assessments of perceived risk by sociodemographic factors reported in our study may be used as basic point of departure for designing effective militaryfocused health education campaigns with networklevel interventions for the specific subgroups taking into account the religious and cultural contexts sex rolerelation behavioral and social norms it is also important that the predictors of epidemiologic risk for acquiring stishiv identified in the current study population be integrated into future education and prevention programs to help reduce the spread of the diseases for instance since personally knowing someone with hivaids significantly reduced sexual risk levels prevention and intervention programs that create more open and less stigmatized environment where individuals can freely disclose their hiv seropositive status to family members friends and colleagues may help to increase perceived risk of stishiv such prevention andor intervention strategies need to support largescale military community risk avoidance as well as change individual behavior in addition longterm vision for reducing the diseases transmission should encompass programs for alleviating poverty gender economic imbalances policy changes including policies on alcohol and drugs abuse provision of free preventive services and community actions this framework may be useful because it shifts the focus of intervention from individuals to the social situations processes and structures in which individuals participate 43 we therefore conclude that the stishiv epidemic dynamics in the nigerian military population seem to suggest a mixed landscape the epidemic may be dynamically driven by personal decisions as well as the influence of community level norms and practices and structural factors such as laws military actions economic conditions and wider cultural beliefs 43 leading to the discrepancies observed in our current study between selfperceived and epidemiologic notions of risk therefore perceptions of risk and actual correlations to behaviors need to be further examined in this population preferably through mass stishiv testing and counseling program the biological data obtained from such intervention programs would serve as reality check and facilitate the adoption of optimal prevention strategies and treatment options for infected persons in addition knowledge of ones hiv positive status can lead to change in behaviors to protect other people from being infected in these regard identifying social cultural and structuralenvironmental factors that facilitate risk would be an important step in addressing the sexual health problems of the female military personnel and indeed the military population in nigeria and other subsaharan african countries

this study examined the sociodemographic and selected behavioral characteristics associated with selfperceived and epidemiologic notions of risk for acquiring stishiv infection using data from a crosssectional survey involving 346 consenting female military personnel from two cantonments in southwestern nigeria findings revealed significant discordance in participants risk status based on the two assessment methods with kappa coefficients ranging from 0021 to 0115 using epidemiologic assessment as the gold standard 454 of the study population were able to accurately assessed their risk levels through selfperception with significant p≤01 sociodemographic variations multivariate logistic regression analyses indicate that stishiv risk models using both selfperceived and epidemiologic notions of risk were significantly determined by different set of covariates it is recommended that stishiv prevention intervention should integrate the identified covariates and be targeted at changing individual risk behaviors and perceptions as well as the social contexts in which risky behaviors occur in the military population

wolves and biodiversity hypotheses facts and reasons for an ongoing debate i introduction fear of a major humandriven species annihilation looms as a major crisis however the restoration of deer to abundant population levels in the northern hemisphere and the recolonization of lost ground by wolves their main predators have not resulted in relief but in conflicts and controversies around their interactions with their environment each other and humans these conflicts challenge us to think hard about what we value in wildlife for deer eg nelson and moss for wolves nie and hermann voß menzel here we review the ecological and sociological costs and benefits that have been identified as accompanying the recovery of these species in a synthetic effort to understand the underlying reasons for conflicts and controversies and to highlight questions to be addressed to help resolve the challenges we face when deer wolves and people and their livestock live together deer and wolves the consequences of a shared history we label deer herbivores because they are highly adapted to find ingest and digest a range of woody browse and herbaceous species but viewing deer only as plant consumers ignores millennia of additional selective forces that have moulded them historically deer have shared habitats with wolves cougar and other predators perceiving deer only as plant eaters seeking to maximize food intake neglects this shared history and its impact on deer bodies and behaviour from studies in places where wolves persisted we know their importance in deer population dynamics through the moulding of their lifehistory and population growth characteristics we can also infer the strength of these effects from the fact that bottomup effects of ecosystem productivity on deer populations are strongly damped in the presence of wolves these behavioural adjustments of deer trading off foraging for safety in the presence of wolves lead to nutritional costs and reduced impacts on vegetation this may be perceived erroneously as the result of a bottomup control of the ungulate populations when predators are present spatial heterogeneity in predation risk can create a landscape of fear that affects the distribution and movement of deer how they forage and thus the distribution of herbivoresensitive plants across the landscape with cascading effects on other species in the absence of predators deer are more homogeneously distributed resulting in more intensive and widely distributed impacts as well as ecological homogenization although the historical proposition that predators reduce plant consumption by herbivores has been challenged recent research substantiated the idea that natural landscapes that have lost carnivores undergo substantial ecological changes the differences between natural landscapes with or without carnivores may be perceived as positive or negative depending on the particular impact and on the perspective of different human stakeholders wolves and humans a complex relationship the relationship between wolves and humans has a long and complex history in many societies observations of and interactions with wolves led to cultural learning in humans lescureux linnell and references therein potentially leading to respect humans also often recognized that like us wolves cooperate in hunting and care for their kin human attitudes towards wolves also were shaped by the multifaceted interactions among geography history beliefs and culture including the local history of interaction between wolves and people boitani mech boitani lescureux linnell moriceau and references therein hunters nomadic or sedentary shepherds farmers and urbanites have all developed idiosyncratic and sometimes deeply contrasting attitudes towards wolves attitudes that shifted with context place and time lescureux linnell shifting baseline sensu pauly in most human societies sharing wolves original range wolves occupied a special place they were associated with the warrior class among indogermans and inner asians in roman mythology a shewolf nursed and saved mars twin sons in the caucasus wolves were seen as a symbol of strength independence and freedom this contrasted with their perception as evil and cruel by the zoroastrian pastoralists who nevertheless showed great reverence for its domesticated kin the dog in western cultures strong attitudes against wolves have been and still are prevalent the status of wolves often contrasts markedly with the status of most other large mammals and especially with attitudes towards domesticated wolves indeed thousands of years ago the special humanwolf relationship brought wolves into the human family as dogs for good and bad since this distant past the advent of livestock herding motivated the eradication of wolves from many landscapes they once shared with us today wolves are still among the few animals for which national parks do not necessarily provide a safe haven from legal hunting or culling even in europe and north america where they are legally protected in parts of the usa for example hunting for wolves can occur over extended hunting seasons with little bag limit and no restriction on killing animals with dependent young although such practices are widely accepted for many species considered as pests they breach accepted hunting ethics and regulations set for most wild animals challenges to be resolved across much of western europe and north america cervid ungulates became far more abundant during the 20th and early 21st centuries in response wolves where protected are making a comeback too but resurging populations of deer and wolves are coming into increased conflict with people especially farmers foresters shepherds or hunters they also generate conflict among segments of increasingly urbanized human societies we review the ecological and sociological challenges these shifts in distribution and abundance pose in particular how and why deer and wolves have shifted in distribution and abundance historically the ecological consequences of deer and wolf recovery the social and socioeconomic consequences of large deer populations and of wolf recovery and finally the questions to be addressed to overcome the challenges posed by deer wolves and people living together ii deer and wolves from decline to recovery how and why did it happen historic declines between 1450 and 1900 whitetailed deer and mule deer populations in what became the usa declined from an estimated 40 million individuals to fewer than half a million in 1900 see mccabe mccabe webb and references therein this largely reflected unregulated commercial and subsistence hunting fuelled by a growing number of settlers by the early 20th century deer populations were extirpated or on the brink of extinction in many eastern states in europe large ungulate populations including deer had become similarly rare or extirpated in many areas by the 19th century in year 1500 an estimated 400 000 wolves probably coexisted with an abundant human population in what became the usa that number suggests that their prey must have been similarly abundant until european colonists transformed the continent in europe wolves remained widespread and locally abundant until the 18th century in the usa wolves declined to become extinct in 47 of the lower 48 states by the mid 20th century remaining only in northern minnesota in europe they were exterminated from most parts by the first half of the 20th century paradoxically wolves were extirpated earlier in the sparsely settled nordic countries yet retained viable populations in many mediterranean parts of europe despite a long history of dense human populations thus habitat loss scarcity of their natural prey and human hunting often organized at the state level have all contributed to these declines deer recovery today a mere century later over 30 million whitetailed deer alone inhabit north america the 20th century also witnessed similar increases in deer abundance and distribution across europe over 10 million roe deer inhabit western europe not counting other ungulates which have also increased in scotland the red deer population has increased to over 300000 individuals the current standing biomass of large ungulates in europe is estimated at 075 billion kg representing a consumption of approximately 20 million tonsyear of green vegetation we are uncertain about the degree to which bottomup versus topdown trophic interactions contributed to these dramatic increases in deer populations the extirpation of most deer predators certainly alleviated direct pressure on deer populations and altered deer behaviour at the same time however major changes in habitat and human land use occurred eg see fuller gill côté et al milner et al and references therein active forest management created abundant early successional habitat edges and fragments which together boosted deer abundance changes in agricultural land use including increased plantings of winter crops and reversion of abandoned fields to forest supported higher deer densities milder winters and developing suburban areas interconnecting unhunted green spaces also contributed as has winter feeding of deer the result of these changes together with favourable legal dispositions has been spectacular continentscale recoveries of deer populations for a uk historical perspective on legal status and trends in deer populations see phillip et al these count as significant wildlife conservation success stories ironically we now see an excess of success as deer have become overabundant across much of their range their abundance has become a challenge to wildlife managers in large parts of north america and europe and legislation designed to protect deer may today conflict with the recognized need to manage their populations it has also led ecologists to investigate the downstream effects of such recoveries on landscapes and ecosystem functions 3 wolf recovery the late 20th century saw the restoration and expansion of several large carnivores across western europe we now tally 12000 wolves distributed in 10 populations spanning 28 countriesa major conservation success this reflects increased prey abundance and effective protection in the form of europes 1979 bern convention this recovery took place despite significant increases in europes human population with intensified land use in many regions coupled with large areas where agricultural lands were abandoned as for their decline wolves recovery has been most successful in rural areas of southern europe but slower or nonexistent in more natural less roaded areas of northern europe as for deer it resulted from a combination of changes in legal status hunting regulations and attitudes in the usa wolf population recoveries occurred across the western and midwestern usa while they were protected under the usa 1973 endangered species act however wolf recovery proceeded at a slower rate and to a lesser degree than deer recovery in europe and the usa it was slowed by legal and illegal hunting and in places by major roads and other human disturbances for the upper midwestern usa see thiel mech et al and mladenoff et al for spain see blanco cortes iii consequences of deer recovery positive and negative perceptions an assessment in progress how has the recovery of deer populations across north america and europe affected people in managed or nonmanaged ecosystems we can categorize perceived consequences of higher deer densities as either beneficial or detrimental how these are viewed often depends on context many celebrate the benefits that deer provide these include opportunities to view and appreciate deer now the commonest wild large mammal in many areas in north america observing wildlife has become increasingly popular deer hunters also exist in great numbers spending considerable time and money to hunt a game species they cherish most directly deer provide food to hunters venison remains popular especially among a newer clientele of hunters eager to obtain and share supplies of lean organic meat many hunters however prefer to hunt large bucks for the challenge this provides although hunting represents a sizeable industry in the usa with 115 million hunters spending 256 billion this segment underwent a 29 decline between 2011 and 2016 in the same period wildlifewatching grew rapidly with expenditures rising 28 to 76 billion while hunters and wildlife lovers welcome abundant deer for these obvious benefits many farmers foresters gardeners and public health officials have begun to focus on potentially negative effects of high deer densities our knowledge of the range and extent of these effects has emerged slowly and remains incomplete although often obvious to specialists many of these effects are far from evident to the general public and correspondingly neglected by those charged with managing deer populations a complication is the differences in attitude between specialists and the general public even when there is agreement on impacts being negative finally it is difficult to find quantitative estimates of likely cumulative ecological and economic impacts of deer and we are not aware of previous efforts to enumerate them comprehensively direct and indirect effects on forest ecology several factors can limit deer populations including harsh winters predationhunting and disease in the hypothetical absence of these factors deer populations are mainly controlled by the food available when deer first colonize a forest devoid of large herbivores the standing biomass of these resources is likely to be substantial this biomass decreases if deer consume more than the yearly plant growth starting with the most palatable species this can eventually lead to a situation where deer populations remain abundant in strongly altered understories in such situations resources are consumed as fast as they appear but little biomass accumulates the impacts of abundant deer on vegetation can be dramatic they include direct impacts on tree regeneration that act cumulatively over successive decades on multiple species to shift overall recruitment and forest composition deer also shift forest understories towards lesspalatable species that resist or tolerate herbivory while reducing understorey cover and diversity these direct impacts in turn trigger a cascade of indirect effects on invertebrates as diagnosed in several biomes around the world vertebrate communities are similarly affected most noticeably songbirds that nest on the ground or in the understorey and for most species depend on invertebrates to feed their young the most critical evidence for these effects comes from studies where longtermhistorical data are available in areas of contrasting browsing history we know less about how deer affect belowground ecosystems nevertheless one survey in the usa used 27yearold fenced exclosures to document that deer increased soil compaction while reducing mean plant height cover diversity abundance tree growth and recruitment and mice and tick abundance drastic reductions in deer abundance can reverse many of these effects although change can be slow partial recovery takes decades for the understorey and necessarily even longer if the overstorey has been affected after a time lag increased cover in the understorey vegetation allows animal communities that depend on such cover to increase as well costs to forestry and agriculture although the ecological effects of deer on forestry and agriculture have been well documented aggregate estimates of the monetary costs of deer impacts to economic sectors like forestry and agriculture are scant the limited information available however suggests that costs are significant in the usa the cost of protecting seedlings from browsing exceeds 500ha in poland the protection of seedlingssaplings against browsing summed to an estimated €1115m euros in 20022003 annual deer damage to forestry costs an estimated €218m in austria €32m in finland and €585000 in hungary in sweden impacts of moose on pine wood quality was at least €50myear in 2005 in addition to their impacts on forests deer often damage agricultural crops damage that can be significant when their populations are high in france costs to agriculture per year were estimated at about €20m in 2004 against €026m for finland in 2006 and €100300000year in slovakia in 20012005 representing costs of about €710 ha for france and of €111410 ha for finland and slovakia costs to human safety and to human and wildlife health high deer populations can also compromise human safety and health as for other sectors we lack systematic compilations of these costs but the examples below illustrate how varied and substantial these can be deervehicle collisions every year many people are injured and some killed by hitting deer with their motor bikes cars trucks or even aeroplanes deervehicle collision risks reflect traffic volume as well as deer densities interacting with local factors across the whole usa there were an estimated 123 million deervehicle collisions between july 2011 and june 2012 killing about 200 people and causing more than 4 billion in vehicle damage in canada in 2000 29000 collisions occurred 23 people died and 1887 were injured in pennsylvania the usa state with the most deervehicle collisions 115000 collisions occurred in 2013 causing about 400 million in property damage individual states in the usa midwest estimate 4060000 such accidents per year typically injuring over 100 people sometimes causing deaths and incurring tens of millions of dollars in medical and property damage in the uk property damage from deer collisions is about €25m per year in germany every year 200000 roe deer collide with vehicles resulting in 50 people killed and 3000 injured the overall cost is about €490m collision costs are estimated at €100myear in france and €163myear in finland for europe overall costs to repair damaged vehicles are estimated to be over €1billion more unexpected between 1990 and 2013 there were 1088 collisions between planes and deer spp elk moose or caribou with most involving deer one person was killed and 29 injured plus appreciable property damage to the planes diseases associated with high deer density diseases associated with high deer densities are increasing in number and severity in both human and livestock populations human diseases borne by ticks that feed on deer include lyme disease babesiosis and erhlichiosis transmitted by blacklegged and lone star ticks in north america lyme disease is now the most prevalent contagious disease in the usa with 2000030000 cases reported annually reflecting a probable overall incidence of 300000 new cases each year according to the center of disease control and prevention chronic cases are debilitating and require protracted treatment in europe more than 65000 cases of lyme disease are treated per year a recent report suggests that lyme incidence in england may be three times higher than previously estimated babesiosis like malaria attacks red blood cells and can be fatal if not treated promptly it emerged recently and is now established in seven usa states that also do these alarming increases in serious tickborne diseases reflect or merely coincide with rapid recent increases in deer populations this question raises controversy with different studies coming to different and sometimes conflicting conclusions some consider deer populations as inherently unlikely to affect lyme incidence because deer rarely provide competent hosts for the borellia bacterium that causes it because deer boost tick populations however with a mature female laying 2000 eggs dense deer populations multiply the number of vectors making tick bites more likely similarly the complexity of ixodes tick life cycles with multiple mammalian hosts typically chipmunks whitefooted mice and deer in eastern north america each responding in its own way to variation in food resources predators and borrelia infections leads to complex interactions complicating our ability to tease out causal effects fragmented forests can also boost the density of nymphs infected with lyme disease these complexities generate variation in how deer densities affect lyme disease prevalence across ecosystems and time despite these complexities several studies suggest that dense deer populations foster higher tick populations increasing the risk for diseases like lyme many have noted the striking geographical coincidence of high deer and tickborne disease levels because these might be dismissed as correlative and misleading however rigorous studies that experimentally reduce deer populations are more definitive one of these showed that experimentally reducing deer numbers substantially reduced tick abundance with nymphal burdens becoming unrelated to habitat structure once deer were removed several studies have now linked densities of ticks andor lyme disease incidence to the abundance of whitetailed deer including at fine geographic scales studies that failed to find relationships between deer density and lyme incidence tend either to be nonexperimental or to involve limited reductions leaving deer above a threshold density such threshold effects do not allow us to conclude that deer abundance is unrelated to disease incidence given the rigorous experimental evidence now available this includes a study in connecticut where the incidence of lyme disease was strongly correlated to ambient deer densities a hunt there reduced deer density to 51 deerkm 2 reducing tick abundance by 76 exposure risk by 70 and the number of reported cases of lyme disease by 80 the studies reviewed suggest that the high deer densities prevalent in most of europe and north america even under conditions where deer are not considered competent hosts for the disease potentially contribute to the dramatic increases in serious human infectious diseases by increasing parasite vector densities and perhaps the frequency of coinfection although fragmented forests and climate change have clearly also played a role our primary option for ameliorating the risk landscape is to reduce deer density telford also emphasizes that arguing against deer reduction as a way to control tickborne diseases conflates its potential efficacy with sociopolitical obstacles to reducing deer numbers high deer densities are also associated with disease outbreaks in deer themselves other wildlife species and domestic livestock the first reported outbreak of bovine tuberculosis in deer was associated with high deer density increases in supplemental feeding enhanced epidemic transmission rates leading to a ban in that part of michigan on such practices fallow deer and red deer in sw england and wales have also tested positive for bovine tb the deer initiative 2009 high deer densities also negatively affect other species by propagating disease for example whitetailed deer sustain reservoir populations of a meningeal parasite that acts as a nonfatal heartworm in deer but as a fatal brainworm in larger ungulates like elk moose and caribou in northern minnesota where moose populations declined precipitously since the 1990s necropsies reveal that this parasite infected 45 of 54 moose evaluated such findings support recommendations to limit deer densities in areas where managers are seeking to reestablish elk and moose finally chronic wasting disease a spongiform encephalopathy similar to mad cow disease and creutzfeldtjacob disease in humans is spreading rapidly across the usa and now in parts of europe it is caused by prions that are taken up in plants and can persist in the soil for long periods in the usa it was originally endemic to a few western states but has broken out repeatedly in areas of high deer density usually in association with game farms andor supplemental feeding efforts to contain such an outbreak in wisconsin in 2002 failed cwd has continued to increase in incidence and spread to neighbouring counties and states despite intense initial efforts by wildlife managers to reduce local deer densities and ban hunters from baiting and feeding deer these efforts generated a strong backlash against the agency leading to the reversal of some efforts and continuing spread of the disease cwd has also spread to other states and canadian provinces deer with cwd also pose risks to other deer species eg to wild reindeer in europe and potentially to livestock these results make clear that high deer populations in many regions generate high costs in terms of human wildlife and livestock health property damage agricultural and forestry losses and a complex set of threats to ecosystem services and biological diversity true comparisons of costs especially those related to the loss of life and benefits are difficult to assess in comparable terms nevertheless the marginal benefits of adding more deer for possible increases in license revenues and commercial activities from huntingan estimated 100 billion in the us in 2001 may be less than the cumulative higher costs these high densities now generate despite increasing research in this domain the full range and significance of deer impacts remain unknown and unquantified they are certainly obscure to most citizens who may only see a few of these this selectivity of vision is exacerbated by the fact that those with special or limited interests can be expected to emphasize those particular benefits or costs of most interest to them the fuller accounting of deer costs and benefits presented here should not be interpreted as pointing a finger at deer rather the objective is to highlight the many ramifications of a situation where little topdown control is exerted on an herbivore that evolved in a world with carnivores this evolution resulted in deer gaining reproductive and foraging efficiencies sufficient to withstand the predation risks faced to enumerate fully the costs and benefits that populations of wolves and other predators provide to humans we must include in our reckoning how these predators act to limit deer numbers and their impacts iv consequences of wolf recovery with abundant prey available and legal protection wolves have expanded in range and population in many regions recovering wolves attract public attention for their own sake and for their impact on domestic flocks of livestock wolves are also animals that have been and are still able to threaten humans directly by contrast the public rarely considers how wolves might benefit humans and natural ecosystems by mitigating undesired ecological agricultural forestry and societal consequences of dense deer populations wolves and biodiversity hypotheses facts and reasons for an ongoing debate restored wolf populations can provide important gains for biodiversity by limiting the density of deer or other wild ungulates positive indirect effects of wolves on understorey vegetation have also been documented in the midwestern usa cascading positive effects on other trophic layers can follow but these have not yet been fully investigated and remain debated indeed debate continues to surround the question of whether wolf populations tend to reflect ungulate abundance or whether predation from wolves controls ungulate abundance the latter hypothesis is gaining support this debate parallels the longstanding controversy over whether herbivores control the abundances of individual plant species within a community or whether the plant community controls herbivore abundance these questions regarding the importance of topdown versus bottomup trophic control have puzzled ecologists since the advent of ecology we think there may be three main reasons why controversies persist over trophic cascades the first concerns the fact that ecologists often prefer to focus on what they consider equilibrium conditions rather than transient population dynamics without changes in population however the cause of such perceived equilibria are rarely clear when they do exist regulated populations of deer for example could reflect finite resources in the form of woody browse and the forbs and grasses that deer prefer to eat in spring and summer or the presence of human control by hunting andor wolf predation without a perturbation of some kind it is difficult to infer why stability persists a second reason concerns the need to distinguish just how prey and predators interact it is easy to see how higher numbers of predators like wolves might directly reduce the number of prey like deer and that lower deer abundance in turn could increase plant abundance it is uncertain however if when and where wolves will recover to densities at which they can have meaningful consumptive effects on their abundant prey in landscapes that are increasingly anthropized consumptive effects can however be complemented or even outweighed by nonconsumptive effects prey respond to predators and in particular change how they use the landscapethe places and time they spend foraging this is the landscape of fear idea of laundré et al this affects where deer spend their time which plants they eat how thoroughly they exploit one patch before moving on to another and ultimately their nutritional status we can thus envision situations where the presence of wolves protects many plant populations by limiting local andor total rates of herbivory or by reducing how selectively deer forage these risk effects importantly may depend less on predator densities than on predator presence and act even when predators remain too scarce to limit prey numbers directly a third reason for controversy is that plants may increase the amount of chemical defences in their leaves or stems in response to herbivory or the presence of chemical signals associated with herbivory in nearby plants such induced defences thus reflect a response to the local presence of an herbivore that may or may not translate to a numerical limitation on its abundance depending on the local availability of alternative food sources ford goheen proposed a gold standard for accepting when a trophic cascade is acting this standard requires that one simultaneously shows that wolves constrain or reduce the abundance of deer that deer constrain or control the abundance of the plants they eat and that more abundant wolves favour more abundant populations of the plants deer eat having to show all three of these effects at the same time sets a high bar for demonstrating a trophic cascade however as it will prove difficult to demonstrate the action of all these forces simultaneously this might still provide a reasonable standard if all three processes are always evident whenever trophic cascades occur more realistically however one or more of these numerical responses could be hidden or difficult to demonstrate due to nonlinear and transient dynamics in the system for example the impacts that deer are having on many plant populations or on the understorey as a whole may be hard to detect for years as deer populations gradually increase reducing the density and relative abundance of certain species progressively until a tipping point occurs when herbivory by deer suddenly greatly reduces or eliminates local populations of favoured species augustine frelich observed such effects in laportea only at this point can we easily observe how sensitive the plants population is to deer herbivory beyond this point deer impacts would again disappear as these plant species become too scarce to detect deer effects as noted for palatable tree saplings by bradshaw waller deer adjust by shifting to lower quality forage recovery of the plant population rarely retraces the initial trajectory both because depleted plant populations provide few seed sources and because selective foraging by deer targets scarce palatable seedlings impeding recovery this again narrows our ability to detect deer impacts to a small part of parameter space trophic cascades commonly exhibit such ecological hysteresis thus even though all three elements in the cascade could be acting and important it may prove difficult or impossible to demonstrate all these interactions at once this greatly constrains our ability to meet ford goheens rigorous criteria this is especially true when we lack observations spanning longer time scales and wider ranges of deerwolfplant densities the benefits of wolf recovery given that dense deer populations threaten the diversity and regeneration of forests agricultural outputs and human and wildlife health we predict that restoring wolf populations would reduce these impacts that is if wolves limit deer numbers and impacts their presence could have high economic value lacking integrated economic assessments of deer impacts we also lack reliable estimates of these potential benefits the yellowstone studies suggested that wolves acted indirectly to modify deer behaviour reducing their impacts on vegetation these results were challenged to conclude that the yellowstone data have been overinterpreted however recent studies in the upper midwest of the usa documented convincingly and in their own right that wolf presence enhances the magnitude and spatial extent of tree regeneration and plant diversity in forest understories these studies suggest that yearround stalking and hunting by wolves acts both to reduce deer populations and to modify the spatial distribution of deer browsing impacts their interpretation was that deer that are wary clumped and moving frequently might be browsing less exhaustively on palatable species reducing impacts on these plant populations these effects likely also depend on the history and characteristics of local wolf populations and on how humans modify the landscapes in which these interactions occur positive effects of wolf recovery to local economies have also been investigated in the greater yellowstone area the presence of wolves increased park visitation by about 4 adding 35 million to the local economy yellowstone of course is already a famous national park with many other attractions nonpark regions that lack clear sight lines and ample wolf viewing opportunities are less likely to benefit to the same degree especially if the local attractiveness of wolves for tourists declines as wolves become more common nevertheless protecting carnivore habitat has been positively linked to the economic development in several communities can predator presence partially mitigate impacts of high deer densities on human safety or property we have few studies on wolves influence on deervehicle collisions but see chapter 2 in raynor for a first assessment of a mitigating effect by wolves but gilbert et al assembled evidence that cougars recolonizing the eastern usa for another 30 years could reduce deervehicle collisions by about 22 preventing over 20000 human injuries 155 fatalities and 2 billion in costs adding in the value of avoided wildlife and human diseases or of reduced damage to forestry and agriculture that would result from lower deer densities might increase the potential value of predators by several times this such benefits of wolf presence on wildlife disease control have been recently documented in bhutan a study showed that the presence of an apex predator the tiger had indirect economic benefits through reduced losses in crops or livestock this benefit however must be balanced against the losses of human lives tigers can cause another study in india documented that the presence of leopards had indirect benefits to public health such savings of life and property should be visible enough to bear on public discussions and decisions about how we manage wildlife better assessing the nature and extent of such beneficial effects in the context of recovering wolf populations in europe and north america is challenging but needed 3 the costs of wolf recovery wolves have direct economic impacts on livestock farmers but incur little or no costs to urban citizens the costs of wolf depredation to livestock in the greater yellowstone area is estimated to be 64000year for a population of 300 wolves or about 210wolfyear costs to livestock breeding have been estimated in other contexts these analyses generally suggest that the direct economic costs of depredation by wolves are minor for the livestock sector as a whole but often substantial for individual livestock breeders these costs also extend beyond the simple market value of losing individual animals to include the sunk costs of past breeding efforts not all livestock breeders are concerned by wolf attacks depredation of livestock varies with livestock species and breed wolf impacts tend to be relatively more important for sheep breeders grazing extensively in seminatural habitats and disproportionately more costly for smallscale sheep breeders whose flocks graze outside in bushy or forested areas costs are generally higher in places where wolves are coming back where livestock may represent up to half the prey items taken during the grazing season in other contexts wolves feed mostly on wild prey with livestock representing 5 of the consumed biomass once wolves become established livestock depredation increases when and where wild prey are rare where hunting and poaching reduce wild ungulate abundance wolves can consume 35 livestock this also increases humanwolf conflict in extreme cases where wolves have access to freeranging cattle during the grazing season the frequency of livestock in wolf scat can reach 45 and 74 of the biomass consumed beyond these economic costs is the underlying perception by the rural people affected that the wider society imposes the recovery of a predator onto them and has little regard on their role or function in society and their values the size and strength of wolves also make them a potential threat to human lives loss of human lives to wolves in the past has been thoroughly and critically examined they were often linked to wolves infested by rabies in contrast to what has been done for other species like brown bear little effort has been made to study the conditions for wolf attacks on humans to occur in the current context and even more so on how to respond in such an event to minimize the risk of a fatal outcome part of the reason is the current relatively rare incidence of attacks on humans in europe and north america compared to fatalities caused by other wild animals or even by domestic animals such as dogs which caused an average of 17 human deathyear in the usa and in excess of 1 deathyear in canada over study periods spanning two or more decades as with benefits wolves have many indirect costs that in aggregate could exceed their direct costs these include the increased costs in time money and energy that livestock breeders incur to defend their herds from wolves this additional workload extends to include psychological pressure when wolves return to an area livestock breeders must adopt new or abandon old practices if more animals are herded into smaller areas returning wolves could result in more overgrazing and soil compaction and undergrazing in other areas influencing both pasture quality and flora wolf attacks can also cause ewes to abort decrease milk production decrease appetite increase stress dismantle the flock structure and result in the loss of herding dogs financial compensation for livestock destroyed by carnivores is usually met favourably but its effectiveness has been questioned for herders accustomed to freeroaming husbandry in seminatural landscapes the return of wolves imposes a new external cost rarely acknowledged by those favouring the restoration of wolf populations the uneven spatial distribution of these costs is another level of uncertainty it could however become an asset to help identify means of coexistence by analysing the mechanisms at work in areas with low or negligible losses hunters often claim that wolves reduce deer harvests such claims may be reasonable if wolves act to reduce deer densities substantially or if deer made wary by wolves are more difficult to shoot wolves were estimated to reduce deer harvests by hunters by 530 in the yellowstone ecosystem appreciably less than was anticipated direct effects of wolf predation on prey abundance has also been studied in polands biełowieża forest there wolves killed and consumed on average 127 large ungulates per year versus 309 shot by hunters these combined losses reduced ungulate populations by less than 10 a value deemed unlikely to reduce hunting opportunities similar impacts and figures appear for north america studies that explore the relative effects of wolf predation climate and hunting on prey populations often conclude that observed declines in deer populations more often reflect human harvest pressure than predation the impacts of wolves on deer populations also reflect habitat productivity and the harshness of winters an intriguing ecological model even goes so far as to suggest that despite the tendency for returning wolves to initially depress deer densities resulting improvements in habitat conditions could boost resource levels enough to favour longterm recovery in the deer population as deer growth and reproduction improve thus deer could recover to densities similar to those without wolves as overall ecosystem productivity improves wolves would then check further increases in deer density preventing excessive browsing and sustaining high productivity such exercises emphasize the need for a longterm perspective and a deep understanding of underlying ecological dynamics v challenges and ways foreward asymmetries in costs and benefits thus far we have documented that both deer and wolves can be seen as either beneficial or detrimental depending on the context and who is viewing them can challenges in living with deer or wolves be overcome by more completely identifying and tallying economic costs and benefits at the moment we see little effort to aggregate the economic costs and benefits of deer or wolves to encompass larger scales or longer periods a search for consensus on how to live with deer and predators is further complicated by the unequal distributions of costs and benefits that individual stakeholders experience this unequal distribution can accentuate extreme feelings and misunderstandings about deer or wolves for example stakeholders directly suffering from deer or wolves see clear benefits in reducing their populations farmers or foresters often suffer significant direct economic losses from abundant deer populations however farmers or foresters who hunt deer or receive revenues from leasing private or public land to hunters can be inclined to accept a tradeoff between having more deer and losing more from those deer the nature of this tradeoff deserves further exploration in the absence of associated benefits the notion of a tradeoff is beyond reach for livestock breeders andor hunters when it includes direct losses due to wolves or carnivores while direct benefits and costs from large deer populations are easy to perceive others such as their direct and indirect impacts on biodiversity or human health and safety are harder to quantify and reveal with wolves this asymmetry in perceiving costs and benefits is radical direct costs such as livestock destruction are easy to perceive they are economical and psychological benefits of restored wolf populations for biodiversity forestry tourism human health and human lives etc are all indirect difficult to assess and timeconsuming to identify and quantify they are thus easy to minimize or overlook the asymmetry in our ability to quantify and to perceive costs or benefits complicates any assessment of the full scope of the problem by stakeholders and the public it certainly plays a role in explaining why human attitudes towards deer or wolf recovery tend to be polarized opposing benefits of one species against the costs caused by the other this is amplified by the natural tendency of any given group of stakeholders to emphasize evidence that confirms their perspective while discounting or ignoring conflicting evidence acceptance versus conflict a matter of time place and species deer generally benefit from a broad level of sympathy across the general population however situations of high abundance especially in suburban areas and in areas with deersensitive crops together with an increasing awareness of the potential harm that high deer populations can cause to resources property health and lives has led to more contrasting attitudes towards their presence cognitive dissonance emerges starkly in a survey of pennsylvania hunters a vast majority of hunters acknowledged that high deer densities impaired forest integrity meaning that controlling deer populations was necessary to keep deer in balance with their food supply and with local plant and animal communities nevertheless a majority of these same hunters disagreed that deer damage to local forests was a problem instead expressing the opinion that deer populations were too low and that permits for antlerless deer should be reduced or eliminated in the same region a survey of agricultural producers and homeowners revealed a direct link between the level of damage they experienced and the perception of deer as a nuisance surveys of the general public showed strong support for deer abundance control to avoid threats to human health or safety or environmental damage but control was judged less acceptable when it was aimed at reducing aesthetic impacts or personal property damage among scottish recreational hunters resistance to regulating soaring deer populations a reluctance rooted in hunting tradition or personal preferences was reinforced by antipathy to conservationists these examples related to increasing deer populations illustrate how personal perspectives influence our ability to envision coexistence strategies based on objective analyses of costs and benefits lacking solid numbers for these costs and benefits only amplifies the importance of personal beliefs when it comes to the presence of wolves the level of conflict and tension is orders of magnitude more acute although a significant fraction of the population perceives their presence as positive those who most favour their presence are often those who interact the least with them positive attitudes towards wolves can decline once wolves become present in an area in a context of an increasing wolf population in the midwest usa attitudes of a selected group of citizens became more negative and fearful over time independently of having been subjected to wolf impact around yellowstone national park although no net change occurred in the generally positive attitudes people held toward wolves after their introduction attitudes became more polarized support for wolves especially decreased among visitors to the park who were hunters or ranchers in some instances however people initially unsympathetic to wolves developed more positive attitudes as their knowledge about wolves increased often via direct interactions with them the opposition to wolves based on livestock depredation recorded in the midwest usa contrasts with the tolerance towards black bears in the same region even though bears caused almost three times as much depredation to livestock paradoxically wolves were also the first species listed as endangered in the usa lethal control a source of conflict resorting to lethal control of wildlife is where opposition in opinions seems most acute culling wild deer in europe or north america often triggers strong reactions from stakeholders and the public whether individuals support or oppose deer culling often depends on their perceptions and the particular impacts being considered or on the ultimate cause of deer overabundance reactions to lethal wolf control are most polarized lethal control is seen as the only real option for some yet as totally unacceptable for others on the surface the rationale is to eliminate a competitor or taker of livestock or game when livestock depredation is the concern lethal control is often seen as preferable to prevention measures eg mech but see musiani et al gehring vercauteren landry gehring et al urbigkit urbigkit and degeorges lalo although its efficiency as currently practiced relative to nonlethal methods has been questioned and should be investigated further in herders the idea of lethal control often correlates with the notion of wolves not in my backyard emphasizing the local spatial component among politicians lethal control is often conceived as a means to increase tolerance but the emphasis can also be on controlling the development of poaching the potential for an actual opposing effect on poaching has been proposed but challenged for people who favour protecting deer and wolves as a coevolved interacting system or are in favour of more ethical relationships with nonhuman life control is perceived as another instance of abusive interference of humans with wild ie selfwilled nature where animals exist for themselves in their own right see foreman and morizot differences in values and the value of disagreement how opposing groups of concerned stakeholders interact will depend on the degree to which each group accepts and understands the challenges constraints and value system of other groups this can be made more difficult if opinion leaders use humanwildlife conflicts as a vehicle to promote their own political agendas ultimately resolution of these disputes will hinge on how much trust each group can grant to the knowledge of other groups somewhat counterintuitively developing such trust fundamentally requires that all stakeholders first agree on their disagreement rather than trying to resolve their differences in opinion prior to working together the recognition of fundamentally different viewpoints should be seen as a necessary preliminary step rather than making humanwolf conflict even more unsolvable assuming that all parties agree to respect their disagreements the common ground of accepted disagreement recognizes and bridges distinct world views providing the basis for working together towards the mitigation of specific and consensual problems posed by living with wild animals this collaborative process could over time erode entrenched emotions and opposing points of view and pave the way to less polarized attitudes by focusing on common visions obscured by distrust or patronizing eg see skogen 2003 or redpath et al 2017 andreferences therein for conservationists is lethal control of wolves acceptable if it aims at reducing the propensity of wolves to attack livestock could then become a valid question for herders how many losses from wolves compensated financially by tax money are acceptable when considering their positive effects on decreasing deer damage to society also could become an acceptable question for hunters it would be about defining an acceptable reduction in game abundance or accessibility in light of the costs of deer presence to agriculture forestry or public safety or in light of wolf sport hunting opportunities for politicians it could be to accept that the question is not a binary one as for example accepting or not the presence of wolves but of defining viable terms of coexistence as they do for example for another highliability component of our societies the individual car a need for a broader perspective controversies whether concerning living with deer or with wolves often seem bogged in essentialisms in the sense that species are seen as uniform entities in need of technical control rather than as an ensemble of sentient individual beings herders hunters environmentalists scientists tend also to be considered as uniform entities in which individuals are uniform vehicles of simple truths devoid of judgment autonomy to date the portraying of a radical headlock opposing herders to conservationists about the presence of wolves has occupied the frontstage and front pages while controversies about ungulate abundance were left backstage given the wide range of deer impacts their sometimes dramatic consequences on human lives and the potential for carnivores to limit these impacts we wonder why the legitimate concerns and distress of livestock herders or those of hunters so consistently capture the spotlight at some point the farreaching consequences deer have for land managers foresters health care providers the insurance industry and citizens concerned for their health and road safety must also count as well as the potential influence wolves may have on the above vi discussion top concerns for a way forward we have reviewed how the relatively narrow visions that often dominate debates over deer and wolf management neglect the intertwined consequences that concern much broader segments of society we suggest a corresponding need to consider a far wider set of perspectives as we address the questions of how best to interact with deer and predator populations the top concerns for future research on these questions should be to approach better in an integrative way the ecological and sociological mechanisms behind increases in deer populations the ecological and sociological mechanisms that drive changes in wolf distribution and abundance the full consequences on our lives of these related dynamics and how to maximize aggregate benefits and minimize the collective costs incurred when we interact with deer and wolves as parts of integrated ecosystems subject to longterm dynamics while an integrative approach in concerns and can build on a broad knowledge base concerns and will pose real challenges even in the acquisition of the basic knowledge needed for an integrative approach obstacles to overcome this broader and more integrated approach which we feel is still lacking both in the research political and public sphere will have to overcome the apparent entrenched attitudes and conflicting values attributed to what are perceived as opposing homogenous groups this would allow the ambivalence and mixed feelings running within these groups to emerge and enrich the debate despite and beyond the perceived need for loyalty towards social boundaries constructed to confront those perceived as adversaries it would also bring to the forefront the question of mutual respect and understanding of differences in values and opinions among those involved in short there is a need to make a better effort to costquantify the indirect effects of wolves and deer encourage conflict resolution by opposing sides respectfully accepting their disagreements and understand the cultural motivations of dislikes to work out the causal reason not the proximal reason for conflicts from conflict to coexistence we must acknowledge that people within different groups not only differ in the values they hold most dear but also that they bear different valued elements of knowledge that must be shared as we seek viable solutions if coexistence is the goal aimed for we need deer and wolves to persevere in ways that are compatible with human interests at the same time human interests would have to be conceived in ways that do not threaten the continued existence of deer and wolves morizot suggests that instead of focusing on one side over another we could instead focus on how to achieve a workable network of ecological and sociological interactions among these components steps towards a more balanced socioecological approach are emerging loud voices will continue to polarize the debate as changes in human attitudes and cultural learning take time but they do occur as these emerge our ecological interactions with deer and wolves will be reshaped vii conclusions historically deer and wolf populations in north america and western europe declined greatly until the 20 th century at which point they began to recover dramatically in terms of geographic range and abundance deer recoveries reflect scarce predators and dramatic changes in hunting policies and land use wolf recoveries reflect both legal protection and responses to rising deer numbers but remain less complete current high deer densities are having many ecological economic and social effects but these are perceived differentially by different stakeholders deer have both direct effects on tree regeneration natural vegetation and planted crops and many indirect effects via their impacts on plant and animal communities diseases and parasites of humans and wildlife and on vehicular accidents where deer populations lack control these collective and cumulative impacts can be large the recovery of wolf populations also has ecological economic and social effects that affect various human groups quite differently although controversies persist over trophic cascades wolves have considerable potential to mitigate negative impacts of deer via both direct effects on their populations and indirect effects on their movement and behavior topdown beneficial effects of wolves include their ability to mitigate deleterious impacts of deer on forestry agriculture tourism and natural ecosystems and to improve human and wildlife health and safety wolves might even relieve deer browsing enough to improve habitat conditions and actually sustain more deer such tritrophic cascades may be common but are difficult to detect and demonstrate sustaining controversies further controversy results from the fact that benefits from wolves are hard to measure and rarely fully accounted for meaning they are rarely weighed fairly against the more obvious impacts wolf populations have on certain rural groups dependent on livestock operations or deer hunting contrasting views on the relative costs and benefits of deer and wolves sustain strong sentiments and controversy we need to aggregate and evaluate the costs and benefits of deer and wolves across larger scales and longer periods even this necessary effort however is unlikely to yield a consensus on how to coexist with deer and wolves as different stakeholders perceive different costs and benefits this difficulty is compounded for deer as their direct benefits are easily perceived while the several costs they incur are often indirect delayed and dispersed among many parties in contrast costs for wolves are easily perceived while their benefits are often indirect and difficult to document this asymmetry tends to polarize human attitudes our review shows that human attitudes toward wolves can shift over time and among regions from conflict to acceptance when conflicts can be resolved through collaborative approaches that respect differences in values we face continuing concerns and obstacles as we move forward from conflict to coexistence integrative approaches that respect and enumerate a full range of values are more likely to succeed although such approaches remain rare progress is possible if we recognize deer wolves and their habitats as a coupled system and highlight the aggregate benefits to be achieved while minimizing costs to affected human groups reduce forage for other species wildlife viewing opportunities threats from parasites and disease ecological conditions deer reduce yew cover favouring other understorey plant species reduce understorey plant cover and diversity reduce animal diversity biotic homogenization facilitate invasions of exotic worms plants and diseases ecosystem processes facilitation of native plant dispersal facilitation of invasive plant seed dispersal and invasive plant establishment accelerate nutrient cycling and nutrient losses increasing stream pollution soil compaction reduced infiltration more erosion eg declines in soil carbon eventual declines in forest tree carbon sequestration and storage legends of figures agriculture and forestry crop losses horticultural damage limit regeneration in many tree species sparse simplified underand midstorey conditions human health food from venison deervehicle accidents also involving substantial property 52 fig 2 damage outdoor pursuits tickborne diseases wildlife health reservoir for bovine tuberculosis parasites limit abundance of elk moose etc chronic wasting disease

humandriven species annihilations loom as a major crisis however the recovery of deer and wolf populations in many parts of the northern hemisphere has resulted in conflicts and controversies rather than in relief both species interact in complex ways with their environment each other and humans we review these interactions in the context of the ecological and human costs and benefits associated with these species we integrate scattered information to widen our perspective on the nature and perception of these costs and benefits and how they link to each other and ongoing controversies regarding how we manage deer and wolf populations after revisiting the ecological roles deer and wolves play in contemporary ecosystems we explore how they interact directly and indirectly with human groups including farmers foresters shepherds and hunters interactions with deer and wolves generate various axes of tension posing both ecological and sociological challenges resolving these tensions and conflicts requires that we address key questions using integrative approaches what are the ecological consequences of deer and wolf recovery how do they influence each other what are the social and socioecological consequences of large deer populations and wolf presence finally what key obstacles must be overcome to allow deer wolves and people to coexist reviewing contemporary ecological and sociological results suggests insights and ways to improve our understanding and resolve longstanding challenges to coexistence we should begin by agreeing to enhance aggregate benefits while minimizing the collective costs we incur by interacting with deer and wolves we should also view these species and ourselves as parts of integrated ecosystems subject to longterm dynamics if coexistence is our goal we need deer and wolves to persevere in ways that are compatible with human interests our human interests however should be inclusive and fairly value all the costs and benefits deer and wolves entail including their intrinsic value shifts in human attitudes and cultural learning that are already occurring will reshape our ecological interactions with deer and wolves

introduction the life story is a form of identity which binds together heterogeneous life events to define the self and establish selfcontinuity and purpose in life the integrative potential of a coherent life story makes it a form of identity specifically adapted to modern societies with highly mobile and individualized life courses and independent selves therefore it is of interest to explore whether the use of the integrative potential of the life story varies between cultures and subcultures depending on how independent versus interdependent individuals are expected to be we first introduce the life story and its empirical qualities then discuss conceptions of cultural differences on the dimension of independenceinterdependence and their possible relation to the life story to finally present two channels through which cultures may influence the life story before we develop our argument by relating the life story to individualistic versus interrelated cultures we need to introduce some qualities of life stories and the corresponding theoretical concepts and technical terms erikson described the life story as the modern form of identity which first develops in adolescence mcadams accordingly defined identity as an internalized and evolving story of the self which is created by individuals and shaped by the culture they are embedded in the individual life story ties together past present and future by providing unity and purpose thereby it helps to maintain a sense of identity across situations and over time the life story is most completely manifested in entire life narratives at any one point in time an individual has one life story but may produce somewhat differing life narratives depending on the communicative situation life narratives allow empirical access to individuals life stories life narratives differ from a mere collection of eventspecific stories by requiring the stories to cohere so that they communicate individuals personal development and therefore reflect their identities the more life narratives are globally coherent the better they integrate specific events and aspects of the self with each other we introduce four aspects of life story coherence as well as autobiographical arguments which are instrumental in creating coherence our aim is to specify how life narratives reflect personal continuity across change which we believe renders them the ideal form of identity for highly mobile individualistic societies habermas and bluck defined four aspects of global coherence of life narratives the first aspect is created by adherence to a cultural concept of biography a standard biography including a list of typical life events with normative timing which is also termed life script temporal coherence refers to how events are narrated in chronological order so that listeners are oriented when in life events took place causalmotivational coherence refers to how narrators create causal and motivational relations between distant events as well as between these and the self and its development these links explain how narrators became who they are at present thematic coherence refers to overarching themes common to heterogeneous events thereby integrating them within the life narrative an important means to create coherence in life narratives is autobiographical arguments they form links among parts of ones life as well as between these and the self and its development in an attempt to integrate ones personal past and present autobiographical arguments can be found in entire life narratives as well as in more limited single event narratives some autobiographical arguments link events to the narrators personality termed selfevent connections these may explain actions and events by reference to stable personality traits thereby maintaining stability or they explain change in personality and insights gained in specific life experiences thus engendering change as does also a mixed group of other autobiographical arguments a coherent life narrative is expected to demonstrate some stability of the narrators personality but also development and change these two aspects of diachronic identity are reflected by stabilitymaintaining and changeengendering autobiographical arguments respectively which in turn contribute to thematic and causalmotivational coherence respectively change engendering selfevent connections and other autobiographical arguments bridge personal change by creating a developmental story thus creating selfcontinuity across change these two aspects of life story integration correspond to the two strategies for maintaining personal identity over time one based on selfsameness across time the other on narrative selfcontinuity across change sameness across time can be maintained under stable social circumstances whereas highly mobile social contexts require engaging in changeengendering autobiographical reasoning which creates selfcontinuity across change having introduced the various aspects of life narratives we now turn secondly to those sociocultural forces that appear to require individuals to elaborate a diachronic identity ie a life story and their historical and crosscultural variation it is not clear whether the subjective life story is a universal phenomenon however the development of western individualism has been linked to the rise of a biographical conception of identity as represented by literary autobiography and individual developmental life narratives superseding a more synchronic identity defined by social relationships and positions the diachronic biographical conception of identity is better adapted to continuously changing relationships and positions which do not follow a clearly predefined route thus in the modern western world the self is conceived as a reflexive individualized project or as a narrative that continuously needs to be updated and rewritten to achieve selfcontinuity across change in sociocultural contexts that require flexibility and individualized lifecourses life narratives need to be causally motivationally coherent to bridge change which is supported by changeengendering autobiographical arguments in contrast sociocultural contexts that define individuals by stable social relations and positions these relationships may be more important for defining identity than the individual life story therefore in these sociocultural contexts life stories may not need to be as causally motivationally coherent and require fewer changeengendering autobiographical arguments cultures have been typified with a dichotomy of western individualism and an independent self versus eastern collectivism and interdependent self the dichotomy has been criticized as too undifferentiated for example kagıtçıbaşı attempted to better capture withinculture variations and effects of migration with a tripartite model linking cultural family models to respective modal person concepts the interdependence family model typical for collectivistic cultures rural regions and low ses has an authoritariandependency oriented child rearing style the resulting related self is sensitive about group loyalty conformity and maintaining family rules the independence family model common among individualistic cultures and urban areas with a permissive parenting style favors developing an autonomous self which is characterized by welldefined selfboundaries and following ones own rules finally the emotional interdependence family model common in urban regions of collectivistic cultures and ethnic minority groups from collectivistic cultures in the western world emphasizes autonomy and close emotional connectedness between generations in childrearing practices the resulting autonomousrelated self is both autonomous and still to a certain degree sensitive to group loyalty and emotional expectations of parents individualization appears to show not only in an independent person concept but also in the individualization of the life course in the european context a preponderance of individualistic values as well as of a more flexible individualized life course can be found in northwestern compared to southeastern european countries finally we highlight two channels through which society and culture influence life stories normative cultural conceptions of the life course and culturally formed reminiscing practices sustaining an interdependent versus independent orientation first the life course itself is shaped by societys institutional and economic structure through determining the timing of schooling and retirement in addition life narratives build upon cultural master narratives and cultural concepts of biography the latter contains culturally conceived life phases and a set of transitional events with age norms attached to them termed life script this script serves as a guide for planning and evaluating life as a framework for recalling important autobiographical memories and for selecting biographically salient events for inclusion in the life story life scripts from different countries such as turkey australia denmark germany the united states japan the netherlands malaysia qatar and china mexico and greenland provide strong evidence for the existence of cultural life scripts with reasonable cultural and religious differences second cultures shape individuals selves by engaging them in different narrative practices geared toward developing the critical skills needed to be a competent member of that culture which in turn influence the development and structure of individual autobiographical memory the goals of the cultural selfconcept affect autobiographical memory in terms of its accessibility style and content compared to individualistic western cultures personal narratives of children and adults in eastern interdependent cultures focus more on themes of community and morality than on themes of autonomy and achievement they tell less detailed personal narratives and focus more on group norms and group needs and less on their own activities thoughts and feelings easterners also describe themselves more in terms of relationships than of personal attributes as expected by kagıtçıbaşı these differences do not only show between western and eastern countries but also within countries for instance between western and eastern turkey summing up individualistic highly mobile western cultures require creating coherent life narratives as primary form of identity which allows an individualized and flexible way of securing selfcontinuity whereas in interdependent traditional eastern cultures coherent life narratives may be less important relative to more synchronic contextualized forms of identity defined by relationships to others accordingly we expected life narratives to be less coherent in interdependent subcultures and to specifically have less causalmotivational coherence two of three relevant studies support this expectation chen et al and reese et al found that new zealand adolescents of european descent embedded turning point memories more in their lives by pointing out earlier causes or motives and later consequences than adolescents of maori and chinese descent in contrast to our expectations dunlop and walker found fewer changerelated other autobiographical arguments and more statements about selfstability in entire life narratives by 28 canadian students of european descent than in 24 students who had immigrated from asia however the focus on change in asian immigrants life narratives may not reflect cultural differences but might have resulted from their recent experience of migrating finally a recent crosssectional questionnaire study with a large sample covering many different countries provided first evidence that a cultures belief that identity was defined by social context and roles was related to defining personal identity across time by selfsameness whereas other cultures preferred to base personal identity in time on constructing selfcontinuity across change in life narratives the present study shows several advantages over the studies just mentioned it compares people living in different cultures compares immigrants offspring with nonimmigrant offspring living in the same country as well as in their parents home country and it compares withincountry differences between urban and rural areas this study investigated differences between kagıtçıbaşı three categories in terms of global coherence of and autobiographical reasoning in entire life narratives furthermore the present study actually measured cultural differences at the individual level by using an individual measure of interrelatedness close to the construct measured conformity with the respective groups cultural life script this study tested two hypotheses individualistic cultures as well as urban life style consider the self and the life story as a project which needs to be worked on therefore the cultural expectation to fashion an individualized identity by creating more coherent life narratives and using more changeengendering autobiographical reasoning should be higher in individualistic and urban than in interdependent and rural cultures hypothesis 1 thus predicts less global life narrative coherence less changeengendering and more stabilitymaintaining autobiographical reasoning in provincial turkey than in urban turkey than in turkish migrants offspring in germany than in urban germans earlier we had found in a larger sample of the same four groups as used in this study and including the present sample that the individually named cultural life scripts conformed more with the respective groups shared cultural life script the more interdependent the group is according to kagıtçıbaşıs model life script conformity was thus highest in provincial turkey next in metropolitan turkey and in turkishgermans and lowest in germans to test in this study whether the group differences in life narratives predicted by hypothesis 1 are mediated by individual conformity we used the similarity of the individual life script with the respective groups shared cultural life script as an indicator of cultural conformity hypothesis 2 thus predicts that individual conformity with the cultural life script mediates the influence of group so that the higher conformity is the lower life narrative coherence and changeengendering autobiographical reasoning will be this would explain at least part of the group differences predicted in hypothesis 1 because this is the first crosscultural study of entire life narratives we also explore group differences in the content of life narratives materials and methods procedure all interviews were conducted by the first author who is a native turk from istanbul and speaks german fluently they were conducted in a room assigned by the respective turkish university or by goethe university frankfurt turkish german participants were free to choose the language they felt most comfortable with half of them choosing german the other half turkish following berntsen and rubin participants were asked to provide a life script by imagining an ordinary infant of their own gender and cultural background to write down the seven most important events that were most probably to take place in their life and to estimate a culturally expected age for each event following habermas and de silveira participants were then asked to write down the seven most important personal memories from their own life and to order them chronologically then we asked them to narrate their life story within 15 min and to integrate these seven memories into their life narrative life narratives were recorded and transcribed verbatim the text was divided into propositions which were defined as all comprehensible main or subordinate clauses two bilingual coders independently divided sixteen life narratives balanced for sex and group into propositions agreeing on 966 of them the remaining life narratives were divided into propositions by one coder reading the life narratives raterscoders could not help but identify the group membership of the narrator one of the two raterscoders was blind to the hypotheses whereas the other was not material global life narrative coherence life narratives were rated for global coherence with manuals already used in an earlier longitudinal study each of the scales was defined in a paragraph and by brief anchor definitions for each of the respective seven points temporal coherence shows how well a life narrative provides an overall temporal orientation to listeners causalmotivational coherence is indicated by the developmental consequentiality of events the scale measures the degree to which the reader understands how past experiences are integrated into a developmental pathway of the narrators personality and life thematic coherence refers to how much diverse individual elements of a life narrative are thematically connected raters were trained by the original rater and coauthor of the scale isabel peters all life narratives were rated independently by the first author and one other rater average measure intraclass correlations based on all life narratives were r ic 085 for causalmotivational coherence r ic 078 for thematic coherence and r ic 072 for temporal coherence autobiographical arguments we coded selfevent connections which link personality or personal values to specific life events we differentiated change engendering from stability maintaining selfevent connections changeengendering selfevent connections include explanations of change in personalityvalues by specific events and revelations of unknown personality aspects by specific events stability maintaining selfevent connections include explanations of eventsactions by personality and the discounting of an event as being atypical for personality we also coded six other autobiographical arguments developmental status biographical background lesson learned generalized insights formative experience turning points which also deal with change both from a theoretical standpoint and empirically the six other autobiographical arguments and the changeengendering selfevent connections bridge change in life and contribute to causalmotivational coherence whereas stabilitymaintaining selfevent connections contribute to thematic coherence coders were trained by the second author who had originally written the manual all life narratives were coded independently by the first author and one other coder cohens kappas based on all participants were k 085 both for other autobiographical arguments and for selfevent connections hypotheses were tested using the 1 3 a development of the personality is claimed but not substantiated or a development of personality is described but not designated as such 4 a development of the personality is basically substantiated by the events described but it is not elaborated upon 5 the development of the personality becomes clear on the whole through some of the events described however not to a full extent 6 the development of the personality becomes clear through some of the events described but is not always comprehensible down to the smallest detail 7 the development of the personality becomes clear in its turningpoints and its motives thematic coherence 1 between the individual episodes narrated no connection is discernible 2 only one theme is addressed which is why the connection between the episodes is not abstract but concrete 3 with some episodes differing in content it is possible to recognize a common motive theme or a thematic category 4 through episodes heterogeneous in content thematic or motivational similarities can be clearly discerned which are not however explicitly named 5 there is a basic attempt to establish a connection between heterogeneous episodes between most episodes however the connection remains unclear or is exclusively implicit 6 between many heterogeneous episodes a connection is established but in part the connection remains unclear or is exclusively implicit 7 between the various heterogeneous episodes there is established a connection in a logical and comprehensible fashion table 2 types of autobiographical arguments stabilitymaintaining selfevent connections personalityvaluetalent is explains or shows in a typical behaviorevent the personality traitvaluetalent is exemplified by an eventaction or the personality traitvaluetalent motivates or explains the actionevent i was always such an extremely shy child so i like almost never said anything and there were thirty of us and the problem was that somehow they all knew each other and i was the only girl who really didnt know anyone atypical actionevent in spite of personalityvaluetalent the link between a traitvaluetalent and event shows an action not typical of the person or the persons refraining from a typical action when suddenly the child plops out and you have it in your arms and that was actually the last time when i really remember when i shed tears so i normally try to control myself but in that case everything like cacame out changeengendering selfevent connections event explains change in personalityvaluetalent through an event the person changes hisher personality values or talents the change is deep reaching and lasting and not simply situative this trip i think changed an awful lot for me so for one thing at that moment i understood what people mean by the meaning of life is living and it just made me a bit more selfaware event revealsleads to the recognition of personality traits values or talents through an actionevent the narrator becomes aware of a hitherto hidden traitvaluetalent the traitvaluetalent already existed before the event thus the event does not change the self but only the perception of the self it took me a long time just to admit for starters that i want somebody and that i would like a woman i like id dealt with it for a long time but underneath the desire as always there and this new therapist was in a position to bring this desires to the light of day other autobiographical arguments developmental status the narrator makes assumptions about a specific developmental status and corresponding abilities interests etc at the time i wasnt aware of any of that after all i was still too young for it biographical background a persons behavior or experience is explained with the help of earlier experiences and circumstances in that persons life that have created a special sensitivity toward certain situations or lent them a particular significance and when he came so threateningly toward me i completely blew my top knocking him to the ground only later did it occur to me that perhaps the reason for it was that he reminded me of the man who raped me formative experiences explicit claim that circumstances and experiences of a persons life have had a lasting formative influence on this person girlfriends have had a strong impact on me yes perhaps it has led to me no longer attaching so much importance to money today lessons learned the narrator draws a lesson from a narrated experience the narrator has learnt something for the future how she should handle certain relatively specific situations in the future after that i told myself next time i fall in love i must take care that school doesnt suffer from that generalized insight life maxims universally valid insights into and realizations about how the world or life generally function included in this code are also maxims you dont get on in life if you dont use your elbows i missed him for many months its probably always like that when its the first kiss turning points code statements about turning points in life a change of direction in life breaks or severe disruptions in life the fact that all of a sudden the child was there turned my life upside down frequency of specified arguments relative to the total number of propositions emotional valence of seven most important personal memories all memories were coded as either negative neutral or positive by two coders average measure intraclass correlation was r ic 097 disagreements in all ratings and codings were resolved by discussion life script conformity to establish shared cultural life scripts for each group we added 80 more participants to each group who were sampled in the same way as the participants of this study we averaged the 104 individual life scripts provided by each group to establish four shared cultural life scripts we needed these cultural life scripts to calculate the conformity of each individuals life script with the respective groups shared cultural life script this score is termed life script typicality score results we start by describing differences in life narratives between groups we first test group differences of coherence and autobiographical reasoning to then test a possible mediating role of conformity ie whether individual differences in conformity explain the group differences with multiple dependent variables we first ran a multivariate and then followup univariate tests with linear contrasts we also report descriptive correlations finally we explore the impact of the valence of events in life narratives description of life narratives in the four groups the number of propositions of life narratives did not differ significantly between groups f 0919 p 0435 η 2 p 0029 with mean number of propositions 2447 for karabük 2615 for istanbul 2545 for turkish germans and 2775 for germans the duration of life narratives did not differ either f 1041 p 0378 η 2 p 0033 mean duration was 1411 min for karabük 1313 for istanbul 1381 for turkish germans and 1403 for germans to provide a sense of the qualitative differences between the four groups we listed in table 3 the frequency with which life events were named among the seven most important memories before being told as part of the life narratives the kinds of most important life events support the idea that culture affects the way we tell our lives by influencing which events are deemed biographically salient to be included in the life story for example the turkish groups from karabük istanbul and frankfurt frequently mentioned life experiences involving interpersonal relations such as family quarrel others death health problems in the family problems with friends being supported by the family family members problems with the law importance of social relations parents divorce financial problems of the family and spending childhood far from ones family for example the percentage of family quarrel was 63 in karabük 54 in istanbul 25 in turkish germans and only 17 in germans moreover the following events were never once mentioned by the german group others death family support importance of social relations spending childhood far from family legal psychological and financial problems in the family on the other hand an orientation toward individualism and autonomy was reflected in the exclusive nomination by germans of leaving parents home and traveling without parents for the first time among the most important life events although the karabük group did not list leaving home among the seven most important seven life events the majority of participants mentioned in their life narratives that they had had to leave their parents home to go to university describing it as a very painful experience most of them wanted to return to their parents home after graduating this difference between the karabük and the german group reflects that while in german culture leaving home is considered a positive developmental transition to adulthood in rural turkish culture it is seen as a stressful nonnormative life event the religious rite de passage circumcision was specific for the turkish german group possibly reflecting the importance of religion in a bicultural context however also the german group mentioned religious rites de passage baptism and confirmation additionally although it was not reported among the most important life events the conflicts between turkish and german life style and the acculturation experiences were prominent in turkish germans life narratives interestingly traveling and secondary school were the items shared only by the two frankfurt groups among the most important memories these commonalities may reflect the integration of two cultures for turkish germans and the role of the national educational system lastly the number of educationrelated events indicates the importance of the educational system in all of these students lives hypothesis 1 group differences in life narrative coherence and autobiographical arguments we expected less global coherence and change related autobiographical reasoning in provincial turks than in urban turks and turkish germans than in urban germans respectively for global coherence we first ran a manova with all three aspects as dependent variables and group and gender as factors the hypothesis was tested by a linear contrast with groups ordered in the sequence karabük istanbul turkish germans germans the istanbul group was positioned before the turkish german group because the latter comprised not migrants but migrants offspring possible gender differences were explored and will be reported only if significant the multivariate linear contrast was highly significant f 1302 p 0001 η 2 0312 as was the undirected difference between groups f 524 p 0001 η 2 0152 univariate analyses confirmed the hypothesis for all three aspects of coherence with significant linear contrasts for temporal coherence f 3445 p 0001 η 2 0281 for causalmotivational coherence f 1616 p 0001 η 2 0155 and for thematic coherence f 1344 p 0001 η 2 0133 figure 1 shows that all effects were in the expected direction karabük students with the lowest and germans with the highest global coherence of life narratives for the second part of hypothesis 1 regarding autobiographical reasoning we expected changeengendering selfevent connections and other autobiographical arguments to increase but stability maintaining selfevent connections to decrease between the groups from karabük istanbul turkish germans and germans again we first ran a manova for all three kinds of autobiographical arguments and group and gender as factors the multivariate linear contrast was significant f 777 p 0001 η 2 0213 as was the undirected difference between groups f 549 p 0001 η 2 0158 gender also made a significant difference f 604 p 0001 η 2 0174 univariate linear contrasts confirmed the hypothesis only for stability maintaining selfevent connections f 1289 p 0001 η 2 0128 the linear contrast for changeengendering selfevent connections pointed in the expected direction without reaching significance f 333 p 007 η 2 0036 finally opposite to the expected direction other autobiographical arguments decreased significantly between karabük istanbul turkish germans and germans f 539 p 0023 η 2 0058 univariate tests also showed that males used more other autobiographical arguments than women f 556 p 0021 η 2 0059 and also more changeengendering selfevent connections than women f 1003 p 0002 η 2 0106 in our life story theory we postulate that autobiographical arguments are instrumental in creating life narrative coherence changeengendering arguments supporting primarily causalmotivational coherence and stabilitymaintaining arguments supporting thematic coherence this was confirmed in a german developmental sample in which causalmotivational coherence correlated with all three kinds of autobiographical arguments and thematic coherence with stabilitymaintaining selfevent connections in the present study however we could only replicate the correlation between causalmotivational coherence and changeengendering arguments in addition thematic coherence correlated with changeengendering arguments and temporal coherence negatively with stability maintaining selfevent connections comparison of withingroup correlations generally showed patterns consistent with the acrossgroup correlations only the group of germans resembled the earlier findings in a different german sample causalmotivational coherence correlating both with other autobiographical arguments and changeengendering selfevent connections this speaks for cultural influences on these correlational patterns hypothesis 2 the mediating role of life script conformity we used the life script typicality score as a measure of individual conformity with cultural norms regulating how to live a life which characterizes an interdependent self in collectivistic cultures by adding life script conformity as an additional continuous predictor to the model that tested hypothesis 1 we tested how much individual conformity actually correlated with life narrative coherence as well as how much this reduced the predictive power of group membership this would signal the expected role of conformity as mediating the influence of group differences as expected conformity correlated negatively with all three aspects of life narrative coherence correlations with autobiographical reasoning were as expected negative for changeengendering arguments but nearabsent for the other two arguments withingroup correlations showed the same pattern we tested a possible mediating role of conformity only for the dependent variables with a substantial correlation with conformity in a manova with the three kinds of coherence as dependent variables life script conformity as a continuous predictor and group and gender as factors conformity significantly predicted coherence f 388 p 0012 η 2 0120 in addition to group which still had a significant multivariate linear contrast f 567 p 0001 η 2 0167 as well as a significant undirected effect f 364 p 0001 η 2 0111 univariate analyses confirmed the influence of conformity for two of the three aspects of coherence f 520 p 0002 η 2 0056 for temporal coherence f 1029 p 0001 η 2 0106 for causalmotivational coherence and a clear trend for thematic coherence f 387 p 0051 η 2 0043 linear contrasts for the effect of group on temporal coherence were f 1570 p 0001 η 2 0153 on causalmotivational coherence f 383 p 0053 η 2 0042 and on thematic coherence f 471 p 0033 η 2 0051 thus when adding conformity as a predictor the multivariate effect size of the linear effect of group on coherence went down from η 2 0312 to about half η 2 0167 and effect sizes of univariate linear group effects went down to almost half for temporal and down to almost a quarter of the earlier sizes for causalmotivational and thematic coherence thus group differences in life narrative coherence were substantially but not totally mediated by life script conformity a parallel anova with changeengendering selfevent connections as dependent variable showed a significant influence of conformity f 783 p 0005 η 2 0083 the linear group contrast was not significant f 003 p 0862 η 2 0000 while the undirected effect of group remained significant f 788 p 0001 η 2 0214 showing that the earlier trend of a linear group effect was entirely mediated by conformity thus cultural conformity as measured by life script typicality clearly served as a mediator between group and life narrative coherence and changeengendering selfevent connections leaving some of the linear group effect on coherence to be accounted for exploring the role of negative events in life narratives to explore the unexpected results regarding group differences in other autobiographical arguments and their missing links with life narrative coherence we conducted a series of exploratory analyses they were based on the idea that a higher proportion of negative life events might require more autobiographical reasoning in the attempt to integrate them into the life story without necessarily succeeding yet such an initially still unsuccessful increase in autobiographical reasoning was termed attempt at meaning making by park to check our coding of the valence of memories we compared it with the valence rated by other participants in the larger sample most events were evaluated similarly differences were noticeable regarding moving which we coded as positive throughout but was rated ambivalently by germans and as mostly neutral to positive by turkish participants and regarding leaving home which was rated positively by germans but ambivalently by the three turkish groups however in this study moving was not named by the germans and leaving home was named almost exclusively by the germans so that these differences probably did not affect the group differences in negativity we then tested group and gender differences in the proportion of negative events among the seven most important own life events with an anova resulting in a strong group difference f 1387 p 0001 η 2 0321 the karabük group selected the greatest number of negative events and the germans the smallest to explore whether more negative events evoked higher degrees of autobiographical reasoning as a part of the process of working through negative events we calculated correlations the proportion of negative events correlated only minimally with any of the autobiographical arguments only temporal coherence correlated significantly and negatively with the negativity of the seven most important memories to test the relative weight of conformity and negativity for explaining group differences in temporal coherence we ran an anova with group and gender as the two factors and conformity and negativity as continuous predictors negativity did not contribute significantly and group and conformity remained significant predictors discussion the aim of this study was to take a closer look at the role of cultural and subcultural differences in life narrative coherence and autobiographical arguments and at their relation to the degree of cultural conformity it is the first study of life narratives across cultures and subcultures following calls for the cultural contextualization of psychosocial identity in the narrative identity tradition we will first discuss results regarding life narrative coherence and autobiographical arguments and the mediating role of life script conformity then possible reasons for and consequences of the more frequent mentioning of negative events in turkish life narratives to finally note limitations and spell out implications of our findings life narrative coherence and autobiographical arguments we had expected individualistic sociocultural contexts to require more individualized life stories which therefore require more efforts to integrate change into a globally more coherent life narrative the main hypothesis regarding cultural differences in global coherence of life narratives as well as the mediating role of individual cultural conformity were confirmed global coherence increased between groups from provincial turkey metropolitan turkey and turkish migrants offspring and germans in urban germany this was partially mediated by cultural conformity as measured by how typical the individual life scripts were for the respective groups cultural life script importantly this findings support the widely held but hitherto untested assumption that in modern life constructing ones own meaningful life story is a veritable cultural imperative these findings support the notion that individualization of the life course and of identity require the creation of more globally coherent life narratives and favors the diachronic form of identity the life story over the synchronic form of social identity as defined by roles hypotheses regarding cultural differences in the degree of autobiographical reasoning were confirmed or supported by a strong trend for both kinds of selfevent connections the mixed group of other autobiographical arguments however showed a linear trend opposite to the expected direction in fact the highest proportion of any kind of autobiographical arguments was used by participants from istanbul corresponding to the somewhat diverging results for life narrative coherence and autobiographical reasoning only one of the expected correlations between the coherence and autobiographical arguments was confirmed namely between causalmotivational coherence and changeengendering selfevent connections a possible explanation for the unexpected high frequency of other autobiographical arguments in the istanbul and karabük groups could be the high frequency of negative life events selfrelevant losses lead to identity disruption negative life events and identity disruptions call for changerelated autobiographical reasoning in order to integrate them into the life story thus the higher amount of negative events in the karabük and istanbul groups might have led to more autobiographical reasoning without yet leading to a full integration of them into the life narrative because processing and integrating negative experiences requires time and emotional distance from them this interpretation however was not supported by this study because the proportion of negative events in life narratives did not correlate with other autobiographical arguments the peak of autobiographical reasoning in the istanbul group may result from the impact of a historical event the gezi protest was a common theme not among the most important memories but in the life narratives data collection in turkey took place some months after the gezi protest a movement with strong student participation which started may 28 2013 they were initially directed against urban development plans for istanbuls taksim gezi park and may have instigated autobiographical reasoning cultural variations in the negativity of life narratives so why do life narratives from turkey contain more negative events than those from germany possibly everyday life is more comfortable in germany because the welfare state better buffers existential risks like illness and disoccupation this might suggest an alternative explanation for the cultural differences in global coherence namely that it is easier to create global coherence if life is easier because negative events are nonnormative and therefore more difficult to integrate into a life narrative than normative events however the closely knit support system of turkish families may compensate or even outweigh the german welfare system in providing support for the contingencies of life anyway the high frequency of negative life events in turkish groups need not reflect an actually higher frequency of negative events in turkish than in german families taking into account the interdependent cultural background familyrelated events play a central role in turkish life style and were named more frequently they tend to be more nonnormative and therefore negative because only the narrators own normative life events help structure the life story and are therefore frequently mentioned but not the normative life events of significant others accordingly positive autobiographical memories are mostly about the self whereas most important negative autobiographical memories are almost as often about others as about the self across cultures thus the frequency of negative events may reflect the central role of family and close relationships rather than differences in the actual frequency of such events however it is more difficult to create a coherent life narrative especially a coherent developmental story if it encompasses more others and more negative life events because they do not conform to the cultural concept of biography and need to be actively integrated into the life narrative this explanation resonates with markus and kitayamas reasoning that an interdependent selfconstrual requires more situational adaptation to others and therefore requires less selfconsistency related findings have led to the coining of the term dialectical selfconcept both explanations fit results from crosscultural research on wellbeing which is influenced positively both by gross national income as well as by individualistic selfconstrual the inclusion of more familyrelated life events reflects a stronger familial interdependent orientation as well as the lower importance given to fashioning a coherent highly individualized life story in that culture limitations and implications cultural differences between groups covaried with differences in parents educational level given the differences in the general educational level between the four sociocultural groups and the influence of formal education on attitudes and the life course this covariation is probably intrinsic to the cultural differences studied nevertheless it would be of interest to compare the possible influence of level of education on the life story between cultures the moderate number of interviewees in each group limits the possibility to generalize from these findings it is due to scarce resources in the face of the laborintensity of collecting and analyzing narrative data however an earlier publication did show that our samples were typical for their respective groups still both expected and unexpected results call for a replication ideally with different subcultures nevertheless future studies should keep the strength of the present study by comparing not only students from different nations but by comparing different subcultures other subcultures than native versus immigrant germans and urban vs provincial turks should also be tested future studies should also measure the timing and severity of negative life events independent from life narratives for example problems in school might be evaluated as not as serious as the loss of a parent so that these events require different degrees of autobiographical reasoning similarly recent negative events could be associated with higher amounts of autobiographical reasoning and might still be more disruptive for life narrative coherence compared to older negative life events therefore it could be argued that negative events are an important negative influence on life narrative coherence and autobiographical reasoning thus the nature of the relation between negative events and life narratives should be further examined conclusion the aim of this first simultaneous study of crosscultural and withincultural differences in life narratives was to investigate the relation between sociocultural environment and life narrative coherence and autobiographical reasoning the study confirmed that life narrative coherence and autobiographical reasoning with selfevent connections is affected by sociocultural context in a predictable way more coherence more changeengendering and fewer stabilitymaintaining autobiographical reasoning characterize more individualized cultures the group of other autobiographical arguments however did not show the expected effects secondly conformity with the cultural life script plays a mediating role for cultural influences on life narrative coherence finally the more interdependent cultures included more negative events in their life narratives matching the more interdependent outlook most of these regarded not the narrators themselves but the relationship with or individual fortunes of family members the present studys findings on cultural differences of entire life narratives provides evidence for the assumed importance of a coherent life story in highly individualized western societies compared to more interdependently oriented eastern cultures they complement and match findings on cultural differences in autobiographical memories of specific events found mostly between united states americans and chinese this study demonstrated that narrative studies like other fields in psychology need to empirically investigate the role of culture for their constructs and findings ethics statement this study was carried out in accordance with the recommendations of ethikkommission des fachbereichs 05 goethe universität frankfurt with written informed consent from all subjects all subjects gave written informed consent in accordance with the declaration of helsinki the protocol was approved by the abovementioned ethics committee with letter 201250 conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

an individualized and coherent life story has been described as the form of identity that is required by highly mobile individualistic western societies whereas more familyoriented traditional societies require more rolebased synchronic identities therefore in individualistic cultures entire life narratives can be expected to be more coherent and to contain more autobiographical arguments that contribute to life narrative coherence this cultural group difference is expected to be mediated by individuals conformity to their respective cultural normative concept of biography such that more conformity leads to less life narrative coherence and fewer autobiographical arguments we tested these expectations by eliciting entire life narratives and cultural life scripts from four different cultural groups of students of technical universities from provincial karabük and from metropolitan istanbul in turkey as well as from students with a turkish migrant and with a native german background from urban frankfurt am main germany n 96 expectations were confirmed for global life narrative coherence and autobiographical arguments with selfevent connections conformity with a normative concept of biography indeed partially mediated cultural influences on life narrative coherence life narratives from turkey also contained more familyrelated events and unexpectedly were more negative thus creating a coherent life narrative is more typical for cultures that require autonomous individualized selves rather than for cultures requiring more related selves reflecting the life storys suitability for expressing individualized identities and its lesser suitability for expressing interdependent identities

introduction most countries are experiencing the fourth wave of the covid19 pandemic and ghana is no exception 1 ghana experienced a surge in its covid19 cases after december 13 2021 between december 1 and 8 2021 covid19 cases increased by 46 cases while it increased by 9257 cases between december 23 and 30 2021 2 vaccination against covid19 is one of the effective measures to slow the spread and reduce mortality associated with it 3 ghanas population is estimated to be 308 million with children younger than 18 years constituting twofifths in 2021 4 the government of ghana aims to vaccinate all ghanaians against covid19 with an initial target of 20 million by the first quarter of 2022 5 owing to this the food and drugs authority of ghana has approved five vaccines astrazeneca sputnik v moderna johnson johnson and pfizer for the use of the entire exercise across the country 6 han et al 7 noted that pfizer and coronavac vaccines were safe for children below 18 years the serum institute of india pvt limited and moderna the companies which manufacture astrazeneca and moderna vaccines respectively are conducting clinical trials to develop covid19 vaccines for children younger than 18 years 8 countries like the united states of america the united arab emirates cuba and china have approved covid19 vaccination for children younger than 18 years 9 in the usa the food and drug administration and centers for disease control and prevention have approved the emergence use of the pfizer vaccine for children aged between 5 to 11 after initially approving it for children aged 12 and older 910 ghanas current covid19 vaccination programme cover persons aged 15 and older 11 previous studies have established that children are less likely to develop severe symptoms of covid19 and are less likely to spread covid19 than adults 712 nevertheless children in ghana have been heavily impacted by covid19 infection 13 child rights international 14 has estimated that about 2180 children younger than 18 years were infected with covid19 between march 11 and november 9 2020 in ghana likewise approximately 2323 students from 363 primary secondary and tertiary educational institutions across the country were infected with covid19 after reopening educational institutions in january 2021 15 children younger than 18 years are regarded as minors they are therefore legally required to have decisions made on their behalf by their parents guardians and other duty bearers in charge of their education social welfare and health 16 17 18 while research on parents and guardians intention to vaccinate their children against covid19 is at an advanced stage in north america asia and europe 19 20 21 22 very little attention has been given to the issue in subsaharan african countries including ghana for example a study among parents in china found that about 73 of parents were willing to vaccinate their children against covid19 when vaccines become available 23 a similar study among adults in the united states found that 73 of adults intended to vaccinate their children against covid19 24 among the factors that influence parents and guardians acceptability of covid19 vaccination for children are parents age educational level and knowledge about covid19 preventive measures other factors include household income levels employment status the number of children parents have children with no chronic illness worry about child getting covid19 confidence in vaccine safety and belief in importance of vaccines 1920 24 25 26 in subsaharan africa few studies have examined the intentions of parents and guardians to vaccinate their children against covid19 for example carcelen et als 27 study among caregivers with children aged six months to 5 years in zambia found that 9 out of 10 caregivers were willing to vaccinate their children against covid19 there is thus a dearth of studies on parents and guardians intention to vaccinate their children against covid19 and factors that influence their intention in subsaharan africa including ghana therefore this study sought to estimate the prevalence of acceptability of covid19 vaccination for children among parents and guardians in ghana it also examined the factors influencing parents and guardians intentions to accept the covid19 vaccination for their children knowing and examining the intentions of parents and guardians to vaccinate their children against covid19 will help researchers and public health practitioners initiate and develop suitable measures to promote the uptake of covid19 vaccination for children in the country materials and methods study design and sampling procedure this study is a crosssectional one conducted among parents and guardians in ghana using convenient and snowballing sampling techniques google form was used to design an online selfadministered questionnaire the online survey was shared on whatsapp meta and twitter platforms it was also shared via email with relatives friends and colleagues parents and guardians were encouraged to share the survey link with relatives friends and colleagues who were also parents or guardians inclusion criteria for the study include respondent being a ghanaian parent or guardian aged 18 and older who has biological or foster children aged below 18 in their care and residing in ghana at the time of the survey also ghanaian parents or guardians aged 18 and older with no biological or foster children aged below 18 in their care were excluded from the study study setting ghana is a lowermiddleincome country located in west africa ghana shares a boundary with burkina faso in the north the gulf of guinea in the south togo in the east and cote divoire in the west ghana has 308 million people and 16 administrative regions as of 2021 the current population comprises 507 female and 493 male 28 ghana covers a land area of 238533 sq km and the greater accra region is its capital about 177 of people in ghana reside in the greater accra region the most densely populated region in ghana 28 currently the greater accra region is the most populous in the country growing from 163 in the last census to 177 in the latest while the population of the ashanti region declined from 194 to 176 data collection the data for the study was collected over three months ending november 2021 from parents and guardians the online survey questionnaire covered four areas sociodemographic characteristics covid19 experience beliefs about covid19 vaccines and intention to vaccinate childchildren the questionnaire had 50 questions comprising 12 questions on sociodemographic characteristics 22 on covid19 experience 11 on beliefs about covid19 vaccines and 5 on intention to vaccinate childchildren the questions on sociodemographic characteristics covid19 experience beliefs about covid19 vaccines and intention to vaccinate childchildren were adapted from previous studies 3192529 however these questions were modified in light of the ghanaian context on the first page of the online survey a brief introduction was provided which contained the aims of the study inclusion and exclusion criteria and consent statement respondents provided written consent to participate in the study by selecting i consent to participate in this study in the consent statement section only respondents who provided written consent could fill out the google form participation in the study was voluntary the study complied with all ethical regulations and written informed consent was obtained from all respondents ethical approval for the study was obtained from the ethics committee of the university of environment and sustainable development somanyaghana study variables dependent variable the dependent variable for the study was parents and guardians acceptability of covid19 for children respondents were asked if an approved covid19 vaccine became available would you allow your childchildren to be injectedvaccinated and the responses were yes no and dont know the no and dont know responses were recoded as no independent variables the studys independent variables included sociodemographic characteristics of respondents covid19 experiences and beliefs about covid19 vaccines the sociodemographic characteristics of the parents and guardians were age sex religion education shs and undergraduate and marital status other sociodemographic characteristics included employment status region of residence household wealth the number of children younger than 18 years parents and guardians were asked about their covid19 experiences questions asked included whether parentsguardians have ever had a covid19 test a member of their household relative friend or neighbour had been diagnosed with covid19 the childs chance of being infected with covid19 at home community or school whether parents and guardians changed their adherence to covid19 preventive protocols due to governments decision to provide covid19 vaccine if it is possible for a healthylooking person to have covid19 and whether covid19 could be cured also parents and guardians were asked 11 questions about their beliefs about covid19 vaccines the response to each question was strongly disagree disagree neither agree nor disagree agree and strongly agree all responses were recoded in the same direction strongly disagree and disagree responses were recategorised into disagree while agree and strongly agree responses were recategorised into agree the reliability of the 11 questions about parents and guardians beliefs about covid19 vaccines was assessed using cronbachs alpha coefficient the cronbachs alpha score for the beliefs about covid19 vaccines was 0738 which indicates it is reliable or internally consistent data analysis the data were analysed using the statistical package for social sciences version 25 for windows descriptive statistics such as frequencies and percentages were used to describe the sociodemographic characteristics of respondents covid19 experiences and beliefs about covid19 vaccines pearsons chisquare test was also used to determine the association between parentsguardians acceptability of covid19 for their children and sociodemographic characteristics of respondents covid19 experience and beliefs about covid19 vaccines the dependent variable was dichotomous so binary logistic regression was used to examine the factors influencing parents and guardians intentions to accept the covid19 vaccination for their children all variables with a pvalue 005 was considered to be statistically significant results acceptability of covid19 vaccine for children younger than 18 years a total of 415 parents and guardians were involved in this study more than twothirds of the parents and guardians indicated their acceptance of the covid19 vaccine for their children younger than 18 years whiles 267 stated nonacceptance of covid19 vaccine for their children the main reasons cited for nonacceptance of covid19 vaccine by parents and guardians included inadequate data about the safety of the new vaccine concern about the adverse effects of the vaccine prior adverse reaction to any vaccine and parents and guardians perceiving their children not to be at any considerable risk of developing complications if infected with covid19 sociodemographic characteristics of respondents regarding age the highest proportion of the respondents were aged 3039 slightly more than half of them were females and nine out of ten were christians in terms of education the highest proportion of the respondents had undergraduate education whiles slightly less than onefifth had less than senior high school education the highest proportion of those with less than shs education indicated their acceptance of the covid19 vaccine for their children than those with shs and undergraduate education about twothirds of the respondents were married while a few lived together on parents and guardians employment status more than twothirds were currently employed and the majority of them resided in the greater accra region a little over half of the respondents had less money than they would need the highest proportion of them indicated having 23 children while less than twofifths reported having four or more children younger than 18 years covid19 experiences covid19 experiences of the respondents are seen in table 3 the results show that about seven out of ten parents and guardians had never tested for covid19 while less than onetenth had members of their household diagnosed with covid19 furthermore the majority of them reported that none of their relatives had been diagnosed with covid19 in addition more than half of the respondents had none of their friends been diagnosed with covid19 also the majority of them reported that none of their neighbours were diagnosed with covid19 regarding the risk of children being exposed to covid19 at home and in their communities 588 and 506 of the respondents indicated that their children had no risk of getting covid19 at home and in the community respectively approximately twofifths of the parents and guardians indicated that their children had no risk at all of getting covid19 at school in terms of government decisions most of them reported that their adherence to covid19 prevention protocols has not changed because the government decided to provide the covid19 vaccine furthermore the majority of the respondents felt that covid19 could be cured a higher proportion of parents and guardians who felt covid19 could be cured indicated their acceptance of the covid19 vaccine for their children than those who felt covid19 could not be cured beliefs about covid19 vaccines on the beliefs of covid19 about 61 of the respondents disagreed with the statement once the vaccine is available and approved it would be safe and a higher proportion of those who disagreed indicated acceptance of the covid19 vaccine for their children than those who neither agreed nor disagreed and those who agreed of those who disagreed indicated acceptance of the covid19 vaccine for their children than those who agreed and those who neither agreed nor disagreed slightly more than half of the parents and guardians disagreed with the statement i believe the vaccine could cause a weakened immune system after administration among the proportion of those who disagreed with the statement about eight out of ten indicated acceptance of the covid19 vaccine for their children than those who agreed and those who neither agreed nor disagreed in addition the majority of the respondents disagreed with the statement i believe the administration of the vaccine might be a means to capture an individuals biodata most of the respondents who disagreed with the statement indicated acceptance of the covid19 vaccine for their children than those who agreed and those who neither agreed nor disagreed about 369 of the respondents disagreed with the statement i am of the notion that physiologicalnatural immunity is better compared to vaccineinduced immunity and most of those who disagreed with the statement indicated acceptance of the covid19 vaccine for their children than those who neither agreed nor disagreed and those who agreed more than half of the respondents disagreed with the statement i believe in gods protection against covid19 compared to vaccines protection and eight out of ten of those who disagreed indicated acceptance of the covid19 vaccine for their children than those who neither agreed nor disagreed and those who agreed the majority of the respondents disagreed with the statement i can relate the fact that the vaccine is likened unto the mark of the beast and most of those who opposed indicated acceptance of the covid19 vaccine for their children than those who neither agreed nor disagreed and those who agreed furthermore about 67 of the respondents disagreed with the statement i believe the vaccine programming may be likened to the new world order and a higher proportion of those who disagreed indicated their acceptance of the covid19 vaccine for their children than those who neither agreed nor disagreed and those who agreed factors associated with parents and guardians acceptability of covid19 vaccine for their children only variables with a p 005 in bivariate analysis were integrated into the model table 5 shows the factors associated with parents and guardians acceptability of the covid19 vaccine for their children the results of the study showed that factors including education of parents and guardians belief that covid19 be cured and beliefs about covid19 vaccines were significantly associated with parents and guardians acceptability of covid19 vaccine for their children parents and guardians with shs education were less likely to accept the covid19 vaccine for their children than those with less than senior high school parents and guardians who did not agree that covid19 could be cured had a lower likelihood of accepting the covid19 vaccine for their children than those who agreed that covid19 could be cured parents and guardians who neither agreed nor disagreed and those who agreed to the statement once the vaccine is available and approved it would be safe were less likely to accept covid19 vaccine for their children than those who disagreed to the statement in addition parents and guardians who neither agree nor disagree with the statement the best way to avoid the complications of covid19 is by being vaccinated were less likely to accept covid19 vaccine for their children compared to those who disagreed to the statement also parents and guardians who agreed to the statement i am of the notion that physiologicalnatural immunity is better compared to vaccineinduced immunity had a lower likelihood of accepting the covid19 vaccine for their children than those who disagreed to the statement finally parents and guardians who agreed to the statement i believe the vaccine programming may be likened to the new world order were less likely to accept the covid19 vaccine for their children than those who disagreed to the statement discussion this study examined parents and guardians acceptability of the covid19 vaccine for their children under age 18 in light of the limited data on the issue in subsaharan africa since most studies have focused on adults acceptability of the vaccine the current study indicates that most parents and guardians intended to vaccinate their children against covid19 if 23 study in china and that of kelly et al 24 in the united states which reported that about 73 of parents would allow their children to be vaccinated against covid19 respectively however in zambia carcelen et al 27 reported that 92 of caregivers intended to vaccinate their children against covid19 du et als 19 study in china also found that 916 of women in their reproductive ages intended to vaccinate their children against covid19 the prevalence of acceptability of covid19 vaccination for children found in this study is higher than the prevalence found in other countries for instance a study in italy among parents and guardians of children less than 18 years found that 604 of parents and guardians intended to vaccinate their children against covid19 21 another study in england among parents and guardians found that 482 of parents and guardians had the intention to vaccinate their children against covid19 25 studies have found that the main reason for parents intention to vaccinate their children is to protect them 30 31 32 33 therefore parents are more likely to vaccinate their children against covid19 if they already receive other national immunization vaccines 273435 on the other hand doubts about a vaccines safety and effectiveness are mainly cited as concerns for vaccine hesitancy 3202536 similarly in this study parents and guardians who were unwilling to accept the vaccine for their children were mainly concerned about the lack of information on the safety and adverse effect of the vaccine however vaccination of children generally has positive health and social impacts such as reducing deaths particularly among children under five years of age better psychological development and learning abilities 1837 this calls for an urgent need for public health practitioners to intensify public communication about the vaccines side effects and safety to alleviate parents and guardians fears educational attainment was the only sociodemographic variable significantly associated with parents and guardians intention to vaccinate their children this finding highlights the importance of formal education on health and related behaviours some studies have demonstrated a positive association between vaccine acceptance and parental education 3839 however comparable to other studies in saudi arabia 40 china 41 and turkey 35 we found an inverse relationship between educational level and parents intention to vaccinate their children against covid19 hu et al 41 explained that a higher educational level might increase concern about the safety and quality of the vaccines hence the lower likelihood of vaccine acceptance among parentsguardians with secondary or higher educational levels this would negatively have an impact on covid19 vaccination for children in ghana with more than half of the ghanaian population with secondary or higher education 42 there is a need for public health practitioners to continuously sensitise the general public particularly the educated about the safety and quality of the covid19 vaccines to reduce vaccine hesitancy for children research has established that the perceived cure for a health condition influences individuals careseeking behaviour 4344 individuals who perceive that their health conditions can be cured actively engage in cure seeking and vice versa this study found that parents and guardians who perceived that covid19 could not be cured were less likely to report the intention to vaccinate their children against covid19 compared to those who perceived that it could be cured it is understandable why these parents and guardians believed that vaccinating their children was unnecessary because they perceived that covid19 could not be cured therefore public health practitioners are urged to increase awareness among parents guardians and the general public of the advantages of vaccinating against covid19 generally beliefs surrounding vaccines may significantly affect their hesitancy or acceptance this was evident in our study we found that four variables that measured beliefs about covid19 vaccines significantly predicted parents and guardians intention to accept the vaccine for their children parents who perceived that an approved vaccine would be safe were less likely to report the intention to vaccinate their children against covid19 the reason could be that beliefs do not necessarily translate to action probably the parents and guardians perceive the covid19 vaccine to be safe but may not see the need and relevance of allowing their children to vaccinate due to the side effects and other related issues this finding is contrary to carcelen et als 27 study in zambia which found that caregivers who perceived that the covid19 vaccine would be safe were more likely to report the intention to vaccinate their children than those who believed otherwise this study also found that parents and guardians who were neutral about the fact that the best way to avoid complications of covid19 is by being vaccinated were less likely to vaccinate their children since these parents and guardians are indifferent about vaccination being the best way to prevent covid19 complications they do not see the need to vaccinate their children against it convincing these parents and guardians that the best way to avoid complications of covid19 is through vaccination would help reduce vaccine hesitancy furthermore parents and guardians who affirmed that physiologicalnatural immunity is better than vaccineinduced immunity were less likely to accept vaccination for their children a possible explanation is that both natural and vaccineinduced immunities are effective against the virus 45 therefore the perception that physiologicalnatural immunity is better may discourage an individual from accepting vaccineinduced immunity parents and guardians who believe the vaccine programming may be likened to the new world order are less likely to accept covid19 vaccination for their children misinformation about covid19 vaccines has been one of the main contributors to the unwillingness of individuals to accept the vaccine 46 47 48 limitations this study has some limitations that are worth noting first the study population is nonrepresentative of ghanas population since we used convenient and snowballing sampling techniques second all respondents who partook in the study had formal education and internet access based on these limitations the findings of this study should be interpreted with caution third the childs age and whether or not the parent and guardian have been vaccinated against covid19 can influence the intention to vaccinate their children against covid19 however these characteristics were not included in the study moreover this study was crosssectional so causality cannot be established finally the link for the online survey was shared on whatsapp meta and twitter platforms and it was anonymous so a respondent could complete the survey more than once despite these limitations this study is among the few studies conducted on parents and guardians intention to vaccinate their children against covid19 in subsaharan africa including ghana therefore findings from this study would contribute to the literature on vaccine hesitancy in subsaharan africa conclusions findings from this study indicated that most ghanaian parents and guardians are willing to accept covid19 vaccines for their children however they have concerns about the inadequate data about the safety of covid19 vaccines and their adverse effects in addition the acceptability of covid19 vaccines for their children was influenced by their educational level perception about the cure of covid19 and beliefs about covid19 vaccines therefore to increase the acceptability of covid19 vaccines for children public health practitioners should consider these factors in designing and implementing covid19 vaccination campaigns specifically public health practitioners should periodically sensitise parents guardians and the general public on the benefits and side effects of covid19 vaccines also they should provide regular and uptodate information about the safety of covid19 vaccines to allay the fears of parents and guardians in addition further studies should use a mixed study approach to understand vaccine hesitancy comprehensively all relevant data are within the paper and its supporting information files writing review editing frank kyeiarthur sylvester kyeigyamfi martin wiredu agyekum grace frempong afrifaanane bernard akyeampong amoh

few studies have examined the intentions of parents and guardians to vaccinate their children younger than 18 years against covid19 in ghana parents are the decision makers for children younger than 18 years therefore we examined parents and guardians intentions to accept the covid19 vaccines for their children an online survey was conducted among 415 parents and guardians in ghana the statistical package for social sciences version 25 was used to analyse the data we found that 733 of parentsguardians would allow their children to be vaccinated against covid19 the binary logistic regression analysis shows that parentsguardians with senior high school education those who believed covid19 could not be cured and those who agreed and those who neither agreed nor disagreed with the statement once the vaccine is available and approved it would be safe were less likely to accept covid19 vaccine for their children also parentsguardians who neither agreed nor disagreed that the best way to avoid the complications of covid19 is by being vaccinated those who agreed that i am of the notion that physiologicalnatural community is better compared to vaccineinduced immunity and i believe the vaccine programming may be likened to the new world order were less likely to accept covid19 vaccine for their children there is a need for public health practitioners to intensify education on the benefits and side effects of covid19 vaccines as well as provide regular and uptodate information about vaccines safety to parents and guardians

introduction hypertension a major cardiovascular risk factor may be on the rise worldwide 12 and a similar trend has been observed in brazil 3 the excess risk of ht among afrodescendants compared to whites has been consistently observed in many populations 4 including brazils 5 in addition to a number of aspects of dietary intake and excess weight among other possible causes exposure to racial discrimination has been increasingly explored as underlying the higher risk of ht among populations of african descent through a variety of mediating mechanisms eg socioeconomic behavioral and pschyconeuroendocrine overall the findings suggest that racism may increase ht risk but evidence is still mixed and almost entirely restricted to more industrialized societies 67 brazil has the largest population of african descendants outside africa and their contemporary social position carries the intergenerational imprint of the enslavement of about 3 million individuals brought from west africa over three centuries 8 which became a major structural component of brazilian society because little is known about the interrelationships between racial and socioeconomic inequalities in this country we report the possible combined effects of african descentperceived racial discrimination and socioeconomic disadvantage on ht risk in brazil a multiracial society in which socioeconomic inequality is pervasive resumo introdução o brasil tem a maior população afrodescendente fora da áfrica objetivo em razão das sequelas da escravidão sobre sua posição social contemporânea foi investigada a relação entre racismo percebido e hipertensão métodos analisamos dados de 3056 funcionários públicos de campi universitários fluminenses participantes do estudo prósaúde resultados casos de hipertensão prevalente tinham pressão arterial aferida igual ou superior a 14090 mmhg ou uso de medicação antihipertensiva via questionários autopreenchíveis aferiuse história percebida de discriminação ao longo da vida nos domínios trabalho moradia escola locais públicos e com a polícia participantes utilizaram 41 termos como respostas a pergunta aberta sobre autoidentificação racial para estas análises 48 foram classificados como afrodescendentes discriminação racial em ao menos um domínio foi relatado por 14 dos afrodescendentes em comparação com participantes brancos as prevalências de hipertensão foram mais elevadas entre afrodescendentes com história percebida de racismo do que entre aqueles sem essa história comparandose afrodescendentes com história percebida de racismo com brancos a associação com hipertensão foi mais forte entre participantes com instrução fundamental do que entre aqueles com nível universitário conclusão é possível que o racismo aumente o risco de hipertensão entre afrodescendentes no brasil a adversidade socioeconômica também influenciada pelo racismo pode potencializar esse aumento de risco palavraschave determinantes sociais da saúde racismo hipertensão saúde do adulto saúde da população negra métodos epidemiológicos methods our subjects participated in two stages of baseline data collection of a cohort study of nonfaculty civil servants at university campuses in rio de janeiro brazil all eligible employees were invited to participate the response rate was 78 more details about the study are reported elsewhere 9 the present analyses are based on data from 3056 subjects after the exclusion of 197 individuals with missing data or who selfidentified as asian or indigenous blood pressure was measured twice with mercury sphygmomanometers in compliance with standard techniques and international protocols by trained and certified technicians cases of prevalent hypertension had systolic blood pressure ≥ 140 mmhg or diastolic blood pressure ≥ 90 mmhg or reported use of antihypertensive medication quality control indicators monitored pari passu with data collection suggest that blood pressure measurements achieved high quality 10 we used selfadministered questionnaires to assess the other variables participants used 41 terms as responses to an openended question on racial selfidentification for these analyses 48 of respondents were classified as afrodescendants by means of an abridged adaptation of the everyday discrimination scale 11 the history of perceived lifetime discrimination was measured by responses to five questions with the same initial phrase have you ever been unfairly treated discriminated against at your workplace for example while getting fired applying for a job or being denied a promotion while getting housing or interacting with neighbors by the police such as being accused searched or arrested in public places such as banks shops hospitals government offices etc in your school or college for example being discouraged to continue your studies participants who reported experiences of discrimination were then asked the last time this happened to you which was in your opinion the main reason for being discriminated against the following response options were offered skin color or race being a man or a woman religion or creed illness or disability sexual orientation socioeconomic condition education or job political activism age physical appearance other in a testretest reliability study we estimated a kappa coefficient of 085 for responses related to overall discrimination for the purpose of the present analyses we created a composite exposure variable combining dichotomous data on racial selfidentification with dichotomous data on the history of skin colorracial discrimination because no white participant reported racial discrimination our exposure variable has 3 categories whites afrodescendants with no history of perceived racism and afrodescendants with history of perceived racism age and sexadjusted associations of the exposure categories with prevalent hypertension were estimated through poisson regression models with robust variance and subsequently analyzed according to three education categories statistical analyses were performed using the spss for windows version 11 the study was approved by the state university of rio de janeiro research ethics committee results our study population was within the age range of 22 69 years 56 of the subjects were females and 48 were afrodescendants the age and sexadjusted prevalence of hypertension was 21 26 and 33 respectively for white people afrono racism and afroracism compared to the whites individuals in the afroracism category had a 21 times increased prevalence of ht and those with no such history showed a prevalence ratio of 14 comparing the afrodescendants with history of racial discrimination experiences to the whites the adjusted association with ht was stronger for those with elementary education than for those with a college degree or with complete high school in an intermediate position discussion the graded associations observed in our study suggest that among afrodescendants in brazil a higher lifetime experience of racial discrimination may substantially increase the risk of hypertension the data are also consistent with the possibility that socioeconomic adversity which is influenced by societal racism may further potentiate this increased risk in a similarly graded pattern in other words a combination of these two axes of social disadvantage may be operating to our knowledge this is the first study conducted with a brazilian population to report such evidence hypertension may be one of several adverse health consequences of racebased discrimination in this study population whereas 34 of the participants reported a history of discrimination in at least one life domain afrodescendants reported histories more frequently than whites across five studied life domains 12 hypothesized mechanisms may be indirect through structuring of socioeconomic disadvantage which may influence dietary and physical activity patterning through differential access to health care or directly through psychoneuroendocrine mechanisms 67 the prósaúde study pioneered the adaptation to a brazilian population of one among several existing questionnaires aimed at the measurement of interpersonal discrimination 12 an additional strength of the study was the use of responses to an openended question that allowed participants to classify themselves by race using their own words because we also included a closeended question with response options being the brazilian census bureau list of racial categories it was possible to observe that a sizeable number of afrodescendants chose whitening categories when forced to choose from the ibge list 14 there are several potential limitations to consider when interpreting our results first we were restricted to prevalent cases of ht in theory psychological effects of hypertension labeling might include an enhanced perception of racial discrimination however we investigated this possibility by stratifying the associations we report according to prior awareness of ht and the results did not differ second even though we studied a population of civil servants with stable jobs and relatively limited socioeconomic variability we found ht prevalence similar to estimates from statewide and nationwide brazilian surveys with similar occupational groups the existing social variability also allowed us to observe distinct associations according to schooling level third we had no available data on which to assess potentially important aspects of our respondents discriminatory experiences and we were unable to analyze some of the available data due to small numbers given the severity and pervasiveness of raceand ethnicitybased discrimination and violence in the world today we believe it is critical to explore and document the health effects of these injustices in one of the worlds most diverse societies further efforts should focus on better measurement which may result from ongoing refinement of scales dealing with specific aspects of brazilian race relations 15 studies should be replicated across larger and more socially and geographically diverse populations with specific regard to hypertension further analyses should explore the association of discriminatory experiences with levels of systolic diastolic and pulse pressure as well as with ambulatory blood pressure and preclinical indicators eg vascular reactivity and endothelial dysfunction importantly the range of healthrelated outcomes of interest should be expanded and whenever possible investigated with longitudinal data specifying life domains types of discrimination and coping mechanisms advances in cognitive research eg implicit association tests may prove especially helpful 16 more broadly it will be important to shed light on the web of proximate factors mediating the associations between race discrimination and health eg lifestyle health care and the direct effect of chronic stress a combination of research methods will allow better investigation at levels of society where complex mechanisms of discrimination beyond interpersonal experiences are known to operate 1617 in particular a detailed life course perspective including concepts such as sensitive and latency periods and ageperiodcohort analyses 18 would benefit further studies of the complex relationships between discriminatory experiences and socioeconomic disadvantage

introduction brazil has the largest population of african descendants outside africa objective mindful of the imprint of slavery on their contemporary social position we investigated the relationship of perceived racism to hypertension methods we analyzed data 1999 2001 from 3056 civil servants mean age 42 years 56 females at university campuses in rio participating in the longitudinal prósaúde study results cases of prevalent hypertension had measured blood pressure equal to or greater than 14090 mmhg or used antihypertensive medication selfadministered questionnaires assessed participants perceived history of lifetime discrimination due to race gender socioeconomic position and other attributes at work and school neighborhood public places and in contact with the police participants used 41 terms as responses to an openended question on racial selfidentification for these analyses 48 were classified as afrodescendants racial discrimination in at least one setting was reported by 14 of afrodescendants compared to whites the ageand genderadjusted prevalence of hypertension was higher for afrodescendants with history of selfperceived racism prevalence ratio pr 21 95 ci 15 30 than for those with no such history pr 15 95 ci 12 18 comparing the former to whites the adjusted association with hypertension was stronger for those with elementary education pr 30 95 ci 13 67 than for those with a college degree pr 17 95 ci 10 31 conclusion racism may increase the risk of hypertension of afrodescendants in brazil and socioeconomic disadvantage also influenced by societal racism may further potentiate this increased risk

introduction in china the rural revitalization strategy was first formally proposed in the report to the 19th national congress of the communist party of china aiming to address the issues concerning agriculture rural areas and farmers in a highquality manner to expand middleincome groups and to achieve common prosperity for all people the issue of absolute poverty in china was solved historically however there will still be people earning low incomes in society according to the bulletin of the third national agricultural census by the end of 2016 largescale businesses accounted for only 192 of the total agricultural households registered in china 1 for professional farmers agriculture is the main source of income in the modern era the key to consolidating the achievement of poverty alleviation is to effectively and consistently increase the income of farmers who live in rural areas due to productivity disadvantages how to increase agricultural income has become key to promoting common prosperity to achieve substantial progress as well as being a highly regarded research topic on the one hand social capital is essential to improve farmers lives which is the essence of rural revitalization 2 traditional rural china is a society of acquaintances or semiacquaintances 3 giving rise to social capital which is an invisible social resource based on emotional connections this relationship network composed of blood relationships geography and kinship is the main form of rural social capital in china 4 in china personal relationships are extremely important in society thus social capital exists among family kinship and neighborhood relationships therefore it is widely believed that social efficiency can be improved through the network relations norms and trust that comprise social capital 5 especially in rural areas where market systems may not yet be perfected this traditional chinese guanxi plays an important role in resource allocation such as creating employment opportunities increasing the income of the most disadvantaged narrowing the income gap and mitigating risk impact which all play an immeasurable role in reducing the incidence of poverty 6 in poor rural areas where both physical capital and human capital resources are relatively scarce social capital has played the role of poor capital to a certain extent 7 helping individuals to obtain sufficient market information reducing transaction costs and promoting cooperation by virtue of private trust and interpersonal relations 8 easing financial pressure through mutual borrowing between relatives and friends filling financial loopholes in rural areas as an informal capital carrier 9 reducing the credit constraints of farmers by representing informal guarantees 10 and providing a sustained impetus to reduce or even eliminate longterm poverty 11 social capital in the form of potential capital also plays a good role in resisting risk 12 moreover social capital can also indirectly improve the level of income by influencing investments in human capital and material capital 13 in the contemporary period social capital is still playing a role in promoting farmers income under rural revitalization strategies and land system reforms the mobility of rural residents has greatly increased leading to gradual loosening of the interpersonal network and reshaping traditional rural social capital which is mainly characterized by acquaintances and closed networks thus the countryside is no longer a closed community 14 in the process of agricultural modernization gradual improvements in the market system and the development of rural areas from closed to open are widely believed to have eroded the chinese guanxi basis of the role of traditional rural social capital which has led to doubts about the role of social capital in promoting farmers income for example zhang shuang et al hypothesized that with improvements in marketization the role of social capital in poverty will be weakened and especially the role of family social networks 15 however it should also be observed that the urbanrural relationship has smoothly undergone the rural hollowing out stage and entered the return stage of migrant workers which has brought back talent technology and capital at this time the network of new social capital is more open and contains a wider range of social relationships including more urban relationships on the normative side the digital economy and the internet have prompted social capital to act in a more resilient manner additionally the internet has further reduced constraints on the level of trust improved the gray character which traditional social capital possesses and expanded the possible ways in which social capital can work to boost farmers incomes and fight poverty under rural revitalization novel rural social capital is becoming more modern advanced extensive and digital as a kind of invisible soft capital it plays a wider role in attracting human capital material and financial resources forming a good circulation network between rural and urban areas and reinforcing mechanisms of the role of traditional social capital in promoting farmers agricultural income ie the expansion of farmers financial sources the enrichment of information and the establishment of social networks therefore social capital and rural revitalization are mutually supportive the embedding of social capital is conducive to the realization of rural revitalization the implementation of the rural revitalization strategy enriches rural social capital and attracts more social capital back to the countryside 2 moreover the degree of modernization in rural areas in china is still weak in the transition period under the condition that system and market are not sound relationship plays an extremely important role as one of the bases and ways for farmers to obtain scarce resources 16 under rural revitalization strategies local employment remains the most effective and sustainable means of alleviating poverty considering the longterm effectiveness and cost the cyclical opening and closing of cities caused by the covid19 pandemic has led to a decline in employment demand in some urban industries especially in the contact service industry ultimately leading to a substantial increase in migrant workers returning home for employment data from the ministry of agriculture and rural affairs of the peoples republic of china showed that by the end of 2021 112 million entrepreneurs had returned to the countryside 11 million more than in 2020 17 therefore the local employment of migrant workers urgently needs to promote the largescale development of agricultural industrialization land is the most basic and important production factor for agriculturalscale management moderatescale agriculture relies on the consolidation of agricultural land and farmland transfer 18 thus an increase in land transfer provides an important guarantee for agricultural modernization 19 in rural china the household responsibility system implemented in the early 1980s promoted production motivation in peasants and led to serious farmland fragmentation which curbed largescale agriculture operations 20 in 1988 the transfer of land contract management rights was officially permitted 21 which effectively promoted the transfer of farmland and created better conditions for moderatescale agricultural management by the end of 2019 the degree of farmland transfer exceeded onethird of the total farmland area 22 for professional farmers one of the best ways to increase income is by transferring into land and developing it into a large agricultural enterprise in order to improve the efficiency of resource allocation professional farmers should expand the scale of farmland to cater to contemporary agricultural production 23 thus far connections between social capital and agricultural development have been the key focus in academia such as the associations between different forms of social capital and innovation in agriculture 24 social capitals critical role in agricultural and rural development in various countries 25 as well as the role of social capital in development of agricultural entrepreneurship 26 however the existing research literature is fragmented with respect to the impact of social capital on farmers income and the impact of land transfer on agricultural scale management ignoring the important intermediary role of land transfer from the perspective of traditional human social relations studies on how to increase agricultural income in the modern era are insufficient the importance of land to farmers is often ignored therefore it is of great practical significance to study the influence of new social capital for rural revitalization on agricultural income through embedding into land transfer land transfer is measured by two variables land transfer in and land transfer out land transfer in means that farmers rent land from other local farmers through written or verbal contract 27 it is more directly related to farmers agricultural income and was the research object of this study china is a society of traditional chinese guanxi in which social capital plays a supplemental role in the formal system 28 in fact rural households with more capital can more easily transfer into land for largescale production and thus earn more farm income 29 land transfer is an important bridge for social capital to embed in rural revitalization which ultimately raises farming income for farmers as an intangible capital embedded in the vast rural areas social capital plays an important role in achieving regional agricultural specialization and scale development as well as supplementing agricultural modernization the trust and relationship values of social capital are embedded in the process of land transfer and become informal institutions which influence peoples interactive behavior thus improving the financial capacity of individuals or households to transfer into land on the one hand and increasing the possibility of transferring into land through social relationship networks on the other therefore with continuous rural revitalization it is highly significant to explore the logical correlation between social capital farmland transfer in and agricultural income with the contemporary rural society becoming more open which is important for reconceptualizing rural social capital improving professional farmers income and promoting the overall goal of rural revitalization the key research questions of this study are how do land transfer in and new social capital affect agricultural income under rural revitalization is farmland transfer in one of the important ways for the new social capital to influence agricultural income under the constraint of the scale of farmland transfer in is there a nonlinear relationship between social capital and agricultural income materials and methods the effect of social capital on agricultural income farmers are the largest social group in china but also a group with relatively low income lower level of living security and weaker endowments of market resources in the foreseeable future farmers will still be heavily reliant on the countryside and agriculture and those who relocate to cities may still return the countryside 3 agricultural income refers to the minimum earnings for farmers who cannot live in cities and those who have returned to their hometowns to maintain basic living security social capital can effectively reduce the incidence of poverty and the income gap through a variety of ways as has been confirmed by many scholars 261113 thus there is also a direct impact of social capital on the agricultural income of general agricultural workers who are the largest population among the most disadvantaged in society for most villagers who have lived in the countryside for a long time their traditional social capital has been seriously drained with farmers urbanization although rural revitalization has injected modern features into the social capital and reconstructed the rural social structure characterized by a traditional closedloop this has led to an irreplaceable role of promoting farmers agricultural income using new social capital the report to the 19th national congress of the communist party of china clearly put forward the general requirements for the implementation of rural revitalization from five aspects these were correlated to contemporary rural issues mainly referring to revitalizing the rural industrial economy optimizing the rural living environment reconstructing rural local culture promoting effective governance and improving farmers living standards 30 the massive backflow of rural labor has brought advanced production factors such as urban technology knowledge experience and capital to rural society with the support of the rural revitalization policy additionally those strategic resources were effectively diffused through the relationship network of social capital on the one hand alleviating the loss of traditional rural social capital and the weak social capital of longstaying rural farmers mainly women the elderly and children and sustaining traditional rural social capital in continually increasing farmers income on the other hand urban capital is injected into rural capital with the return of migrant rural workers alleviating the plight of farmers who find it difficult to raise funds to expand agricultural production especially in remote mountainous areas in china where the returned social capital becomes a key resource at the same time as an information carrier novel social capital implies a broader social relationship referring to urban relations carrying advanced production factors which can improve agricultural productivity and modernization and ultimately contributing to increased farmers agricultural income under rural revitalization as an invisible soft capital new rural social capital has a broader role in attracting human capital material and financial resources forming a good circulation network between rural and urban and reinforcing the mechanisms of the role of traditional social capital in promoting farmers agricultural income notably through the expansion of farmers financial sources the enrichment of information and the establishment of social networks based on the above discussion this study proposes the first research hypothesis hypothesis 1 rural social capital can still contribute to the growth of agricultural income of farm households through various mechanisms ie social capital has a direct relationship with agricultural income influence of land transfer in behavior on farmers agricultural income as a typical chinese guanxi society the characteristics of acquaintance society exist across rural china social relations play a very important role in resource acquisition distribution and transaction 31 and become an important influencing factor in the farmland transfer among the forms of land transfer the most popular is land leasing farmers pay a certain amount of farmland rent and lease land thus expanding their production scale when the marginal revenue exceeds the marginal cost farmers can profit from agricultural production the incomeincreasing effect of agricultural land transfer is mainly manifested in the economy of scale effects economy of scope effects and the labor division effects of agricultural production farmland transfer in may exert several effects on agricultural income the first and most important effect is the scale effect then the scope economy effect and the division of labor effect specifically the transfer of agricultural land has realized increases in land input factors and expanded the production boundary of land factors under the actions of advanced technology knowledge and human and material capital of rural revitalization thus increases in land inputs can bring increasing returns to scale and promote the effective expansion of agricultural output specifically land transfer in implies a land input increase for agricultural production whereas the improved technology knowledge talent and material capital of rural revitalization extend the production boundary of land factors enabling increases in land inputs to bring incremental returns to scale and promote the effective expansion of agricultural output then the expansion of cultivated land area enlarges the adjustable range of agricultural production 32 the average longterm cost of output tends to decline as the category of agricultural output increases by optimizing the planting structure and factor input ratios farmers can achieve the best agricultural outputs finally the transfer in of farmland is conducive to the moderatescale operation of agriculture and the consolidation of farmland is conducive to the mechanization of agriculture 33 these are conducive to the growth of new agricultural business entities led by professional farmers and of family farms at the same time however some farmers who transfer out of the land will change from professional farmers to parttime farmers or enter the nonagricultural population this differentiation of the labor force will undoubtedly lead to a differentiation between agricultural production and income accordingly research hypothesis 2 was formulated hypothesis 2 land transfer in can promote farmers farm income impacts of social capital on farmland transfer in behaviors the role of social capital in all aspects of agricultural production is similar the process of land transfer for agricultural income generation involves reduced transaction costs the access to lease capital and information risk sharing and cooperation mechanisms in the establishment of longterm land transfer behavior and the input of urban production factors all carried out under a network of rural social interactions therefore rural social capital can effectively promote farmers land transfer in behavior which in turn promotes agricultural income growth thus land transfer plays an intermediary role in the process of social capital promoting the growth of farmers income and is one of the mechanisms through which social capital directly affects farmers agricultural income accordingly research hypothesis 3 was formulated hypothesis 3 social capital has a positive effect on land transfer in and land transfer in is an important way for social capital to increase agricultural income and plays an intermediary role finally existing studies have identified that the more disadvantaged people are not originally superior in terms of social capital accumulation ie social capital does not significantly increase agricultural income when farmers social capital is low and social capital can only significantly contribute to higher farm household income and thus reduce farm incomes poverty when social capital crosses a certain threshold value 34 therefore research hypothesis 4 was hypothesis 4 the scale of rural land transfer in has threshold characteristics under the constraints of different scales of farmland transfer in the impact of social capital on agricultural income is also different the theoretical analysis framework of social capital→farmland transfer in→agricultural income and hypotheses are shown in figure 1 finally existing studies have identified that the more disadvantaged people are not originally superior in terms of social capital accumulation ie social capital does not significantly increase agricultural income when farmers social capital is low and social capital can only significantly contribute to higher farm household income and thus reduce farm incomes poverty when social capital crosses a certain threshold value 34 therefore research hypothesis 4 was hypothesis 4 the scale of rural land transfer in has threshold characteristics under the constraints of different scales of farmland transfer in the impact of social capital on agricultural income is also different the theoretical analysis framework of social capital→farmland transfer in→agricultural income and hypotheses are shown in figure 1 data variables and methodology data the data used in this study were acquired from china family panel studies according to the introduction from china family panel studies is a nationally representative annual longitudinal survey of chinese communities families and individuals launched in 2010 by the institute of social science survey of peking university china the survey focuses on economic activities education family behaviors etc and covers 25 provinces in china over a wide range of locations giving it great research value it is presented in the form of questionnaires including individual questionnaires family questionnaires and village questionnaires this study used data obtained in 2020 which are the most recent publicly available data some villagelevel control variables were used in this study therefore the cfps 2014 village data and 2020 household data were matched and combined in addition some variables from the 2010 baseline survey which were not included in cfps 2020 were used the research object was agricultural income thus the samples of households not engaged in agricultural production were omitted after processing this study obtained a final 3789 effective samples of agricultural families which were distributed in 297 villages around 25 provinces in china compared with previous studies the data used in this study have the advantages of a large sample size new data and wide geographical coverage variables dependent variable the dependent variable in this study was the agricultural income of households engaged in agricultural production the family questionnaire of cfps 2020 includes the question in the past 12 months how much does your family get by selling agricultural products including the crops you cultivated forestry products poultry livestock fishery this study used data obtained in 2020 which are the most recent publicly available data some villagelevel control variables were used in this study therefore the cfps 2014 village data and 2020 household data were matched and combined in addition some variables from the 2010 baseline survey which were not included in cfps 2020 were used the research object was agricultural income thus the samples of households not engaged in agricultural production were omitted after processing this study obtained a final 3789 effective samples of agricultural families which were distributed in 297 villages around 25 provinces in china compared with previous studies the data used in this study have the advantages of a large sample size new data and wide geographical coverage variables dependent variable the dependent variable in this study was the agricultural income of households engaged in agricultural production the family questionnaire of cfps 2020 includes the question in the past 12 months how much does your family get by selling agricultural products including the crops you cultivated forestry products poultry livestock fishery products and other sideline products produced or raised by your family the answer to this question was the dependent variable we adopted in this study the unit of measurement of the variable was cny and we treated the data logarithmically main independent variable farmers social capital to date due to the extensive meaning of social capital there is still no unified standard for selecting indicators for this variable according to the definitions of social capital outlined by james s coleman et al 35 all points emphasize the connections among people based on reciprocity and trustworthiness generally the maintenance of this kind of connection not only depends on blood relationships and geographical connections but also on the economic exchanges to reflect the level of favor exchanges engaged in by farmers gift spending is a stable index 36 in addition the total amount of money spent annually on relatives neighbors and friends including transfers represents the daily economic exchanges 28 communication fees were also considered in this study in the family questionnaire of cfps 2020 all the answers pertaining to communication fees gift spending and money given to relatives and to others were totaled to measure the level of favor exchanges which represents the spending on social capital the unit of measurement of this variable was cny and we treated these data logarithmically land transfer in although there are many different forms of land transfer in rural china in the questionnaire only farmland leasing was studied thus in this paper land transfer in refers to renting in farmland from others in the family questionnaire one question is in the past 12 months did your family rent any other land than the collectively distributed land from other people or the village collective regardless of paying land rent or not the answer to this question represented the independent variable land transfer in here was a dummy variable if the farmer had rented farmland from others in the past year the variable value was 1 otherwise the value was 0 control variable inspired by previous studies in order to control the impacts of other factors on agricultural income this study controlled the characteristics of family and village in addition province dummies were included control variables relating to the family included farmland size family size farm machinery rental fee family deposits machine values other income sources and life status village control variables included village economic status altitude village farmland size the number of noticeboards and urban and rural categories the model variables are all described in table 1 machine value methodology to evaluate the influence of social capital and land transfer in on agricultural income the benchmark model was set to equation agricultural income β 0 β 1 social capital β 2 land transfer in γx ε to test the intermediary effect of land transfer in referring to baron and kenny 37 a threestep regression was used in this study three regression models were set as equations agricultural income α 0 α 1 social capital γx ε land transfer in θ 0 θ 1 social capital γx ε agricultural income β 0 β 1 social capital β 2 land transfer in γx ε to test h4 whether the scale of rural land transfer exhibits threshold characteristics the threshold regression model was set to equation agricultural income ϕ 0 ϕ 1 social capital •i ϕ 2 social capital •i γx ε in equations and agricultural income is a continuous variable and these three models adopted multiple linear regressions in equation the dependent variable of land transfer in is a binary variable which uses the probit regression model in equation the threshold variable of the scale of land transfer in equals the ratio of farmland transfer in area to the households operational farmland acreage where i is the indicator function and λ is the threshold value x represents a series of matrix of control variables ε is a standard error and α β ϕ θ and γ are the parameters to be estimated empirical results the impact of social capital and land transfer in on agricultural income stepwise regression was adopted to estimate the effect of social capital and land transfer in on agricultural income in addition in this study the proxy variable of social capital was the money spent on maintaining the acquaintance relationship which could lead to a twoway causal relationship thus the variable of social capital was an endogenous variable in the basic model to solve this problem an instrumental variable was adopted in the village questionnaire of cfps 2014 one question concerns the proportion of popular surname in rural china in the same village people with the same surname are usually more closely related residents with the same surname can represent more useful social capital for villagers in their daily life it is obvious that the proportion of popular surname is a good instrumental variable which is not only exogenous but also highly correlated with the independent variable after the exogenous test and weak identification test the instrumental variable was shown to be effective then 2sls and gmm models were used to estimate the impact of social capital on agricultural income table 2 reports the empirical results of the ols 2sls and gmm models models to show the stepbystep addition of control variables the results of models and were obtained after adding instrumental variables table 2 shows that the coefficients of social capital and land transfer in are consistently significantly positive in the process of adding control variables one by one the estimation results presented in table 2 indicate that more social capital can help farmers access more effective help and increase agricultural income at the same time the transfer in of agricultural land is conducive to the expansion of the scale of agricultural production which can help increase agricultural income the results support research hypotheses 1 and 2 of this study social capital effectively promotes the development of rural society through network norm trust and other attributes farmers can have advantages in agricultural management and production by virtue of the materials and relationship support provided by social capital thus the amount of social capital that farmers have is transformed into their ability to obtain agricultural income similarly the increasing input of land factors can still significantly promote agricultural production in the process of rural modernization social capital can form a positive interaction with land transfer in and better social capital can promote the smooth conclusion of land leasing whereas land leasing can effectively expand interpersonal networks and trust capital which together can contribute to the increase in farmers agricultural income when household and village characteristics are controlled the results of model 5 show that the effects of housing type wage income and urban households on agricultural income are negative but insignificant whereas the effects of the remaining control variables are positive but not all significant the type of house reflects the economic level of farmers to a certain extent therefore it will affect their agricultural income people with wageearning and urban households tend to have less willingness to engage in agriculture ie income diversity can replace agricultural income and lead to a decrease in farm income models and imply that after dealing with endogenous problems effectively the coefficients of the main independent variables become larger robustness test subsequently we used the method of throwing samples to examine the robustness of the benchmark regression results firstly model reports the impact of social capital and farmland transfer in on agricultural income with the whole sample secondly as a comparison model to model report the regression results of the partial samples the research object of this study was households engaged in agricultural production which were mainly located in rural areas urban households were included in model similarly village samples without cultivated land were removed in model in model the agricultural households samples without contracted farmland were removed because their agricultural outputs were all dependent on land leasing which may interfere with the regression results finally because chinas agricultural production is based on households and smallscale operations still occupy a large proportion the samples of family farms with a farmland acreage larger than 30 mu is excluded in model to test whether the effect of social capital on agricultural income is stable among farmers engaged in smallscale agricultural production table 3 reports the parameter estimation results with the change in sample size with the decrease in sample size the influence of social capital and farmland transfer in on farmers agricultural income is still significantly positive for farmers whose farmland operation scale is less than 30 mu the contribution of social capital to agricultural income is more obvious and the marginal contribution is up to 2792 thus for professional farmers who stay in rural areas for a long time possessing a certain amount of social capital can provide them with certain resources for agricultural production rural social capital undergoing revitalization still actively influences farmers willingness and behaviors it can be seen from table 3 that the results of the benchmark regression model are still reliable when the sample size changes individual and regional heterogeneous impacts this study adopted quantile regression to estimate the individual heterogeneity in table 4 for different quantiles of agricultural income impacts of social capital and farmland transfer in on agricultural income were different model and model show parameter estimates for selected quantiles model deals with the endogenous problem model implies that with the increase in quantile the coefficient of social capital increases significantly in other words compared with farmers with low agricultural incomes for farmers with higher agricultural incomes social capital plays a greater role in increasing agricultural income however the effect of land transfer in on agricultural income is the opposite model shows that for farmers with low agricultural incomes land transfer in plays a more important role in increasing agricultural income which to some extent implies that the agriculturalscale operation of lowincome farmers is insufficient and increasing the land use area is more relevant for lowincome farmers to increase their agricultural income 8 and standard errors in parentheses of model and p 005 p 001 the main grain producing provinces include liaoning hebei shandong jilin inner mongolia jiangxi hunan sichuan henan hubei jiangsu anhui and heilongjiang to evaluate regional heterogeneity rural china was separated into two parts model outputs the regression result of the maingrain producing area in china in contrast model presents the regression result of other regions in china in the 13 main grainproducing areas the output value of the primary industry accounts for a large proportion and the grain output accounts for more than 70 of the national share due to different geographical factors the types of agricultural crops in the maingrain producing area and other regions are different and the degree of agricultural modernization is also different comparing the results of model and model we can see that social capital has a significant positive effect on agricultural income in the maingrain producing area however in other regions the role of social capital is positive but not significant farmland transfer in is helpful to increase agricultural income but this effect is more obvious in secondary grainproducing areas this result suggests that the use value of land should be further reflected in rural areas and farmers income space should be expanded and fully integrated with local conditions the intermediary mechanism test in order to further determine the mechanisms of social capital and farmland transfer in on farmers agricultural income this study took farmland transfer in as an intermediary variable and further estimated equations after performing the sobel test the original hypothesis that there was no mediating effect was rejected and a mediating effect was shown to exist table 5 presents the threestep regression results model shows that social capital has a significant positive effect on agricultural land transfer in at a significance level of 5 indicating that the role of social capital is conducive to the transfer in of farmland and the expansion of agricultural scale model is the direct impact of social capital on agricultural income model shows that the effect of social capital on the increase in agricultural income is significantly weakened after adding the intermediary variable the regression coefficient changed from 01818 to 01656 which further verified the existence of partially mediating effects this conclusion proves that the transfer in of farmland is an important mechanism for social capital increasing agricultural income and plays an intermediary role 18 and is agricultural income the threshold mechanism test the effect of social capital on agricultural income is strongly dependent on land transfer in which implies that there is a threshold of the scale of land transfer in to be identified after attempting to identify the threshold effects we obtained statistically significant results with three stable threshold values as shown in table 6 the first and second threshold values of the farmland transfer in scale were 014 and 0176 respectively at a significance level of 5 the third threshold value of the farmland transfer in scale was 15 with a significance level of 10 table 7 presents the results of the threshold regression the results in table 7 imply that under the constraint of different scales of farmland transfer in the influences of social capital on agricultural income are disparate under the condition that other related variables are controlled it can be found that when the ratio of farmland transfer in area to the households operation farmland acreage is ≤14 the effect of social capital on agricultural income is significantly positive but when the ratios of farmland transfer in area to the households operation farmland acreage are 14 and ≤176 the effects of social capital on agricultural income are negative when the ratio of the farmland transfer in area to the households operation farmland acreage is 176 the role of social capital will significantly contribute to the increase in agricultural income and with the expansion of land transfer in scale this role will become more obvious this result also provides strong evidence for moderatescale agricultural operations discussion based on the data of 3789 rural households from the china family panel study this study examined the direct impact of farmland transfer in and social capital on agricultural income and the mediating role of land transfer in in the process of social capital contributing to farm income generation compared with previous studies marginal contributions of this study include based on the era of rural revitalization this study explored the impact of new social capital on the agricultural income of farmers who have stayed in rural areas for a long time on the basis of traditional rural social capital this study not only considered the direct impact of social capital and land transfer in on agricultural income but also tested whether land transfer in behavior plays a mediating role in the effect of social capital on agricultural income establishing a theoretical analysis framework of social capital→farmland transfer in→agricultural income this study responds to current questions about whether the new social capital reconstructed under chinas rural revitalization strategy can still significantly contribute to farmers agricultural income and confirms that social capital still plays an active role in chinas new rural areas this study has dealt with the endogenous problem and discussed the individual heterogeneity of farmers and regional differences in rural china this study has discussed the nonlinear relationship between social capital and agricultural income under the constraints of different scales of farmland transfer in which enriches the literature on agricultural income from a worldwide perspective the use of the acquaintance relationship is beneficial to farmers which has implications for all agricultural households for farmers land is the most basic living guarantee and agricultural income is the most basic source of income how to increase agricultural income is a topic worth considering under rural revitalization strategies currently the weakest links to achieving widespread prosperity are agriculture rural populations and farmers for rural areas in the primary stage of revitalization it is still necessary to strongly consider social capital however the use of the acquaintance relationship should only be a supplement to the standardized market and should not become the mainstream there are many similarities and differences between this study and previous analyses presented in the literature social capital contributes to farmland transfer which is similar to the results obtained by of chen h and wang j 38 however we further analyzed the complex relationship among social capital land transfer in and agricultural income moreover based on the novel background of the gradual disintegration of traditional rural society this study explored whether new social capital under rural revitalization can still promote growth in agricultural income and addressed some doubts qian 39 studied the role of social capital in land transfer however we discussed the endogeneity and heterogeneity expanding the research future regarding the relationship between agricultural land transfer and agricultural income this study proves once again that the moderatescale operation of agricultural land is conducive to increasing agricultural income which is consistent with the results of yan et al 40 our research also has some shortcomings first of all there were some limitations in the selection of proxy variables of social capital which cannot summarize all the characteristics of social capital secondly the impacts of social capital and farmland transfer on agricultural income are dynamic although crosssectional data were used in this study thus panel data could be used for future research additionally social capital will not only affect farmland transfer in but also affect farmland transfer out which will also affect agricultural income thus the influence of social capital on land transfer out and agricultural income could be a research topic in future studies conclusions based on this analysis several conclusions can be drawn in rural china social capital is a useful resource for farmers which is conducive to farmland transfer in thus contributing to increases in agricultural income with the increases in social capital investment agricultural income will also increase and after controlling other related variables the marginal contribution of social capital investment to agricultural income is 1656 and the marginal effect of farmland transfer in on agricultural income is 119 social capital and land transfer in are directly related to agricultural income in addition the impact of social capital and farmland transfer in on agricultural income presents individual heterogeneity and regional heterogeneity the farmland transfer in is a mediating variable which is one of the important channels for social capital to influence agricultural income land is a direct factor of agricultural income and one of the mechanisms by which other variables affect agricultural income farmland transfer in ratio is a threshold variable and under the constraint of the scale of farmland transfer in a nonlinear relationship exists between social capital and agricultural income farmland transfer in is conducive to increasing agricultural income but this effect is more obvious in secondary grainproducing areas from the results of this study it seems that for farmers in an acquaintance society proper maintenance of acquaintance relationship is beneficial for government departments the implementation of the separation of three rights land policy could better address the issues concerning agriculture rural areas and farmers and have a beneficial impact on local farmers income complemented by social capital finally the standardized development of the land transfer market is very important social capital plays an important role in the vast rural areas of china where market modernization is inadequate however the use of an acquaintanceship can only be a supplement to standardized markets and the process of agricultural and rural modernization still needs to be accelerated as well as the need for traditional social capital to be further reconstructed data availability statement the data used in this study comes from china family panel studies author contributions data curation wz methodology sp writingoriginal draft hy all authors have read and agreed to the published version of the manuscript

exploring the role of land transfer and social capital in improving agricultural income under the background of rural revitalization

introduction depression is a common mental health issue experienced by adolescents in south korea researchers have found that one contributing factor for high levels of adolescent depression is neglect by parents or caregivers 4 5 6 7 one intervention that has been found to be successful in reducing levels of depression among highrisk adolescents are formal mentorship programs or programs where one person is matched with another person who provides support in various ways formal mentorship programs are distinguished from informal mentorship programs by the fact that formal programs have a set of guidelines or a process in which the mentorship takes place while informal mentoring is more unstructured 10 some aspects of effective formal mentorship programs include consistent meetings between mentor and mentee and open communication between mentor and mentee 1011 such mentorship programs may be particularly beneficial for adolescents with neglectful parents and caregivers as such programs provide them with an adult who takes a supportive and structured role in their lives however more research is needed on the moderating role of participation in a mentorship program on the relationship between adolescents experiences of parental neglect and adolescents depression literature review 21 depression among lowincome adolescents a few studies have examined the relationship between income or socioeconomic status and depression among adolescents in south korea and findings have been mixed as to the association between depression and household income or socioeconomic status 21213 data from a 2006 survey of korean youth indicated that adolescents with a lower socioeconomic status were more likely than adolescents with a high socioeconomic status to experience depression 2 however data from another national survey of korean youth revealed no significant differences in adolescent depression depending on their households monthly income 12 additionally in one sample of more than 75000 middleand high school students 4396 of girls and 3203 of boys reported experiencing depressive symptoms in the past year and students in highincome households reported worse depression than students in lower income households 13 despite these mixed findings on the association between socioeconomic status and depression prevalence of depression has been found to be fairly common among south korean adolescents with prevalence rates ranging from across a number of studies 1314 of note the recent covid19 pandemic has also contributed to increased depression among adults in south korea and adolescents in other countries including australia china and the united states 6 15 16 17 such increases in depression have been particularly evident among lowincome adolescents or among adolescents whose parents have experienced a job loss 18 19 20 increases in depression during the covid19 pandemic may be associated with reduced contact with friends and extended family a reduction in physical activity or participation in sports difficulties with virtual schooling boredom and fear of coronavirus infection for example 15161819 negative effects of parental neglect during adolescence researchers have found that experiencing parental neglect during adolescence is positively associated with adolescents depression 4 5 6 7 first in a study of multicultural adolescents living in south korea with a korean father and a nonkorean mother adolescents who reported that their parents engaged in a neglectful parenting style had higher depression than those who did not 6 further in a longitudinal assessment of the effect of childhood and adolescent neglect and abuse on adolescent and adult depression the researchers found that american adolescents who had experienced neglect were 249 times more likely to be diagnosed with major depression than those who did not experience neglect 4 additionally among a large sample of us adolescents with a current case with child protective services researchers found a significant impact of parent or caregiver neglect on adolescents depression 5 last in a rapid systematic review of the research on adolescent neglect published between 1990 and 2014 nine of the thirteen included studies found that neglect was positively associated with internalizing symptoms including depression 7 positive effects of mentorship programs during adolescence mentorship programs have been found to have various benefits for adolescent mentees in an evaluation of a communitybased intervention that included mentorship and weekly meetings among the 1012yearold girls who attended they showed improvements in selfesteem peer bonding and school attachment 23 a systematic review of mentorship programs targeted at young people with disabilities revealed that such programs had positive outcomes related to academic achievement and employment outcomes 21 in another systematic review of mentorship programs in new zealand researchers found that 86 of such programs were effective at reaching their goals relating to psychological outcomes and 73 met their goals relating to youths interpersonal outcomes 24 additionally mentorship programs specifically have been found to affect participating adolescents depression 8922 in a schoolbased mentorship program that paired us elementary and middle school students with learning disabilities andor attentiondeficit hyperactivity disorder adhd with mentors showed that participating students had decreased depression after participation in the program compared to baseline while students in the control group experienced increases in depression over the period of the mentorship program 8 moreover in a study of swedish eighth graders students who participated in structured afterschool activities had significantly lower depression than adolescents who did not participate in such an activity and this was particularly true if the adolescent reported a high level of support from the adult running the activity 22 further participation in an afterschool activity was associated with lower depression among adolescents who reported a detached relationship with their parents characterized by feeling distant or not spending much time together 822 last 1215yearold atrisk us youths who participated in a program that assigned the youth to a trained adult mentor in the community showed a significant decrease from prepost levels of depression 9 the current study researchers have found that depression is common in adolescence particularly among those from lowincome households 214 that parental neglect in adolescence is associated with increased depression and that participation in a mentorship program is associated with decreased depression despite this little research has examined the moderating role of participation in a mentorship program on the relationship between parental neglect in adolescence and adolescents depression particularly in the south korean context nor has there been a great emphasis on the effect of adolescents satisfaction with the mentorship program on these relationships at the time this study was conducted in april 2021 the world was still combatting the covid19 pandemic however in south korea schools were partially reopened beginning in june 2020 did not have a fullscale lockdown and had a comparatively low mortality and case rate compared with other countries 25 26 27 with this in mind in this study we address the following research question among adolescents from lowincome households participating in a mentorship program does satisfaction with the mentorship program moderate the relationship between parental neglect and depression methods participants and sampling participants were middle and high school students in south korea participating students were limited to those who had grown up in lowincome households the korea development bank kdb foundation which is a charitable and nonprofit organization recruited middle and high school students in lowincome families to provide a mentorship program yearly poverty income guidelines were employed to determine if they were lowincome students a total of 264 participants from all provinces in south korea were registered for the kdb foundations mentorship program data collection occurred in april 2021 and the questionnaire was provided via google forms we sent a text message to participants with a link to the online survey experts in working with lowincome students such as a social worker in the kdb foundation and a middle school teacher reviewed the questionnaires to refine the questions and to protect students rights students who engaged in the online survey were given a 5 gift card as a reward on average it took about twenty minutes for students to finish the survey a consent form was provided before the online survey and required consent from both students and their caregivers some students did not participate in the survey because either they refused to consent or their caregivers did further other students who we could not reach due to wrong contact information were excluded thus a total of 255 respondents were included in the final sample as this survey did not collect any private information such as name address etc and did not have any risks to participants the institutional review board approved the current study measures depression respondents were asked to report levels of depression this study used a short form of the center for epidemiologic studies depression scale cesd to measure participants depression the measurement consists of seven items i did not feel like eating my appetite was poor i had trouble keeping my mind on what i was doing i felt depressed i felt that everything i did was an effort my sleep was restless i felt sad and i could not get going a fourpoint likerttype scale was employed and response options ranged from rarely or none of the time to most or all of the time the score of all items was summed and higher scores indicate higher levels of depression cronbachs α of the cesd scale in this study was 081 neglect neglect in this study refers to how much middle and high school students have experienced neglect by their parents or caregivers the parentchild conflict tactics scale ctspc developed by straus hamby finkelhor moore and runyan 28 was utilized to measure neglect of students by parents or caregivers the fiveitem neglect scale one of subscales of the ctspc was provided to students in the original scale parents or caregivers were asked to report neglect but in this study we had the child or adolescent report neglect the five items of this subscale include i had to be home alone even when some adult should be with me my parents or caregivers were so caught up with their problems that they were not able to show or tell me that they loved me my parents or caregivers were not able to make sure i got the food i needed my parents or caregivers were not able to make sure i got to a doctor or hospital when i needed it and my parents or caregivers were so drunk or high that they had a problem taking care of me response options in this study were 1 this has never happened 2 not in the past year but it happened before 3 12 times in the past year 4 35 times in the past year 5 once a month 6 23 times a month and 7 more than once a week each item was summed and higher scores mean higher levels of neglect the neglect scale had a cronbachs alpha of 082 satisfaction with the mentorship program respondents were asked to answer the extent to which they were satisfied with the quality and benefits of the mentorship program the mentorship program provided by the kdb foundation provides oneonone mentoring by matching mentees with a mentor lowincome students selected by the kdb foundation have the mentorship program until they graduate high school if they would not refuse to the mentorship program generally mentees were recruited at the beginning of academic year mentors include social workers teachers professionals who specialize in psychology etc and mentees were middle or high school students in lowincome families based on a guide provided the kdb foundation for the mentoring program the mentors encourage students to develop their abilities for future careers and increase psychological wellbeing through mutual communication inperson communication with a mentor was available at least once a month but online formats including phone call or webinars were an alternative way for the meeting due to covid19 generally the meeting lasts more than two hours however it is flexible depending on students needs thus the mentorship program provides inperson meetings at least once a month as well as continuous interactions between mentees and mentors to help middle and high school students psychological health and to support their developmental achievement in other words mentors advice and feedback based on mutual communication play an important role to buffer against antisocial behaviors and juvenile delinquency additionally beyond the general mentorship program that every student received extra mentoring was provided that was tailored to the students age for example the extra mentoring program consists of three different contents based upon age and grade a program improving quality of relationships for middle school students a program improving career maturity for high school students in the first grade and a program experiencing artistic and cultural activities for high school students in second and third grade to measure how satisfied lowincome students were with the mentorship program they responded to seven items i am satisfied with the relationship with my mentor my mentor helps me to achieve my developmental tasks the mentorship program improves the quality of my life the mentorship program is beneficial for my psychological health i am satisfied with the frequency of inperson or online meetings with my mentor i am satisfied with the frequency of the extra mentoring tailored for me and i am satisfied with the quality of the extra mentoring tailored for me each item was rated on a fivepoint likerttype scale with response options ranging from 1 to 5 all items were summed and higher scores referred to greater satisfaction with the mentorship program the cronbachs α of the fivepoint likerttype scale was 094 control variables respondents gender age and academic performance were assessed and their parents higher education attainment was also considered if both mothers and fathers received higher education they were classified into higher education analysis strategies descriptive analysis was used to describe the descriptive statistics used in this study the process macro 34 for statistical product and service solutions was employed to identify the hypothesis that satisfaction with the mentorship program moderated the relationship between neglect and depression among middle and high school students from lowincome families a bootstrap method was utilized to examine the moderating effect of satisfaction with the mentorship program fivethousand iterations of the bootstrapping method were performed at the 95 bootstrap confidence intervals results descriptive statistics are shown in table 1 the average scores of depression and neglect among lowincome students were 571 and 769 respectively average satisfaction with the mentorship program was 3103 about half of total respondents were girls and respondents average age was 1736 given cultural differences in south korea their international age was 1636 years old as a newborn starts at one year old in asian countries the average score for academic performance was 766 indicating that the average letter grade in primary classes was about c for parental educational attainment 396 of respondents parents including both mothers and fathers received higher education table 2 shows the moderating effect of satisfaction with the mentorship program on the association between neglect and depression among students in lowincome families the moderating effect of satisfaction with the mentorship program was statistically significant in other words satisfaction with the mentorship program moderated the relationship between students neglect and depression additionally we found that neglect was positively related to depression accounting for age gender academic performance and parental education and parents higher education was negatively associated with depression figure 1 indicated the moderating effect of satisfaction with the mentorship program on the relationship regardless of how satisfied middle and high school students in lowincome families were with the mentorship program those who experienced low levels of neglect also reported low levels of depression however students who were more satisfied with the mentorship program showed lower levels of depression compared to those who were less satisfied with the mentorship program regardless of how much they had experienced neglect by their parents that is depression among lowincome students was greatly influenced by levels of satisfaction with the mentorship program in particular if students frequently encounter neglect by their parents the effect of satisfaction with the mentorship program was greater showing a 182 score gap in depression among the less satisfied group while there was a 038 score gap among the more satisfied group discussion and conclusions this study explored the relationship between neglect and depression among income students since covid19 as well as the moderating effect of satisfaction mentorship program on the relationship we found that lowincome middle and discussion and conclusions this study explored the relationship between neglect and depression among lowincome students since covid19 as well as the moderating effect of satisfaction with a mentorship program on the relationship we found that lowincome middle and high school students who have been exposed to more neglect by their parents were also more likely to be depressed further satisfaction with the mentorship program moderated the relationship between neglect and depression among students from lowincome families therefore during the covid19 pandemic additional programs such as a mentorship program operated by a nonprofit organization play an important role to relieve mental health problems among students from lowincome families this study revealed that neglect is positively related to depression which is consistent with previous research 4 5 6 7 given that the period from middle school to high school is an important period for psychological development middle school and high school students who experience more neglect by their parents are more likely to be at risk of depression thus this study sheds light on why neglect by parents is an important issue related to mental health among adolescents in lowincome families since covid19 for students in lowincome families their parents may not have enough time to take care of their children because they have to work many hours to support the family 30 considering this study investigates this relationship since covid19 both mothers and fathers in lowincome households may be forced to spend more time in the workplace than before covid19 due to the related economic recession 31 as a result children in lowincome families are more likely to experience neglect since covid19 during a time when they need more care from parents as they are spending increased time at home because of hybrid or online classes as such adolescents need more protection and care since covid19 however their parents might have reduced time to care for their children leading to more neglect thus middle and high school students who were exposed to more neglect reported more depression 4 5 6 7 in addition the covid19 pandemic has greatly affected humans worldwide including increased stress 3233 parents who experience more stressors in their workplaces and in daily life because of the negative effects of covid19 might pay less attention to their children as they are too exhausted therefore it is particularly critical to pay attention to adolescents in lowincome families as they might be particularly affected by relatively limited resources and low family support than higher income households 34 during the covid19 crisis parents in lowincome families may be forced to work more in order to maintain the same financial quality of life as before covid19 thus increased neglect occurring in lowincome families during covid19 should be addressed by governmental andor community support visits from social workers or other advocates or volunteers to lowincome families with children may be helpful to address depression among lowincome students because they have some time to communicate with others if inperson visits are not available because of the spread of covid19 online meetings using tools such as zoom can be an alternative way to contact students in lowincome families the significant moderating effect of satisfaction with the mentorship program indicates that providing a highquality mentorship program is beneficial to address depression among adolescents who experience neglect by their parents middle and high school students still need their parents support to successfully complete their developmental tasks however adolescents in lowincome families tend to experience more neglect because their parents may be busy working to support the family as a result middle and high school students in lowincome families are more likely to be at greater risk of depression given that depression is relatively common in adolescence 1214 a mentorship program for lowincome students can play an important role against adolescents depression because mentors can support their mentees mental health as this study confirmed the moderating effect of satisfaction with the mentorship program mutual interactions between mentees and mentors may increase levels of satisfaction with the mentorship program leading to reduced levels of depression among lowincome students who experience either more neglect or less neglect specifically lowincome students who were more satisfied with the mentorship program showed lower levels of depression even if they were exposed to higher levels of neglect this sheds light on the importance of perceived quality of and satisfaction with the mentorship program generally mentorship programs have been regarded as a good way to support students 92124 along with this this study contributes to understanding how the quality of the mentorship program determines how satisfied participants are with the program particularly for lowincome students given that lowincome students are more frequently exposed to neglect by parents 35 the role of a mentorship program is important to address mental health among lowincome students experiencing neglect by their parents thus high quality mentorship programs should be more provided to lowincome students for their mental health funded particularly in the context of corporate social responsibility 36 generally it is encouraged for government or community centers to offer mentorship programs but more attention should be given to the role of corporate foundations to better societies and communities and to expand financial support for programs like the mentorship program for lowincome students in particular during the covid19 pandemic which has greatly deteriorated quality of life among lowincome families financial contribution by corporations would be valuable to reconstruct the damaged quality of life and psychological wellbeing among lowincome adolescents limitations although this study contributes to the understanding of the importance of a mentorship program on the relationship between neglect and depression among lowincome students we encourage readers to consider several limitations of the current study first perceived quality of the mentorship program may be different in other countries as these findings are limited to a south korean context further characteristics of lowincome students and other cultural differences should be considered when interpreting these findings to apply to other cultures second using a selfreported survey may bring about a social desirability bias thus responses particularly regarding neglect by parents may be higher in actuality than our results indicate data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to ethical reasons author contributions conceptualization jl ja and gc formal analysis hl and jj funding acquisition jj investigation hl methodology jl hl and gc project administration hl gc and jj resources gc and jj supervision jl and jj validation gc and jj writingoriginal draft jl and ja writingreview editing ja all authors have read and agreed to the published version of the manuscript funding this research received external funding from kdb foundation institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the institutional review board of inha university informed consent statement informed consent was obtained from all subjects involved in the study

this study examines the moderating effect of a mentorship program on the relationship between parental neglect and depression among adolescents from lowincome households since covid19 a total of 264 participants from all provinces in south korea were registered for a mentorship program provided by the korea development bank kdb foundation which is a charitable and nonprofit organization twohundred fiftyfive middle and high school students from lowincome families were included in the final sample the mentorship program was provided to students based on mentors advice and feedback a bootstrap method using the process macro 34 for spss was utilized to examine the moderating effect of satisfaction with the mentorship program neglect was positively related to depression among lowincome students satisfaction with the mentorship program moderated the relationship between lowincome students neglect and depression visits from social workers or other advocates or volunteers to lowincome families with children may be helpful to address depression among lowincome students high quality mentorship programs should be provided to more lowincome students for their mental health funded particularly in the context of corporate social responsibility particularly since the covid19 pandemic financial contributions by corporations would be valuable to reconstruct the damage to quality of life and psychological wellbeing among lowincome adolescents

introduction for providing universal access to reproductive health including basic health services such as antenatal care skilled healthcare at childbirth and information about contraceptive methods its counseling and supplies increase in population plays a crucial role 1 family planning program has been introduced as a key component to deal with rapid population growth and low economic status in developing countries an anticipated 225 million women would like to delay or stop bearing child but are not using any method of contraception 2 nepal demographic and health survey 2011 revealed that 27 percent of currently married women had not yet met their need 3 the unmet need of family planning is still high in nepal beyond the huge achievements in this sector 4 unmet need of family planning is defined as a gap between ones indicated fertility preferences and his or her contraceptives use at a given period 5 unmet need is not only limited to whether womenhusbands were not provided with family planning facilities it also means that provided services have not been introduced as an motivating source to women due to lack of adequate information and qualitative services 6 males are also recognized to be accountable for the large section of ill reproductive health suffered by their female partners 78 men involvement helps not only in accepting a contraceptive but also in its effective use and continuation 8 studies have shown that partners who communicate regarding the number of children they want or the use of family planning are more likely to use a contraceptive than those who do not 910 community and opinion leaders need to engage in family planning so that they can advocate for the use of fp methods in their community 11 wide gap is seen between total demand of family planning and current users ultimate goal of family planning program is to reduce the unmet need of family planning and for this exploring the determinant factors associated with unmet need is required 12 tharus constitute 675 of total population of nepal and are indigenous group of inner terai valleys of nepal 13 kamaiya is a traditional system of bonded labor common in the western plains of nepal affecting mostly the indigenous tharu community 14 tharus without land or work could get loans from landowners and were forced to perform slave labor for years and even generations to pay loan for which they had to work on the landowners land as quasi slaves and became marginalized 15 marginalized communities are socially excluded groups of people for different reasons such as age physical or mental disabilities economic status access to education or living in isolated places or depressed areas 16 being marginalized and disadvantaged group they are economically socially educationally and politically backward and also deprived of various facilities including the health services 17 very limited research has been conducted to investigate the reason for unmet need among the marginalized and tribal communities including tharu in nepal thus this study aims to provide fundamental data to stakeholders and program managers necessary for intervention which will ultimately improve the family planning program in marginalized communities materials and methods study design and source of population communitybased crosssectional study was conducted in dang district nepal among married tharu women of age group 1549 between october 2015 and april 2016 all married tharu women of reproductive age group 1549 were included in the study while unmarried or in union tharu women of reproductive age and women with mental problem were excluded from the study however women who are not using contraception due to absence of husband for more than one year were included during data collection but not included in analysis of unmet need of contraception sample size determination and sampling technique sample size was 650 married women which was determined by using formula n z 2 pql 2 18 with 95 level of confidence interval 35 margin of error 5 nonresponse rate and 27 of women estimated to have unmet need 3 tulsipur municipality out of 4 municipalities and hekuli and pawan nagar vdcs out of 31 vdcs were selected purposively as they cover large portion of tharu population further 3 out of 20 wards from tulsipur municipality and 3 out of 9 wards from both vdcs ie hekuli and pawan nagar were selected randomly for data collection then house to house survey was used to trace out respondents in communities data collection procedures and validity face to face interview was performed using pretested semistructured interview schedule for collecting data the questionnaire was translated into nepali then into english and again into tharu language to find misinterpretation and then correction was made five data collectors including one principal investigator with qualification of masters in public health as well as masters in sociology and four enumerators with qualification of bachelors in public healthnursing were involved in data collection data processing and analysis data checking compiling and editing were performed manually by the researcher collected data were coded entered into microsoft excel and cleaned and then further analysis was done by spss version 17 software package simple descriptive statistics such as frequencies means and standard deviations were calculated and associated factors between the different variables in relation to the outcome variable were measured by chisquare test having odds ratio with 95 confidence interval bivariate analysis was used primarily to check whether variables have association with the dependent variable individually and multivariate logistic regression was conducted to analyze factors which were associated with unmet need of family planning while assessing for multicollinearity all variables found to be associated with the main outcome variables by having odds ratio reaching statistical significance in the bivariate model were nominees for the multivariable model at 95 ci the data were summarized adjusted odds ratios were estimated and their corresponding value at 95 confidence intervals was computed 20 among total population 2952 were tharus where 3027 and 2885 were male and female tharus respectively 19 setting concept of unmet need of family planning unmet need of married women was introduced in this study which was estimated using westoff model 21 total demand for family planning was calculated by sum of the percent of unmet need and the percent of using contraception the surveyed women were first divided into two groups ie those who had used contraceptives and those who had not used those methods the nonusers were then subdivided into pregnant or amenorrheic women and nonpregnant or nonamenorrheic categorized at the time of the survey the pregnant or amenorrheic women were further subdivided into three categories ie those whose pregnancy was intended mistimed and unwanted at the time of survey those who had mistimed and unwanted pregnancy were regarded as one component of the total unmet need the other component consists of those who are neither pregnant nor amenorrheic further they were divided into fecund or infecund fecund women were again subdivided by their reproductive preference into 3 categories ie those who want pregnancy soon want no more pregnancy and want pregnancy later results and discussion 31 results the mean age and parity were 30 ±731 and 2 ± 069 respectively about 43 of women and 19 of their husbands were below 18 years during their marriage almost onefifth of respondents were found still unable to read or write and slightly more ie 23 had their informal class known as praoudh sickshya most of the respondents ie 98 had heard about family planning methods regarding the users of family planning slightly less than twofifth of the women and 8 of their husbands were using family planning during the survey among 255 respondents who had used family planning nearly onethird had used the permanent method and among 50 husbands more than half had used condom more than twothirds of the women and their husbands obtain family planning devices from government health facilities among 62 pregnant women 16 want to do abortion major reason for not using of family planning method was due to fear of side effects and inaccessibility was 1 figure 1 illustrates the unmet need for contraception during the survey 47 of women were using contraceptive unmet need for limiting was 27 while unmet need for spacing was 22 by using westoff model the total unmet need was estimated as 49 likewise total demand for family planning was 96 table 4 represents logistic regression model where number of living sons ≥ 1 and its relation with unmet need of family planning similarly for women education lower secondary level and secondary husband education lower secondary level and secondary and husband occupation wage labor significant associated factors with knowledge about method of family planning were found having very good knowledge was 049 however some variables such as religion womens age at marriage place of residence birth interval of child fear of side effects husbandsfamily members objection inconvenience to use distance to reach family planning and time to reach family planning were not found significant with unmet need after subjected to multivariate model age family size family type number of living children sex of youngest child women international journal of reproductive medicine occupation earning status of women and knowledge about sources of family planning were not associated with total unmet need for family planning which were seen significant in bivariate analysis discussion the finding of this study revealed that 49 of respondents had unmet need of family planning which was higher than the national and regional unmet need in 2011 and 2014 respectively 322 likewise the study conducted in a district of eastern nepal documented a lower unmet need 4 than the present study total demand for family planning 486 469 955 figure 1 unmet need for contraception note fifteen respondents who are not using any contraceptive methods with the reasons of absence of husbands from last one year are excluded from the total unmet need report which shows higher contraceptive rate including modern as well as natural method 28 however this is relatively high contraceptive rate in this type of tribal society this may be due to expansion of equitable access and utilization of highquality family planning services strengthening public and private sector health systems and increasing the availability of modern family planning methods by government of nepal 29 though similar result was found in a study conducted by prusty rk in 2014 where 45 of hindu tribal women in india used modern contraceptives 30 the total demand for family planning in the current study is 96 which is higher than the national level 328 this divergence emerged because of the high prevalence of unmet need for family planning among the disadvantaged community in the current study statistical association was established between number of living sons and unmet need which is also supported by studies done by bhandari gp in eastern nepal nazir s et al in india and dahal gp in nepal 43132 the present study revealed that women and husband education was statistically associated with unmet need similar pattern follows in studies conducted in west bengal of india kassala state of eastern sudan oromia region of ethiopia nigeria and bangladesh but the study contradicts with a study by anthony oi et al in southeast nigeria 2327 33 34 35 36 statistical association was established between husbands occupation and unmet need similar result was found in study done at tamil nadu india but the study contradicts with a study by anthony oi et al in southeast nigeria 3637 the study found significant association of unmet need of family planning with knowledge about method of family planning this observation is in agreement with other studies from different lowincome countries such as west bengal of india pakistan and eritrea demographic and health survey 2002 233839 major reason for not using family planning in this study was found as fear of side effects this is in accordance with a study conducted by mustafa g et al in rural areas of pakistan and govindasamy and boadiin in ghana 4041 about onefourth of the women in the current study were not using family planning due to the husband objection and 14 due to objection of family members in concordance with the study conducted by bhattacharya sk et al in kolkata india where main reason for unmet need was opposition from husband family and community 25 however few percentages were found in study done by ebrahim sm and muhammed nk in basrah city in south of iraq 42 conclusions majority of women had heard about family planning methods however few had practiced them which results in high unmet need among married tharu women of dang district the gap between knowledge and practice regarding family planning needs serious attention from the concerned authority to be addressed the contraceptive prevalence rate of dang district will be doubled if those women with unmet need also used any method of family planning in this context this study concerns the need for the policy maker government officials and program managers to focus on strategic behavior communication program regarding reproductive health including family planning among tribal communities like tharus international journal of reproductive medicine with report and manuscript preparation sigma bhattarai assisted in data collection report writing and manuscript preparation data availability the data used to support the findings of this study are available from the corresponding author upon request international journal of reproductive medicine ethical approval this study obtained ethical approval from institutional ethical review board of national medical college which is institutional review board of nepal health research council consent the key informants were officially contacted through letters and permission was obtained at all levels written informed consent was obtained from all the participants whereas parental consent was attained from the participants under 16 years old after giving explanation of the study providing all the purposes and procedures every study participant was informed about confidentiality and privacy conflicts of interest the authors declare that there are no conflicts of interest authors contributions chet kant bhusal conceived the study designed the protocol and collected analyzed and interpreted data along stem cells international

background increase in population plays a decisive role in providing universal access to reproductive health however there is very limited evidence about the reason of unmet need among marginalized and tribal communities such as tharus this study aimed to determine the factors affecting unmet need of family planning among married tharu women of dang nepal methods communitybased crosssectional household survey among 650 married tharu women of age group 1549 in october 2015 to april 2016 was conducted in dang district nepal randomly 3 wards were selected from each tulsipur municipality hekuli village development committee and pawan nagar vdc results the mean age and parity were 30±731 and 2±069 respectively out of 650 women 47 were using contraceptives westoff model was used for calculating total unmet need which is 49 where unmet need for limiting and spacing was 27 and 22 respectively hence after combining the current users and total unmet need total demand for family planning was 96 after adjustment significant relation was observed between number of living sons ≥ 1 and unmet need of family planning or 0

introduction education is essential for humans education is given to children from the cradle to the end of their lives god almighty entrusts children to educate their parents to be good and useful human beings in their environment education is like an experiment that is never finished at any time as long as there is human life in this world because education is part of human culture and civilization it continues to grow education is essentially an effort to pass on values that will assist and determine humanitys way of life and improve humanitys destiny and civilization without education humans today are no different from generations of humans in the past compared to todays humans they have been left behind in the quality of life and the processes of empowerment in extreme terms it can be said that the success or failure of the civilization of a society and a nation will be determined by the education that the people of that nation undergo research conducted by found that in central lampung 11 out of 91 parents of mts nurul qodiri students had a university education 15 people had high school or ma education 30 people had smp or mts education and 35 people had sd or mi education based on the learning motivation of mts nurul qodiri lampung tengah students 42 students had high learning motivation and 49 students had low learning motivation based on the authors analysis there is a correlation between parents educational level and the learning motivation of mts nurul qodiri lampung tengah as evidenced by an interpretation value of 22084 then research conducted by found that of his research explains that parents in their role as educators for their children act as role models for children parents are the first teachers for their children so their education is very important the main responsibility of parents in the family is not only to provide for their children but also according to islam to educate their children furthermore research was conducted by found that of his research explained that the questionnaire or list of questions related to parents perceptions of early childhood education in the thousand islands which were distributed on several islands including untung jawa island pramuka island panggang island pari island and lancang island showed this there were 151 respondents all parents with children aged 0 to 6 years the parents perception questionnaire produced the following results 4370 in the strongly agreecategory 5231 in the agreecategory 264 in the disagreecategory and 132 in the strongly disagreecategory it was concluded that parents perceptions or views of their childrens early education on several islands in the thousand islands including pari island untung jawa island lancang island pramuka island and panggang island met the agree criteria the research above focuses more on the influence of parents on childrens learning motivation the role of parents in childrens education and parents perceptions of childrens education while this study focuses on the perceptions of parents with low education on the continuity of childrens education in indonesia the focus of the study is to see how childrens education is in indonesia and examine the perceptions of parents in indonesia with low education on the continuity of childrens education in the preamble of the 1945 constitution paragraph 4 states that then instead of that to form an indonesian state government that protects the entire indonesian nation and all of indonesias bloodshed and to promote public welfare educate the nations life and participate in carrying out world order based on independence peace and social justice then the independence of the indonesian nationality was drafted in a constitution of the state of indonesia which took the form in a structure of the republic of indonesia which has peoples sovereignty based on belief in one almighty god just and civilized humanity indonesian unity people led by by wisdom in deliberationrepresentation and by realizing social justice for all indonesian people this mandate of the 1945 constitution should reflect to parents that education for children is one of the mandates of the heroes of independence parents have a big responsibility to provide better education for their children for the progress of the indonesian nation the definition of basic education in the law referred to as low education is very clear this level is the level to foster interest hone the ability to think and exercises the body and instincts based on article 17 of the republic of indonesia law no 20 of 2003 paragraph explains that basic education is the level of education that underlies the secondary education level paragraph describes basic education in the form of elementary schools and islamic elementary schools or other equivalent forms as well as junior high schools and islamic junior high schools or other equivalent forms in 2015 the indonesian urban village underwent a merger with the kramatsari village and the kraton kidul village so that it became the pasirkratonkramat village administratively indonesia is not a village or subdistrict but part of the pasirkratonkramat subdistrict kelurahan is the lowest administrative area led by a lurah according to monograph data in 2014 the total population of indonesia is based on education level 136 people are kindergarten graduates 1437 are elementary school graduates 1628 are junior high school graduates and 385 are school graduates at senior high school 55 people graduated from academyd1d3 55 graduated from strata 1 327 graduated from islamic boarding schools 416 graduated from madrasah and 715 graduated from courses skills from this data it is clear that most indonesians are graduates of primary or lower education parents in indonesia have different perceptions about their childrens education some parents have low educational backgrounds and have the assumption that when children have graduated from elementary school they are directed to work whether working in or outside the city such as jakarta and bali there are also parents with low educational backgrounds whose children are directed to continue their education so that their children will be able to become better people in their lives more specifically to improve the familys economy some parents support continuing education through the package pursuit program according to the childs education level parents with low education in indonesia have different livelihoods some work as laborers some work as batik entrepreneurs and some work as traders this economic background can affect the perception of parents when sending their children to school from the background as described above and to find out more this study aims to analyze the perception of parents with low education on the continuity of childrens education in indonesia research method the method used in the research was field research with a qualitative approach this field research is essentially a method of studying the background of the current situation and the environmental interactions of a social unit individuals groups institutions or communities regarding the perception of parents with low education on childrens education in indonesia intensively the approach used in this research is a qualitative one which deals with efforts to answer current problems and present them based on the data found with data collection techniques using observation interviews and documentation this research data analysis technique had 3 steps data reduction data presentation and drawing conclusions data reduction is a researchers activity in selecting and selecting data from observations interviews and documentation then the data was processed to make it easier for researchers to present the data the next step was the presentation of the data the data that had been obtained and had gone through data reduction was then presented as a narrative furthermore the last step was to provide conclusions the data that has been presented then draws conclusions or what is commonly called the researchers argument results and discussion parents are the subjects in this study with an educational background of junior high school graduates primary school or islamic primary school and some who did not finish elementary school the data is as follows after the researchers conducted interviews they got an explanation from the research subjects about the state of education in indonesia most informants have low or basic education such as elementary to junior high school graduates parental education in indonesia the family environment is the first educational environment because children first receive education and guidance from their parents the main tasks of parents in educating their children are to lay the foundation for moral education and a religious outlook on life the nature and character of children are mostly taken from their parents and other family members of the eight informants the educational background of the informants was basic education some graduated from junior high school some from elementary school and some did not pass there are various reasons for the educational background including educational conditions family economic conditions and individual awareness of school both parents and children according to ki hajar dewantara in hasbullah education is guidance in the life of childrens growth as for the meaning education is to guide all the natural forces that exist in children so that they as humans and as members of society can achieve the highest safety and happiness height based on the previous explanation most parents education in indonesia is basic education this is evidenced by the indonesian monograph data in 2014 namely from a population of 8272 1437 people graduated from elementary school and 1628 people graduated from junior high school three hundred eightyfive people are high school graduates fiftyfive people are graduates of academyd1d3 and 55 are graduates of strata 1 but armed with basic education the informants guide their respective children to become good public individuals a high level of education will make them a generation of qualified people in their fields parents education influences the continuity of their childrens education in the future because parents knowledge about education will direct their children to higher education they can advance to the next level if they already have savings some informants give directions for children to continue their studies children have the will to continue their studies evidenced by the interview results with informants i directed them to enter one of the universities in pekalongan parents educational background is essential in determining a childs education education provides experience to parents so parents are obliged to provide education to their children and most importantly when the relationship between parents and their children is natural and healthy according to law number 20 of 2003 article 7 the rights and obligations of parents are to participate in selecting educational units and obtaining information about their childrens educational development and parents of children of compulsory school age are obliged to provide basic education to their children parents are responsible for educating their children especially those who are obliged to provide basic education to children aged between 6 and 15 years based on the explanation from the informant they will provide education to children at least up to the upper secondary level it is evidenced from the interviews with informants that the childs parents can work after graduating from high school and they have the will that the child can at least graduate from high school it shows that parents educational background is used as the informants spirit to send their children to school education of children with loweducated parents in indonesia what is meant by childrens education is guidance given intentionally by adults to children in their growth so that they are useful for themselves and society thus education for children is seen as one aspect that has a main role in forming humans into perfect human beings or having a main personality parents must provide education to their children because education can benefit children to be useful in society childrens education in indonesia is good because from the informants explanations they can send their children to school until they finish compulsory education there are even children who reach higher education it is evidenced from the interviews with informants that children must continue their studies to completion unlike their parents who graduated from elementary school it shows that parents are responsible for their portion this is supported by the opinion of mahmud heri and yuyun in their book islamic religious education in the family that parents have responsibilities for childrens education including fostering faith moral development child health care intellectual development childrens personality and social responsibility parents in indonesia provide their children with a good education this enables them to fulfill the rights that exist in a child as explained by mufidah childrens rights include the right to life the right to clarity of lineage the right to breastfeed the right to care care and maintenance and the right to education and teaching perceptions of parents with low education on the continuity of childrens education in indonesia perception is a way of seeing viewing or interpreting something based on experience through the five senses whether it is about objects events or relationships obtained by interpreting information or messages received from the experience in the process of perception formation the environment stimulus response and individual are all interconnected parents have an important role in their childrens education children in deciding their further education ask their parents for their opinion parents also provide direction to children in choosing a school or college this is evidenced from the results of interviews with informants that the child will continue school according to his ability if his ability is sufficient i direct him to the same junior high school as his older brother the eight informants explained their respective perceptions of childrens education according to the expert there are two types of perception positive and negative positive perception describes all knowledge and responses that align with the object of perception which is continued with efforts to use it while the negative perception describes all knowledge and responses that conflict with the object of perception researchers interpret positive perception as the perception of parents who think they will continue their childrens education to the level of higher education the negative perception is the perception of parents who refuse to continue their childrens education to higher education of the eight informants two parents negatively perceived their childrens education the child has had enough education the informant directs him to work to help his family especially in the economic field it is evidenced by the results of interviews with informants that after graduating from high school i directed my children to work to help develop my work if parents can no longer pay for their children and see the childs lack of interest in continuing school they direct them to work as well in providing perceptions parents have factors that can support and inhibit parents with low education in sending their children to school as follows factors that support loweducated parents in sending their children to school among others 1 school necessities the cost shows that the school can provide good facilities for education so the cost of education is not an obstacle to sending children to school costs are included as external factors 2 parents motivation the motivation of parents who want their children to go to school to get a good and proper education is psychologically an encouragement for children to realize this desire parents motivation is to encourage children in school to achieve good grades to make their parents proud with the motivation of parents children feel they get support parental motivation includes internal factors for parents and external factors for children 3 childrens interest the childs interest is a factor that enables him to grow the spirit of doing something he wants as is the case with childrens interest in school to add friends gain knowledge and experience and become wise teachers childrens interests include internal factors 4 parents educational background most residents in indonesia are graduates of basic education both primary and junior high schools parents with basic education backgrounds are elementary school graduates some do not even finish elementary school it makes parents support for children to go to school difficult parents thoughts on education not enough but not enough to be complicated the experience of parents who graduated from elementary school is used as a spur so that their children can be better than themselves the educational background of parents is an internal factor for parents factors that prevent loweducated parents from sending their children to school include 1 family economic condition cost can be a limiting factor for parents when sending their children to school when parents earn barely enough to meet basic needs they do not think about being able to set aside a little money for their childrens school savings sometimes parents have difficulty obtaining them it makes the familys economic condition an inhibiting factor for childrens schooling 22 lack of motivation from parents encouragement from parents is a motivation for children this encouragement or motivation is not only in the form of material but also in the form of parental attention to their children when parents do not encourage children this has an impact on children children may become less enthusiastic about completing their schooling or their achievement may decrease lack of parental motivation including external factors for children 3 surrounding environment many children in indonesia are of school age and continue to carry out their activities as schoolchildren elementary schoolchildren junior high school children and high school children however many children also drop out of school at 14 he was already looking for work as a laborer in a sewing house there is also a shirt button installer and there is also a sewer it is a factor inhibiting parents from sending their children to school parents believe that elementary school children can earn money rather than spend money on school and that school is free the surrounding environment includes external factors conclusion it can be concluded that the perception of parents with low education on the continuity of their childrens education is good although some parents have negative perceptions of their childrens education many also have positive perceptions that parents will continue their jurnal paedagogy jurnal penelitian dan pengembangan pendidikan childrens education to a high level at least to senior high school according to the childs will parents support the idea that childrens education today is very important this education can be a provision for children to have a better fate than their parents schooling up to the higher education level can provide valuable experiences particularly for children with education children can get a wellestablished and good job to be selfsufficient one day moreover with education children can realize their ideals as desired if the child has an established life later the parents will be proud and happy seeing that their child can prosper recommendation it is recommended that parents prepare early for the needs of children the needs of childrens schooling include important school fees and providing an overview of the school to children to fit their interests and talents parents as much as possible pay attention in the form of motivational encouragement to children so that they are more active in learning and going to school parents are the first and foremost teachers in forming a childs attitude toward being motivated to continue school moreover one day the children will be the nations successors ten years later be as candidates for the generational renewal of this country armed with education the world is in his hands

this study aims to analyze the perception of parents with low education on the continuity of their childrens education in indonesia this research method used field research with a qualitative approach data collection techniques used interviews observation and documentation this research data analysis technique had 3 steps data reduction data presentation and drawing conclusions the study results explain that some parents had a bad view of their childrens education however many also had a positive opinion that parents would continue their childrens education to a higher level at least until high school following the wishes of the children themselves parents support that their childrens education was essential currently this education can be a provision for children to have a better fate than their parents children attending school up to higher education can provide valuable experience especially for children with education children can get an established and good job to fulfill their lives later

methods retrospective cohort study 231 pregnant african immigrant women were recruited from 20072010 in northern spain a spanish population sample was obtained by simple random sampling at 13 ratio immigrant status prenatal care and social risk factors were treated as independent variables low birth weight and preterm birth were collected as neonatal morbidity variables crude and adjusted odds ratios were estimated by unconditional logistic regression with 95 confidence intervals results positive associations between immigrant women and higher risk of neonatal morbidity were obtained crude or for preterm births in northern africans with respect to nonimmigrants was 228 and crude or for lbw was 177 introduction available literature evaluating the association between neonatal morbidity and immigrant status presents contradictory results some studies show risks that are similar to or lower than those for nonimmigrant women these are related to what has been called the healthy immigrant effect or the epidemiologic paradox which states that immigrant women are likely to have better health outcomes including reproductive outcomes because they are younger and have healthier lifestyles this effect was first described in latino immigrants in the united states 1 and has also been described in african immigrant women in europe 2 3 4 and in spain 5 6 7 in contrast other studies identify higher risks for preterm birth or low birth weight among pregnant immigrant women 89 however these studies have not taken into account poorer compliance with prenatal care in this population as a confounding variable greater risk of neonatal morbidity in the immigrant population was reduced after adjustment for prenatal care in a recently published crosssectional study conducted in spain suggesting that compliance with prenatal care could play an important role as a confounding variable 10 in addition several studies have shown that immigrant women from poor countries live under worse conditions and in worse socioeconomic situations in their host countries and have a greater risk of inequality in the social determinants of health when compared with nonimmigrant women it places them in positions of social risk and vulnerability 11 12 13 14 social risk has also been associated with poorer neonatal outcomes 15 16 17 and could thus be another important confounding variable in the relationship between immigrant status and neonatal morbidity according to this rationale we hypothesized that the association between immigrant status and a higher risk of neonatal morbidity could be spurious owing to confounding caused by social risk factors or poorer prenatal care both of which are associated simultaneously with immigrant status and neonatal morbidity this could explain the contradictory findings in published studies feminization of the migration flows to spain has developed over the last decade and the increase in foreign mothers giving birth in spain has been studied in various fields 1718 it is estimated that more than half of female immigrants are of reproductive age which means that many of their social and health needs have to do with issues of reproduction and maternity number of preterm infants in cantabria and violate the privacy and confidentiality of personal information of research subjects 1920 in 2010 the majority of foreign women who gave birth in spain came from africa and were mainly from morocco 21 we undertook a retrospective cohort study to examine whether the lack of adequate prenatal care and the existence of social risk factors are confounding variables in the relationship between the status of african immigrant women and neonatal morbidity materials and methods approval of the research protocol was obtained from the clinical research ethics committee of cantabria before data acquisition began on october 8 2010 patient records and information were anonymized and deidentified prior to analysis study design and participants in this retrospective cohort study the study population comprised aiw with uncomplicated pregnancies and delivery dates between january 1 2007 and december 31 2010 who attended one of the 41 primary health care centers in the cantabria region of northern spain in the spanish national health system prenatal care for an uncomplicated pregnancy is carried out by a primary health care midwife and a general practitioner we undertook a search using the clinical databases of the cantabrian primary health care centers patient country of origin was subsequently collated with the connectis consulting services civitas population information system we found 264 births in 237 pregnant aiw during the study period among these births both first and second pregnancies were identified of the 264 births 27 were second pregnancies we included only information about first pregnancies in our analysis in the case of six pregnant women followup was referred to an obstetrician owing to a change in their status from uncomplicated to complicated pregnancy because these women were not fully under the care of a primary health care center the final study population was reduced to 231 pregnant aiw with uncomplicated pregnancies a flow diagram showing the final included aiw study population and their country of origin can be found in s1 fig a spanish population sample was obtained by simple random sampling using a 13 ratio stratified by the primary health care centers of the 231 aiw study participants thus we defined a population of 693 pregnant spanish women of these 693 spanish women 66 were excluded because their status changed to complicated pregnancy and they were referred to an obstetrician therefore the final population for the comparative analysis was 627 spanish women with uncomplicated pregnancies a flow diagram showing the final population of spanish women included in the study is provided in s2 fig data sources and variables measures information for each pregnant woman included in our study was obtained from the computerized clinical databases of each primary health care center and from hospital birth records the adequacy of prenatal care was estimated based on the kessner index 22 the ki combines three variables the start of prenatal care the total number of consultations and the length of pregnancy the ki makes an adjustment to the number of consultations considered adequate for pregnancies that finish before the predicted birth date in the case of a terminated pregnancy prenatal care is considered adequate if the first prenatal visit took place before week 14 and at least nine visits were made prenatal care is considered inadequate if the first visit was after week 28 or fewer than four prenatal visits were made with cases that did not fall into either of these two categories prenatal care is considered intermediate in addition we created our own index based on seven quality indicators found in current national and international guidelines 23 24 25 prenatal care before week 12 folic acid supplementation before week 8 ultrasound scan between 11 and 14 weeks of amenorrhea ultrasound screening for fetal abnormalities between weeks 18 and 20 hepatitis b and hiv screening in the first trimester gestational diabetes screening between weeks 24 and 28 and at least six completed prenatal visits prenatal care was considered adequate based on compliance with all oi indicators care was considered intermediate if one to three indicators were unmet and inadequate if four or more indicators were unmet the current spanish prenatal care protocol sets the minimum periodicity of visits at one per month until week 36 and once every two weeks between weeks 36 and 40 therefore by week 28 any pregnant woman having received adequate prenatal care should have completed six prenatal visits and undergone the appropriate checks in compliance with all the quality indicators the criteria identifying the need to refer pregnant women to a social worker are based on certain characteristics that increase their social risk and place them in a position of vulnerability or chronic stress these characteristics include precarious living conditions such as insufficient income living in a small or unhealthy environment having an inadequate diet and potential situations of abuse or domestic violence in the official spanish prenatal care protocol when the midwife or general practitioner identifies any social risk factor the pregnant woman affected is then referred to an sw with a note made in the protocol regarding the necessity of referral to an sw the main neonatal morbidity variables considered were low weight and preterm birth statistical analyses discrete variables were expressed as counts and continuous variables as mean statistical differences between groups were assessed with the chisquared test using the yates correction or fishers exact test when appropriate for categorical variables the students ttest was used for continuous variables immigrant status of the study participants was categorized as spanish subsaharan african or northern african the subsaharan and northern african categories were then combined to create a dichotomous variable spanish versus african the adequacy of prenatal care as measured by the ki and oi indexes was categorized as adequate intermediate or inadequate preterm birth and low birth weight were treated as dichotomous dependent variables in the regression models for low birth weight the normal weight category was treated as the reference category and macrosomic birth weights were excluded from the analysis a basic unconditional regression model was used adding only the frequencymatching variable the primary health care center odds ratios with 95 confidence intervals estimated by this basic model were treated as crude odds ratios to analyze the effect of social risk factors and compliance with prenatal care as confounding variables in the relationship between immigrant status and neonatal morbidity these variables were first added to the basic logistics model separately and then both were added together last analysis using an overall regression model was performed adjusting for immigrant status referral to a social worker prenatal care age of the woman and number of previous pregnancies tests for or trends were calculated for the ordinal ki and oi index categories using logistic models that included categorical terms as continuous variables for these trend tests we used a likelihood ratio test the alpha error was set at 005 and all pvalues were bilateral all statistical analyses were conducted using ibm spss statistics version 210 results the majority of aiw came from countries in the north of africa n 160 participants were mainly from morocco n 144 followed by subsaharan countries such as nigeria n 18 or senegal n 18 and cameroon n 17 table 1 shows characteristics of the mothers and their newborns as well as the type of birth and prenatal care according to country of origin the aiw were on average 345 years younger than spanish women and showed healthier lifestyles with respect to alcohol consumption and smoking a total of 47 of aiw were referred to an sw by midwives owing to detection of social risk compared with 5 of spanish women prenatal care was considered to be adequate in 27 and 22 of aiw using the ki and oi respectively compared with 78 and 76 of spanish women the aiw had a greater percentage of preterm births and low birth weight cases tables 2 and3 show the crude and adjusted associations between immigrant status and the risk of preterm birth and low birth weight respectively all aiw especially those from northern africa were at higher risk of preterm birth however these associations were spurious becoming protective after adjusting for compliance with prenatal care and social risk factors this association did not change after including maternal age and number of previous pregnancies in the models a lack of compliance with prenatal care based on ki was the main independent risk factor for preterm birth a very significant doseresponse pattern was found the greater the lack of prenatal care compliance the greater the association for preterm birth existence of social risk factors was an independent risk factor for preterm birth but this association diminished in the overall adjusted model with respect to low birth weight crude associations between status as an immigrant and low birth weight changed becoming protective after adjusting for poorer compliance with prenatal care andor social risk factors lack of compliance with prenatal care based on the ki was also an independent risk factor for low birth weight with a very significant doseresponse pattern found existence of social risk factors was an important independent risk factor associated with low birth weight discussion poor compliance with prenatal care was the main risk factor associated with neonatal morbidity in our study with statistically significant doseresponse patterns found the existence of social risk factors was independently associated with neonatal morbidity especially low birth weight here both variables played an important role as confounding variables being simultaneously associated with immigrant status and neonatal morbidity and causing a spurious relationship between immigrant status and higher risk of neonatal morbidity as mentioned above crude associations between status as an aiw and neonatal morbidity which are supported by different studies in spain 17 europe 20 26 27 28 and the united states 2930 were not maintained in the multivariable models that included poor compliance with prenatal care or the existence of social risk factors this supports the results of castelló et al 10 in which associations between being an immigrant and the risk of very preterm birth and very low birth weight were weaker when adjusting for adequacy of prenatal care the metaanalysis published by bollini et al 31 indirectly supports our results in 12 countries receiving immigrants that were studied from 1966 to 2004 pregnant immigrant women showed a greater risk of low birth weight and preterm delivery these risks were clearly and significantly reduced in those countries with stronger integration policies that lowered both access barriers to prenatal care and the existence of social risk factors even after adjusting for maternal age at the time of birth after adjustment status as an immigrant was protective in our study the aiw in our study were younger but also had healthier lifestyles in terms of alcohol use and smoking this could explain the adjusted protective effect obtained in the multivariable regression model that also included maternal age as a covariate this would support the healthy immigrant effect or epidemiologic paradox which state that immigrant women have better reproductive outcomes because they are younger and lead healthier lifestyles in comparison with nonimmigrant women the greater associations found here between poorer compliance with prenatal care and neonatal morbidity are supported by several studies specifically in immigrant populations 29 32 33 34 the existence of a doseresponse pattern would provide additional support for a real association and not owing to chance the ki is a classical prenatal care indicator this index similar to other published indexes such as the adequacy of prenatal care utilization only considers the number of visits during pregnancy but not their content the apncu index considers the same three parameters considered in the ki index but in a different way 35 in spain delgadorodriguez et al compared the ki with the apncu index to examine the degree of association of both indexes with respect to risk of preterm birth 35 the ki was considered a better predictor for preterm birth than the apncu therefore we chose the former for our work the latest recommendations from international organizations such as the world health organization or national institute for health and care excellence 2425 place more importance on other prenatal care quality indicators than on the number of visits with at least six visits considered optimal this arises from the fact that no statistically significant differences have been found with respect to neonatal and maternal morbidity when more than six visits are completed as long as the other quality indicators are complied with 3637 on the basis of these recommendations in addition to the ki we used the oi in this study which considers both the number of antenatal care visits and compliance with the other quality indicators according to the oi six visits for a term pregnancy would be considered adequate prenatal care as long as the remaining prenatal care quality indicators are complied with however according to the ki pregnant women who have complied with the remainder of the spanish prenatal care quality indicators but who have only completed six seven or eight visits would be considered to have had intermediate prenatal care by virtue of having completed fewer than nine prenatal visits according to the oi 12 out of 62 aiw and 15 out of 491 spanish women were classified in the adequate care category however these women were classified as intermediate care by the ki simply because they had six to eight prenatal visits despite having complied with the remaining quality indicators among these 12 aiw there was one case of low birth weight and among the 15 spanish women there were five cases of preterm birth and six cases of low birth weight these extra cases of preterm births and low birth weight newborns in the adequate category according to the oi would explain the lower associations found using the oi when compared with the ki both in aiw as well as in spanish women therefore our results do not support those of villar et al 3637 because we found a greater prevalence of neonatal morbidity in pregnant women who complied with the quality indicators proposed by those authors and recommended by the world health organization but who had fewer than nine prenatal visits which is the minimum number of visits used in the kessner index although the relationship between social risk factors and risk of neonatal morbidity has been less investigated our results are supported by several studies sparks et al showed that preterm birth differences in the united states were more associated with social risk factors than with country of origin 16 garciasubirats et al showed that the unemployment rate was associated with preterm births in every maternal age group 17 an association between low birth weight and social risk factors such as being a teenage mother or single mother is also supported 15 a relationship between the existence of social risk factors and maternal stress biomarkers together with a greater rate of genital tract infections could explain the pathogenic basis of this association 38 39 40 in retrospective studies based on secondary information one of the main limitations could be the low quality of the information owing either to incomplete records or a lack of agreement among the different records in our study information about the main variables was collected in more than 97 of women and agreement for the country of origin was 100 another caveat relates to the lack of availability of other potential risk factors which are unavailable from the secondary registers used in our study in conclusion poor compliance with prenatal care and the existence of social risk factors were major confounding variables in the relationship between immigrant status and neonatal morbidity in our study further epidemiological studies should include both variables as confounding variables to prevent biased results regarding impact in the clinical setting our results have identified poor compliance with prenatal care as the main independent risk factor associated with both preterm birth and low birth weight in both immigrant and nonimmigrant pregnant women which supports the importance of compliance with more than six prenatal visits the existence of social risk factors was an important independent risk factor associated with low birth weight this lends support for the joint role played by social workers and midwives in maximizing the level of proper prenatal care among pregnant women with increased social risk relevant data are available on request from the university of cantabria archive for researchers who meet the criteria for access to confidential data requests may be sent to supporting information

literature evaluating association between neonatal morbidity and immigrant status presents contradictory results poorer compliance with prenatal care and greater social risk factors among immigrants could play roles as major confounding variables thus explaining contradictions we examined whether prenatal care and social risk factors are confounding variables in the relationship between immigrant status and neonatal morbidity

introduction the size of the asian american population living in the us is projected to increase by 132 and will comprise 9 of the total us population by 2050 as compared to whites blacks and hispanics asian americans have distinctive profiles for leading causes of death specifically cancer is the leading cause of death for asian americans specific information on asian american subgroups indicates that korean americans have the highest cancer mortality rates and the lowest breast and colorectal cancer screening rates korean american men and women have the highest incidence of stomach cancer compared to other asian subgroups which is five times higher than rates for nonhispanic white men and seven times higher than nonhispanic white women korean american women have the highest incidence and mortality rates for liver cancer compared to other asian american subgroups while korean american men have the second highest incidence and mortality rates for liver and colorectal cancer given the high incidence of cancer among korean americans and the dramatic increase in the percent of korean americans living in the us since 2000 oncology professionals will likely be caring for more korean cancer survivors and will need more accurate and culturally and ethnically relevant information about their cancer experience quality of life and factors that affect it one of the persistent problems in understanding the experience of korean americans with cancer is that current studies often focus on asian americans as one large homogeneous group a practice that obscures the heterogeneity that exists within the asian american population past epidemiologic studies indicate that lifestyle factors genetics nativity socioeconomic and environmental factors may influence the development of cancer and survival among immigrants however these findings vary by specific ethnicity designations within the broader racial categories using aggregated data to represent all subgroups of asian americans hinders understanding of the diversity that exists both across and within these subgroups further aggregated data obscures the identification of risk factors and causes of mortality within each group and also decreases the ability to tailor interventions to the unique needs of specific subgroups of asian americans the present study uses an integrative review of the literature to address the limitations of aggregated data from multiple asian american subgroups and increase understanding of korean americans cancer experience the integrative review focused specifically on korean american cancer survivors and examined their qol and factors that affected it this information is essential for fostering a better understanding of the cancer experience in this group and planning culturallyethnically appropriate interventions to support them in this review the term cancer survivor refers to a person who has been diagnosed with cancer including anyone who is currently getting treatments for cancer as well as those who have been treated for cancer and are presently cancer free characteristics of korean american immigrants the majority of koreans came to the us after congress passed the immigration act of 1965 that enabled people from other countries to seek a better life pursue their education and join family members living in the us currently the top three states where most korean american immigrants live are california new york and new jersey about 40 percent of korean immigrants live in metropolitan areas such as los angeles new york and washington dc general demographic characteristics of korean american immigrants in the us indicate that more than half are foreignborn 52 percent have a bachelors degree or higher and among asian american subgroups they have the highest rate of selfemployment compared to the six largest asian american subgroups korean americans have the lowest median household income despite having high educational attainment korean american cancer survivors cultural values and quality of life research indicates that korean american cancer patients qol is strongly influenced by their cultural norms which are based on confucianism in confucianism gender and familial roles are clearly delineated traditionally men are the breadwinners and decision makers for the family women are obligated to cook for the family raise children maintain the household and help financially these cultural norms shape family members expectations that wives and mothers who are diagnosed with cancer will continue their usual cultural gender roles as caregivers and in managing the household this conflict between expectations and the experience of living with cancer and its treatment creates enormous strains that negatively impact the emotional wellbeing of female cancer survivors although the literature on the qol of korean american cancer survivors is limited prior research indicates that korean american cancer survivors have lower levels of acculturation and lower quality of life when compared to other asian cancer survivors korean american cancer survivors also report lower psychological qol than their native korean counterparts but higher physical qol korean american cancer survivors report difficulty adjusting to cancer due to language barriers they face that hinders their understanding of health information and ability to communicate with health professionals in sum due to the small number studies in this area and acknowledged limitations of the literature little is known about the qol of korean american cancer survivors more information is needed on their qol and associated factors in order better to understand and plan culturallyethnically appropriate interventions to support them this integrative review was conducted to assess the current state of the literature and to gain a better understanding of qol issues among korean american cancer survivors literature search this integrative review was conducted with focused searches using pubmed cinahl google scholar and ebsco databases and were limited to studies published from january 2000 to january 2014 searches were conducted using the following key words korean american or asian american cancer patients or survivors experiences or quality of life including at least the word quality of life with either korean american or asian american which were used as exploded medical subject headings terms for example using the search korean american cancer survivors quality of life and the mesh terms of korean american cancer survivors quality of life were used in the pubmed database both english and korean language publications were retrieved studies were included if they were primary quantitative qualitative or mixedmethod studies that described the experience of korean american cancer survivors and factors that influenced their quality of life studies that were based on samples that focused broadly on quality of life of asian americans but that reported the results for korean americans as a specific subgroup were included in the review quotes from a qualitative study among asian american cancer survivors were also included in this review if the quote was directly attributable to a korean american cancer survivor data evaluation prior to data analysis potential studies were reviewed by four researchers and any discrepancies were resolved by evaluating the overall quality of each study each study was rated on a 2point scale based on the relevance of findings to the purpose of the review also studies were evaluated for adequate conceptual definitions of variables appropriate use of research design and method and appropriate data analyses data analysis data from all studies included in the integrative review were extracted the most commonly measured variables in the quantitative studies and the most commonly discussed issues in the qualitative studies that affected qol of korean american cancer survivors reflected 3 main themes social support communication and acculturation presentation of findings a total of 13 studies that included korean american cancer survivors were retrieved from the search 7 quantitative studies 5 qualitative studies and 1 mixedmethod study table 1 provides details about the 13 studies all studies were obtained in english except one qualitative study that was written in korean by choi and colleagues two studies consisted of korean americans only nine studies included korean americans with other asian american ethnic groups and two studies compared native koreans to korean americans the number of korean americans in the studies ranged from less than 10 to a high of 71 demographic characteristics the mean age of the cancer survivors was 56 years a majority of participants in the studies reviewed attained more than a high school degree and had an average income level of less than 25000 cancer survivors average length of stay in the us was 218 years and 98 of them were born in korea of the thirteen studies reviewed all were conducted with female cancer survivors most studies were conducted with women with breast cancer and a few were conducted with women with gynecologic cancer korean american breast and gynecological cancer survivors generally had lower income but higher education than their native korean counterparts korean american breast cancer survivors had the lowest income compared to other asian american breast cancer ethnic groups and also the lowest level of qol several socioeconomic indicators predicted or were related to qol income was inversely associated with psychological distress and positively associated with qol higher education was associated with positive physical and mental qol in regard to acculturation factors language barriers were identified as a primary indicator of korean american cancer survivors level of acculturation higher levels of acculturation were positively related to their level of qol high language barriers were related to lower social network involvement longer length of stay in us was positively associated with larger social network size greater social involvement and fewer language barriers social support perceptions of korean american cancer patients and caregivers studies included in the integrative review documented the importance of social support for korean american cancer survivors qol higher perceived social support was one of the factors that positively influenced higher levels of wellbeing in a study of korean american gynecological and breast cancer survivors social support was also negatively associated with psychological distress and the positive impacts of spirituality for better overall qol was mediated via perceived social support lim also found that breast cancer survivors who used more social support from extended family friends and neighbors or sought more spiritual support had better mentalrelated qol furthermore those with positive social network structures had better emotional support and qol these studies all suggest that social support is a key factor related to korean american cancer survivors qol and that social network size and network involvement have a positive influence on emotional support however korean american cancer survivors had significantly smaller networks and less network involvement as compared to their native korean cancer survivors five qualitative studies found that family was perceived as both a major source of support and a major source of stress for korean american cancer survivors perceived stress can be attributed to survivors adherence to ethnic values that emphasize the importance of fulfilling family role expectations even after receiving a cancer diagnosis perceiving family as a source of stress was also associated with survivors belief that their family members did not know or understand what they were really going through for example a breast cancer survivor said my family expects me to work and function the same as before the surgery it saddens me elderly korean american cancer survivors reported that it was difficult to seek support from younger adult family members because they did not want to become a burden by relying on them too much elderly survivors felt cancer was their battle to wage alone to illustrate a korean american oncologist said older generations feel that they are a burden to their family so thats another different issue that some of my patients do go through obtaining support from the community was also difficult for korean americans studies indicate that cancer survivors wanted support groups to share feelings and experiences but were not able to locate support groups that were language appropriate further because many community members were immigrants who had demanding work commitments for surviving through immigrant life cancer survivors did not perceive that they had much support from their own korean american community korean american cancer survivors also perceived a lack of support from the western community language barriers were a primary reason that limited their ability to relate and share their feelings freely with people from the western community one cancer survivor said americans dont seem to share their emotions with immigrants like us they dont try to talk to us first direct quotes are provided in table 2 as a consequence cancer survivors were unable to receive emotional support from either the korean or western communities communication and cancer several quantitative studies examined the relationship between korean americans communication behaviors and their physical and mental qol lim found that cancer survivors who communicated effectively within the family improved their own physical and mental qol similarly among 71 korean american breast cancer survivors family communication was directly associated with mental and physical qol other studies focusing specifically at family relationships found that higher family support was related to more family communication communication within a family was sometimes a barrier for korean american cancer survivors choi et als qualitative study of first generation korean american breast cancer survivors found that although their main emotional support came from family members cancer survivors had difficulty communicating with their second generation adult children due to language barriers adult children were more fluent in english and firstgeneration immigrant cancer survivors were more fluent in korean firstgeneration korean american cancer survivors identified this language barrier as an obstacle to receiving adequate emotional support from their family korean american cancer survivors also perceive that cancerassociated stigma has limited their ability to effectively communicate with their family members and others some korean american cancer survivors felt ashamed of having cancer which made them reluctant to talk about their feelings with others who were healthy because of the stigma they also limited their interactions with others but then felt lonely and distressed by hiding their cancer korean american cancer survivors were able to avoid hearing negative comments or questions such as how much longer they indicated that negative comments from others were difficult to hear and had a negative effect on their qol feelings of shame for having cancer and the need to protect themselves from others comments were reported mainly by female cancer survivors whose observance of cultural norms prevented them from sharing their experiences studies examining communication and the relationships between korean american cancer patients and their physicians found physicians assistance in managing patients stress had positive effects on qol in qualitative studies korean american cancer survivors reported that their doctors attitudes and communication was important to them during their cancer treatment and followup care however some korean breast cancer survivors said that they worried that asking too many questions could result a negative relationship with their physicians this was not the belief of other asian subgroups who felt that patients should ask their physician questions in general first generation cancer survivors said they preferred a koreanspeaking oncologist because they would be able to understand information about their course of disease more easily however it was difficult for the survivors to find a koreanspeaking oncologist within their korean american community further korean american cancer survivors said they were limited to those hospitals or oncologists that were covered by their insurance this hindered their ability to find a korean american oncologist who also spoke korean and with whom they could have effective communication acculturation degree of acculturation to their host culture is highly related to healthrelated qol in studies of korean american cancer survivors 1 higher acculturation influenced their multidimensional qol through better social support and 2 higher acculturation was directly related to higher social support in both studies the degree of acculturation was assessed using measures of cultural identity and knowledge language use and food and diet patterns as well as additional acculturation factors such as birthplace primary languagelanguage barriers and length of stay in the us studies of acculturation indicated that korean american cancer survivors were much less acculturated as compared to chinese cancer survivors even with comparable lengths of stay in the united states further those who completed surveys in english were more acculturated than those who completed surveys in their own native language among asian groups korean americans had the highest rate of completing surveys in their own language suggesting lower levels of acculturation acculturative stress is a common response to the process of acculturation that is reflected in lower mental health status higher psychosomatic symptom level and identity confusion factors associated with acculturative stress can lead to lower levels of qol among immigrant cancer survivors versus nonimmigrant cancer survivors immigrants who are diagnosed with cancer reported compounded stress from a variety of sources in addition to the stress of being an immigrant korean americans who receive a cancer diagnosis reported more stress from 1 a lack of knowledge or education related to understanding of the us health system and finding resources 2 language barriers related to understanding healthrelated materials after surgery chemotherapy instructions or side effects from clinicians 3 a lack of support and availability of korean cancer support groups and 4 having to work while being treated for cancer due to lack of insurance and need to support their immigrant family findings from qualitative studies indicate that cancer survivors had limited understanding of the us health care system related to its highcost and fragmented care system and had a lack of trust in the system also breast cancer survivors did not have knowledge or education specific to cancer genetic testing or about the need for cancer screening in situations of a family history of breast cancer finally because of their limited english and language barriers korean american cancer survivors played a less active role in their treatment plan and they were less likely ask questions or express concerns discussion this integrative review identified 13 studies focused on factors affecting the qol of korean american cancer patients the most common factors or topics that were studied were social support communication and acculturation which all demonstrated significant relationships to qol more specifically higher family support better family communication and higher level of acculturation were associated with higher quality of life among korean americans the central findings of this review are that korean american cancer patients 1 received inadequate social support from both their own ethnic community and the western community 2 had difficulty communicating with their adult children 3 experienced stigma from having cancer 4 were not able to receive health information in their own language and 5 experienced acculturative stress which hindered effective communication with others and ultimately affected their qol these findings are consistent with a literature review of studies of asian american breast cancer survivors living in the us in that literature review quantitative studies indicated that cultural health beliefs immigration stress acculturation level english proficiency social support and spirituality were associated with asian american breast cancer survivors quality of life the qualitative studies indicated that cancer survivors reported a lack of physical and emotional support a lack of knowledge and language barriers during cancer survivorship an important finding from this review of quantitative and qualitative studies was that korean american cancers survivors are often uncomfortable or uncertain about interacting with their oncologists korean american cancer survivors were hesitant asking questions and worried that if they asked too many questions it would have a negative effect on their doctorpatient relationship female korean american cancer survivors often deferred to their physicians when considering treatments were less active in the decision making process and often wanted to follow their doctors recommendations to promote a good relationship korean american deference to their physicians may be associated with the fact that most of them were elderly first generation immigrants who were strongly influenced by their koran cultural beliefs and less likely to be acculturated the integrative review also indicated that because families are the main source of social support for korean american cancer survivors it is important to include family caregivers of cancer survivors in future studies however caregiving is a part of cultural obligations in korean culture given this a full appreciation of the cultural meaning of caregiving will be crucial for assesing the patientcargiver relationship past studies indicate that korean american caregivers have higher levels of depression burden and anxiety than white americans caregivers suggesting that they may also have needs for specific types of information and support as caregivers direction for future research given the paucity of research on korean american cancer survivors there is a need for more research including descriptive exploratory and longitudinal studies that focus only on korean americans studies with larger samples of korean american cancer survivors will further clarify the relationships between social support communication acculturation and qol also future studies will need to assess korean american cancer survivors with different types of cancer in light of the high incidence of stomach and liver cancer among korean americans it is surprising that none of the studies included survivors with these types of cancer in addition because korean americans have the lowest use of cancer screening compared to other asian subgroups studies focusing on increasing cancer screening using culturally tailored interventions are needed limitations of existing literature this review is constrained by a number of limitations in the existing literature on the qol of korean american cancer patients and caregivers first only two studies focused exclusively on korean american cancer survivors although the remaining studies included korean american as one subgroup of asian americans analyzing the experiences of only korean american cancer survivors was challenging second studies in the integrative review were focused on breastgynecological cancer survivors which limited our understanding of the relationship between support communication and acculturation among survivors coping with other types of cancer also the findings may be relevant primarily to female korean american cancer survivors who made up the sample for most of the studies reviewed third the majority of the studies were conducted by the same team of researchers using a few large surveys which may limit the generalizability of the findings fourth most of studies had small sample sizes finally the research designs in prior studies were primarily secondary analyses crosssectional or qualitative designs limiting our understanding of the experience of korean american cancer survivors over time implications for practice understanding and acknowledging the cultural background of korean american cancer survivors is essential to improve their qol based on the concept of confucianism and filial piety korean american cancer survivors may not seek professional help to build social support improve communication skills or report feelings of depression or stress clinicians will need to pay closer attention to the quality of family communication as families prefer to resolve conflicts internally or they may try to avoid even talking about conflicts therefore providing a safe environment for both cancer patients and their family caregivers to talk about healthrelated issues is important it is also important for health professionals to understand that korean americans may prefer to make medical decisions as a family rather than leave these decisions to the patient only the findings indicated that most of first generation korean american cancer survivors will trust their clinicians and take their recommendations during decisionmaking therefore clinicians play a critical role in the decisionmaking process providing health information such as side effects of treatments chemotherapy healthy behaviors postsurgery complications and reconstructive surgery options in an easy to understand manner will help reduce cancer survivors stress during the cancer experience and promote better qol also having an interpreter present during consultations may help cancer survivors to ask questions more freely without having to rely on their own interpreter to enhance making autonomous decision currently the american cancer society has educational materials for various asian or pacific islander languages that includes korean for koreans there are education materials related to 1 cancer prevention and early detection 2 side effects and treatment 3 general knowledge of different types of cancer 4 healthy behaviors 5 caregiving and 6 the patientdoctor relationship korean american cancer survivors respond positively when clinicians provide health informational brochures providing culturallyappropriate american cancer society educational materials that are culturally and language appropriate could further capitalize on their acceptance and prove to be very useful in informing both patients and caregivers most korean americans rely on their own ethnic community centers and churches for social support to extend their social networks and to access health services given this clinicians or public health nurses may need to work with ethnic affiliated communitybased organizations to provide culturally effective nursing interventions collaborating with korean american community centers is critical since they have staff who can speak english korean or both languages to help patients and caregivers since community centers may have already established good rapport and relationships with cancer survivors providing education or support groups through community centers can provide a safe environment for cancer survivors to talk about their emotions or ask for help for secondgeneration cancer survivors who prefer to join nonkorean american organizations an organization like the cancer support community can be a useful resource where they can receive psychosocial care at no cost finally acknowledging the importance of providing culturally appropriate programs at nonprofit organizations is imperative westernoriented therapy or support groups focus on open communication open discussions about conflicts and emphasize individuals as compared to the family all features of therapeutic approaches that are unfamiliar and more difficult for people from asian cultures modifications of this form of therapy are needed to enhance the effectiveness of therapy or a support group for korean americans or other ethnic groups who follow confucianism values in summary cancer is recognized as the leading cause of death for korean americans in the usa population that will increase in size over the coming decades this review of the literature identified social support communication and acculturation as key factors related to the level of qol in korean american cancer survivors these findings have implications for future research on korean american cancer survivors as well as for health care professionals who may provide care to this group ongoing efforts to infuse research and practice with culturallyrelevant and sensitive interventions and therapeutic approaches hold promise for ensuring that korean american patients and their families receive high quality care that improves their quality of life consort diagram variables topics findings social support family i believe that cooperation and love from family and husband have helped me a lot families dont understand they say they understand but they expect us to be the same people as before the disease my family expects me to work and function the same as before the surgery i have been devoted to my family…i just tolerate everything as many korean women do even after getting chemo i still had to take care of my children so that was hard my children are barriers for me i am sure the fear is the same or even more because they dont have as much family support in this country but we dont hear as much communication healthcare system i realized that doctors are very friendly its frustrating that i cant communicate with them well we firstgeneration korean americans prefer korean speaking doctors because of the language barrier i had a few consultation sessions with a doctor before surgery… it was a little regretful because i did not get any detailed information first vs second generation communication my mother is very emotional person… doesnt talk much… i think my thoughts become americanized acculturation living as immigrant most of immigrants have acculturative stress when they immigrate…i had stress from living together with my sisters family to save money language barrier i felt stressed due to the language problem… so i wonder if i would not have gotten cancer if i had stayed in korea

problem identificationthere is limited understanding of korean american cancer survivors quality of life qol within a cultural context the study examined factors associated with the qol of korean american cancer survivors

background the family planning program is one of the efforts made by the government to overcome population problems in indonesia the family planning program is an integrated part of the national development program its aims to create economic spiritual and sociocultural welfare for the indonesian population so that a good balance can be achieved with the ability of national production the primary purpose of implementing family planning is to improve the health and welfare of mothers children families and the nation and reduce the birth rate to raise the standard of living of the people and the government the national family planning movement has succeeded in encouraging community participation in building quality small families this success must be considered and improved because the achievements are still uneven local to solve the problem the success of family planning programs in indonesia is influenced by several factors including socioeconomic cultural educational religious and womens status the progress of family planning programs cannot be separated from the economic level of the community because it is closely related to the ability to buy contraceptives several cultural factors can influence clients in choosing a contraceptive method education level affects the willingness to use family planning the choice of a method research conducted by abar showed that there was no relationship between the number of children and the use of this type of contraception with a pvalue 0590 and a study pissn 26852020 eissn 2685eissn 2012 conducted by abar showed that there was no relationship between the number of children and the use of contraceptive methods with pvalue 0590 the success of the family planning program is influenced by several factors including socioeconomic culture education religion and status of women economic level and level of education so this study aims to determine the relationship between these factors based on a preliminary study conducted at the south magelang health center in 2022 it can be seen that in the first quarter of 2022 there are 31 acceptors both new and old acceptors with types of contraceptive method users injection 22 iud 7 and implant 2 acceptorsfrom these data the majority do not use longterm contraception which is the main hope of the government in the coverage of longterm contraceptive use methods this research uses quantitative research with survey methods and data collection time with a crosssectional approach the study the population in this study were all contraceptive acceptors namely 31 pus in the south magelang health center and the sampling technique was the total population statistical test using chisquare test with an error level of 5 result and discussion a relationship between the economic level and the use of contraceptives of 18 respondents who were in the category of high economic level the majority used hormonal contraceptivesof the 13 respondents who were in the variety of low economic classess the majority used nonhormonal contraceptives based on the chisquare statistical test it can be seen that pvalue is 0158 so it can be concluded that there is no relationship between the economic status and the use of contraceptives in this study there is no relationship between economic level and contraceptive use it is possible because the use of contraception is a government program in which the acceptors are not charged for contraceptive devicesdrugs because in general all people already have health financing guarantees that guarantee free services for contraceptive services this means that the community does not incur costs to get contraceptive services regardless of the costs that must be incurred maybe it would be different if there was no guarantee of free contraceptive services because the community had to allocate funds every time they made a repeat visit to get contraceptive services especially the type of injectable contraception that had to be done every 1 or 3 months b the relationship of maternal age and the use of contraceptives of 21 respondents who were at the age of setting the interval between pregnancies the majority used hormonal contraception in comparison of the 10 respondents who were at the age of terminating pregnancy the majority used nonhormonal contraceptives based on the chisquare statistical test it can be seen that pvalue is 0131 so it can be concluded that there is no relationship between the maternal age category and the use of contraceptives age is divided into three productive age periods the first is the period of delaying pregnancy for pus with wives under 20 years of ageit is recommended to postpone their pregnancies the second is the period of spacing their pregnancies the period for wives aged 2029 years is the best period for giving birth to children with a birth spacing of 34 years the third is the period of ending birth namely the age over 35 years after having three or more children these results are the same as the research conducted by abar the results show no relationship between the number of children and the use of this type of contraception with a pvalue of 0590 this result is not with the research conducted by sabngatun et al with the title the relationship between age and education level with the choice of injectable contraception with pvalue of 0033 c relationship between the number of children and the use of contraceptives of the two respondents who were poor children 50 used hormonal contraceptives and 50 used nonhormonal contraceptives meanwhile of the 29 respondents who were in the number of good children catagory the majority used hormonal contraceptives based on the chisquare statistical test it can be seen that pvalue is 0887 so it can be concluded that there is no relationship between the number of children and the use of contraceptives this result is the same as the study conducted by abar pissn 26852020 eissn which showed no relationship between the number of children and the use of this type of contraception with a pvalue 0590 d the relationship between education level and the use of contraceptives of the 2 respondents in the basic education level category 100 use hormonal contraceptives meanwhile of the 25 respondents in the category of secondary education level the majority use hormonal contraceptives namely 60 and of 4 respondents in higher education levels 50 use hormonal contraceptives and 50 use nonhormonal contraception based on the chisquare statistical test it can be seen that pvalue is 0778 so it can be concluded that there is no relationship between the level of education with the use of contraceptives this result is not the same as the results of abar et als study which shows a relationship between education level and contraceptive use with pvalue of 0000 this result is also by the research conducted by sabngatun et al with the title of the relationship between age and education level with the choice of injectable contraception with a pvalue 0000 e the relationship between the level of knowledge and the use of contraceptives of 1 respondent in the variety of lack of knowledge 100 use hormonal contraceptives meanwhile of the 9 respondents who are in the category of sufficient knowledge the majority use this type of hormonal contraception of 21 respondents who are in high command the majority is 524 use hormonal contraception based on the chisquare statistical test it can be seen that pvalue 0642 so it can be concluded that there is no relationship between the level of education with the use of contraceptives this result is different from the research conducted by arbaiyah et al with the title the relationship between the level of knowledge and husbands support with the use of iud contraception with a pvalue 001 renis research states that most respondents have a good story of knowledge about the benefits of hormonal contraception the level of knowledge affects not only the willingness to use family planning and the choice of a method good knowledge the understanding of various types of contraception will have an impact on the choice of contraception in this study there is no possible relationship because the use of contraception is a government program where the acceptor does not have the freedom to choose contraception because of certain provisions related to health insurance facilities that are directed only at the use of certain types of contraception with the increasingly widespread use of various media in delivering of information to the people including the delivery of information about family planning it has been widely accepted by the public both formally and informallyfrom nonformal for example through print and electronic mediaadvertisements namely magazines newspapers television and youtube however the information obtained is often superficial unlike when it is carried out intensely by health workers directly to the community for example through family planning counseling conducted to family planning community groups the implementation of family planning counseling that can disseminate information about contraception in the south magelang health center area is carried out only during ante natal care or less intensive class time for mothers more indepth counseling is carried out at the time of installationservice not before the selection of contraceptives f the relationship between the husbands support and the use of contraceptives of 5 respondents who are in the category of husbands support the majority less than 60 use hormonal contraceptives in the comparison out of 13 respondents who are in the husbands support category the majority use hormonal contraceptives which is 692 and of 13 respondents who are in the husbands support category the majority namely 538 also use hormonal contraception based on the chisquare statistical test it can be seen that the pvalue is 0776 which is more than 005 so it can be concluded that there is no relationship between the husbands support and the use of contraceptives the results of liliks research show that the husbands help in selecting mkjp is in the form of transportation information and joint discussion this result is inversely proportional to the research conducted by arbaiyah et al pissn 26852020 eissn 26852012 entitled the relationship of husbands knowledge and support with the use of iud contraceptives obtained a pvalue 002 which means that there is a relationship between the husbands help and the use of iud contraceptives the role of this behavior does not work in the community because in general a family head feels more responsible for earning a living than his involvement in fulfilling his wifes reproductive health it often happens in the community that contraception is only a womans business in this case the wife so the husband only supports it in terms of costs compared to other supports including assisting the husband in visits to health services to get contraceptive services it is not uncommon to use contraception because this influence can be received from friends relatives neighbors or other family members who have used contraceptive methods conclusion and suggestions there is no relationship between economic level a pvalue of 0158 maternal age with pvalue of 0131 number of children a pvalue 0887 education level with a pvalue of 0778 level of knowledge about contraception with a pvalue of 0642 and family support a pvalue 0776 with the use of this type of contraception because the family planning program is a government program and is free for the community the community has no difficulty getting access to contraceptive services because they are guaranteed costs from the government suggestion the community especially women of childbearing age should seek more and more indepth information about various types of contraception for public health center it is necessary to provide health education about different contraceptives to the community intensively and more deeply so that women prospective acceptors have a better understanding of different contraceptives provide leaflets about various contraceptives that prospective acceptors can have before determining the type of contraception to be used

the success of family planning programs in indonesia was influenced by several factors including socioeconomic cultural educational religious and womens status at the south magelang health center in 2022 it can be seen that in the first quarter of 2022 there are 31 acceptors active acceptors with types of contraceptive method which is injection 22 acceptors iud intra uterine devices 7 acceptors and implant 2 acceptors the success of the family planning program is influenced by several factors including socioeconomic culture education religion and status of women economic level level of education so this study aims to determine the relationship between these factors methods the type of quantitative research with survey methods and data collection time with a crosssectional approach independent variables economic level age number of children education level level of knowledgeand husbands support dependent variable use of contraception the research instrument used a questionnaire the population in this study were all contraceptive acceptors namely 31 pus in the south magelang health center area with data analysis using chie square with alpha 5 results the results of the univariate analysis are shown there is no relationship between economic level pvalue 0158 maternal age with pvalue 0131 number of children with pvalue 0887 education level with pvalue 0778 level of knowledge about contraception with pvalue 0642 and family support with pvalue 0776 with the use of contraceptives conclusion extensive and detailed information about various contraceptives is carried out before a person chooses certain types of contraception

introduction family physicians role in rural communities fabric should be emphasized as the demographic composition of these areas leans towards aging there is a pronounced need for focused medical care with a particular emphasis on preventing chronic diseases 1 this demographic shift accentuates the necessity for family physicians to be deeply entrenched in the sociocultural dynamics of the older rural populace orchestrating health interventions via community collaboration 2 this editorial underscores the importance of incorporating reflective practices in rural family medicine advocating for a synergy between healthcare professionals and the community through health dialogues the role of rural health dialogue central to the discourse on rural health is the dialogue a platform that fosters a symbiotic interaction between healthcare professionals and the community 3 spearheaded by family physicians these dialogues pave the way for rural inhabitants to introspect on their existing helpseeking behaviors with their expansive knowledge and holistic care approach family physicians shepherd rural residents toward an enhanced comprehension and potential reconfiguration of their hsbs as evidenced by prior research a considerable portion of the rural populace grapples with confidence regarding their hsbs often culminating in suboptimal healthcare decisions 3 persistent engagement in these health dialogues can catalyze a more proactive involvement of the rural community in their health decisions family physicians championing the core tenets of their specialization should approach every patient encounter as a golden opportunity for health promotion or disease prevention 4 these dialogues afford them a window into the communitys collective psyche regarding health and disease narratives armed with these insights they can tailor interventions that resonate with the communitys lived experiences and daily life fostering more effective health behaviors building trust and enhancing hsbs the regularity and consistency of health dialogues in rural settings lay the groundwork for an enduring trust between rural citizens and family physicians 3 while the innate curiosity of rural inhabitants propels them towards acquiring knowledge about health and new hsbs the perceived chasm from medical professionals can be a deterrent the continuous rhythm of these dialogues can dispel such inhibitions nurturing a community better equipped to make informed health decisions 3 aligned with the principles of family medicine physicians are implored to immerse themselves in the unique challenges rural communities face this closeknit engagement fosters a more genuine understanding bridging psychological and informational gaps thus catalyzing more effective hsbs optimizing limited healthcare resources rural health dialogues serve as catalysts motivating citizens to utilize the available healthcare resources judiciously with their depth of knowledge family physicians guide these dialogues towards actionable insights suggesting avenues to harness these resources for preventive and promotive health key to this endeavor is the comprehension of the sociocultural fabric of the community 4 such open forums embolden rural citizens to voice their concerns challenges and aspirations allowing for healthcare interventions that are both personalized and impactful overcoming the evidence pipeline challenge for the rural health dialogue to be impactful family physicians must foster an environment of trust through adept communication and keep abreast of the latest medical developments 3 the metaphor of the evidence pipeline with leakage underscores the challenge and importance of translating cuttingedge academic research into actionable insights for the community family physicians stand at this critical juncture ensuring that rural communities are kept in the evolving landscape of medical knowledge embodying the communitycentric ethos of family medicine physicians should position themselves as more than just healthcare providers they are allies partners and advocates 5 their role transcends diseasefocused interventions emphasizing a holistic personcentric care paradigm as leaders they are poised to drive collaborations fostering an environment of mutual respect understanding and shared goals conclusion family physicians stand as pillars in the edifice of rural healthcare orchestrating meaningful health dialogues that bridge divides build trust and enhance community health behaviors their continuous and profound engagement in these dialogues ensures that rural communities are not just passive recipients but active stakeholders in their health narratives family physicians are carving out a more integrated responsive and effective rural healthcare mosaic through their leadership expertise and dedication additional information author contributions all authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work concept and design ryuichi ohta chiaki sano acquisition analysis or interpretation of data ryuichi ohta chiaki sano drafting of the manuscript ryuichi ohta chiaki sano critical review of the manuscript for important intellectual content ryuichi ohta chiaki sano disclosures conflicts of interest in compliance with the icmje uniform disclosure form all authors declare the following paymentservices 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

health dialogue plays a pivotal role in sustaining rural communities by enhancing helpseeking behaviors hsbs this article delves deep into how family physicians accentuate the efficacy of rural health dialogues prompting rural citizens to evaluate and adapt their current hsbs critically establishing a foundation of trust in rural family physicians significantly influences the motivation for refined hsbs additionally such engagements optimize the application of limited healthcare resources for these outcomes to be realized family physicians must amplify their communication and leadership abilities and confront the inherent challenges of disseminating contemporary medical evidence in rural domains

introduction this papers aim is to inquire into the representation of muslim women in two memoirs i am malala the girl who stood up for education and was shot by the taliban by malala yousafzai and red white and muslim my story of belief by asma gull hasan in so doing we draw upon the framework provided by saba mahmood about muslim womens unique subjectivity and agency in her work politics of piety the islamic revival and the feminist subject we argue that the kind of subjectivity and agency portrayed in the memoirs written by muslim women are more in keeping with secularist modes of being which prize individualist struggles at the expense of collective and religious approaches the ideas of the self that are promoted and endorsed in such works are grounded in the empowerment of the individual girl as she struggles against the supposedly constricting norms of her society the lives of muslim women are accordingly measured against the enlightenment ideas of freedom choice and autonomy the representation of muslim womens lives thus takes on an essentialist turn normalising the empowered and liberated woman who is active in the public sphere and by the same corollary undermining the woman who is a homemaker and prefers collective familial ideals engaged in struggles that are not centred on individualistic goals our main purpose in this paper is not to challenge the struggle that malala stands for or to subvert the kind of islam approved and endorsed by diasporic figures like asma gull hasan but to showcase the intricate ways through which these memoirs endeavour to validate their representation as the only truth about islam this depiction therefore is a crucial means of disrupting a nuanced picture of islam and acts as a major site of regenerating clichéd platitudes about islam in the case of memoirs like malalas where an individual figure is provided amnesty against the purportedly oppressive environment of her society we contend that the coveted subjectivity of freedom choice and liberty becomes an effort on her part of equating her religion with the absence of these ideals her rescue is not therefore a benign activity of rescuing an oppressed victim but is teeming with multiple implications that need careful unpacking on the other hand memoirs like asma gull hasans are imperceptibly upholding the supremacy of secularist subjectivities in their overenthusiastic selfexplicatory approach writers like her believe quite naively so that if islam is only held commensurate with secularist modes of life then that would extricate this religion from the negative undercurrents it has allegedly been allied with another facet of this inconsistent representation is that secular values act as the reference point against which the validity of islam is to be tested therefore while engaging with mahmoods theory of subjectivity of muslim women this paper probes into the representation of muslim women in muslim womens memoirs as it looks into the kind of subjectivity and agency of muslim women depicted in the two selected memoirs it further explores how in the muslim context this portrayal promotes a specific kind of subjectivity and agency which runs parallel to secularist modes of individual empowerment muslim womens memoirs after 911 a contextual overview at this point it seems appropriate to highlight the importance of the fact that muslim womens memoirs burgeoned in the aftermath of 911 this key event revived a fresh an interest in muslim lives and has been a determinative reason for once again stirring up the platitudinous notions about islam as being conservative and muslim women being oppressed since then islam has been seen as irretrievably linked with terrorism being a patriarchal religion oppressive to women as a corollary the muslim woman has come to be seen as a pitiable figure sans subjectivity or agency incapable of exerting her own free will or choice against this milieu a number of memoirs mostly written by muslim women appeared on the literary scene in response to the curiosity that has risen anew in the enshrouded figure of the muslim woman the most acclaimed amongst them are accounts such as azar nafisis reading lolita in tehran marjane satrapis persepolis the story of a childhood azadeh moavenis lipstick jihad a memoir of growing up iranian in america and american in iran asra nomanis standing alone in mecca and sumbul alikaramalis the muslim next door the quran the media and that veil thing the proliferation of memoirs written by muslim women might have been to bail islam out of the pit of notoriety however the response to these accounts has been quite ambivalent in literary circles cynthia enloe remarks that the narratives of muslim women are imperially constructed to explain muslim women she further posits that the simplistic narrative has been disseminated with a militarizing effect the nondescript portrayal of muslim women takes either of the two extremes a plagued damsel in need of rescue or a liberal empowered individual much like her secularist kinswoman in the west in either case the desired subjectivity which the protagonist either seeks or proves her strong affiliation with is the one which fits within the secularist framework of liberty choice and resistance mahmoods work politics of piety inhabits a key locus in the aftermath of 911 when islam and muslims were faced with the agonising task of redefining their suspect identities they had to explain islam to the nonmuslim world when the latter was framing islam as conservative and outdated mahmood was among the leading critics who indicated the reductionism of secular modalities and western feminism in politics of piety she pointed out the deep ties which feminism enjoys with secularliberal politics therefore muslim women who do not let themselves be defined through liberal values are termed as agents of dangerous irrationality in giving preeminence to individual empowerment choice and liberty the secularist paradigm seeks to denigrate the societies which thrive through communal values and religious ethos it promotes career women and defies the subjectivities of women who are housekeepers and who do not pose a resistance to their societal or religious values mahmood elaborates upon the negativity that enshrouds the islamist movement womens participation in such events incurs strong responses from a broad range of political spectrum they are taken as pawns in the grand patriarchal plan as mahmood explains secular neoliberal sensibilities are troubled when they observe womens active support of socioreligious movements that sustain principles of female subordination in other words mahmood contends with the normative claims of the secularist discourse which excludes those women as agentic who prefer to express their subjectivity through communityoriented values or who set their coveted goal as submission to a transcendental willand thus in many instances to male authority her project of examining the lives of pious muslim women in cairo from 1995 to 1997 was mainly executed with an objective of foregrounding how muslim women cannot be defined through the supposedly liberal and democratic ideals of feminism the hidden paradox is that the western project of reforming and liberating muslim women from islamic patriarchy is once again an oblique reaffirmation of imperial hegemony this neocolonial practice is in complete disregard of the specific context in which a muslim woman defines and asserts herself a muslim womans definition of subjectivity and agency is therefore not in any way at par with the western ideals of females striving for freedom and visibility mahmood reacts against the premise that freedom for a muslim woman has the same meaning as the one that defines a western woman in politics of piety she avers that in liberal political theory an individual is considered at liberty only when her actions are the result of her own choice and free will rather than of custom tradition transcendental will or social coercion she questions the liberal presuppositions that have become naturalised in the scholarship on gender liberty she propounds is not necessarily contingent upon a challenge to the societal norms and prescribed traditions the prevalent image of a muslim woman is that of a docile passive being without agency or free will she is considered agentic only in her act of rebellion against her religious norms and mores this secularist paradigm presupposes an instinctual abhorrence for the traditional islamic mores that used to enchain them this concept of a socially and morally autonomous individual inadvertently influences any study of a muslim woman she appears to the western eye as necessarily confined persecuted and desperate to break herself free from chains in her essay feminism democracy and empire islam and the war on terror mahmood dilates upon islams mistreatment of women which is used as a diagnosis as well as a strategic point of intervention for restructuring large swaths of the muslim population if not the religion itself mahmoods anthropological work between 1995 and 1997 was based on the mosque movement of muslim women of egypt and expressed them through a different mode of agency that incorporated the islamic values of shyness and modesty this concept of agency was not based on resistance and opposition as is endorsed by western feminism or secular liberal thought for instance in politics of piety she cites the rigorous efforts of a group of four women to indoctrinate the virtue of modesty and shyness mahmood explains the unique concept of haya which implies being diffident modest and able to feel and enact shyness she also concedes to the fact that all islamic virtues are gendered when applied their measure and standard vary for men vs women but this is nowhere truer than in the case of the virtues of shyness and modesty such gendered injunctions have always posed a problem for secularist modes of thinking and for current feminist political thought to envision valuable forms of human flourishing outside the bounds of liberal progressive imaginary mahmood contends that both secularist modes of governance and post structuralist feminist theory are necessarily liberatory in approach the sanctioned concept of agency is postulated on the binary model of subordination and subversion drawing upon her anthropological focus on a muslim womans exclusive subjectivity our contention is that representation in muslim womens memoirs is more in accordance with the secular modes of being this kind of portrayal of either vying for the kind of liberty and empowerment guaranteed by secularism or of justifying islam as a religion that ensures the same kind of rights enjoyed by women in the west leaves much to be desired for one it makes the lives of those women seem underprivileged who believe in living a religious life and who are not struggling for the coveted ideal of individual empowerment what mystifies the west according to mahmood is the ambivalent relation women have with the social structure that seemingly narrows down and curtails their authority that muslim women whether in their home countries or living a diasporic existence should favour whatever seemingly goes against their own freedom is a dilemma for the feminist analysts this confusion springs from the false assumption that secularism is universal and so is the desire to aspire for a separation between religion and politics it is presumed erroneously of course that freedom of the individual is only guaranteed in secular ideals hence secular liberalism is the most publicised and the most soughtafter ideal for the west and of feminism that is patronised by the west mahmood criticises this tendency to take the secular liberal woman as the normative benchmark against which a woman with religious inclinations should be measured mahmood must be given credit for exposing the limitations and normative claims of secular modalities which according to her is another way of reaffirming the preeminence of christianity this prevailing bias as mahmood sees it has its origins in the selfunderstanding of europe as essentially christian and simultaneously secular in its cultural and political ethos mahmood thinks that present secular ideals are having deep links with neocolonial designs at this point an important fact that should not be overlooked is that secularism gained currency in the postcolonial world this entanglement of secularism with imperialism in the aftermath of 911 is vociferously articulated by many writers for example talal asad in his book formation of secular christianity islam modernity explains that west european history has profound consequences for the ways that the doctrine of secularism has been conceived and implemented in the rest of the modernising world mahmood seems to second her mentors thoughts in her essay secularism hermeneutics and empire the politics of islamic reformation dilating upon the efforts of us department of state to change islam from within to bring it closer to secular ideals and to ward off the dangers of religious strife sunaina maira in her article good and bad muslims citizens feminists terrorists and us orientalisms discusses the categorization of good and bad muslims by the us to justify the war on terror maira purports that this war is based on a binary framework she further explains that practices of state terror are often justified by distinction between premodern and modern subjects civilised people who deserve rights versus those who are evicted from the modern political community this distinctive theory of muslim womens subjectivity and agency provided by mahmood allows us to problematize the representation of muslim women in the memoirs coming from within the muslim world we claim that these writers have internalised the principles of secularism and the subjectivity of women as defined under this ideology they are either desirous of individual empowerment as is evident in the case of malala or they are desperate to equate islamic values with secular ones thereby holding them as compatible malala in her vulnerable position stands as a proof of the oppressed muslim girl who must be rescued and taken to a safer place to realise her potential her injured state is an oblique criticism of her society which cannot guarantee her freedom agency and privileges that her new sanctum promises on the other hand throughout her account hasan reiterates the primacy of secular values and how islamic tenets neatly fit within that frame such depictions we argue undercut the role of a woman who prefers to sacrifice her individual goals for familial bonds and who as per this definition of subjectivity does not seem empowered enough secondly and more importantly this demarcation is a major source of the recasting of muslim women as the objects of patriarchal as well as religious oppression at this point a brief background of the two selected writers is necessary malalas name hardly needs any introduction since she became famous after being the victim of a taliban shooting in 2012 the celebrity treatment that she was accorded in the west made her a highly polarised figure in pakistan her memoir coauthored with christina lamb was published in 2013 the second version of the same memoir meant for children was cowritten with patricia mccormick in 2014 it tracks down the struggle of malala against the restrictions imposed by the taliban highlighting her resistance against taliban authority and was resultantly shot by one of their members malala has not only been an iconic figure but a winner of many accolades and awards asma gull hasan on the other hand is a highly prolific and versatile figure working as a lawyer and making regular appearances in fox news and cnn she aims to reinstate islam and inform the foreign audience about what is really cool being a muslim the account mixes autobiographical material with feisty insights into islam and the many misconceptions people have about it the selected memoirs are symptomatic of many others of their type almost all of these memoirs come up with the claim of dispelling stereotypes about muslim women and yet what distinguishes them is a repetition of specific thematic patterns so that their stories become almost identical reinforcing the worst platitudes about islam and muslim women among them are accounts such as reading lolita in tehran by azar nafisi love in a headscarf by shelina jan mohamed threading my prayer rug by sabeeha rehman laughing all the way to the mosque by zarqa nawaz and a number of collections which contain such personal accounts as living islam out loud american muslim women speak shattering the stereotypes muslim women speak out all of these works come with proclamations of presenting an unalloyed version of islam however hala halim in her review of the book shattering the stereotypes muslim women speak out throws in a note of warning halim concedes to the fact that these books indeed prove successful in modifying stereotypes but the muslim women in the title may run the risk of operating from within the terms of discussion dictated by western neo colonial discourse we thus question their representation of claiming to stand for a true and pure islam which we argue rests on the model of subjectivity propounded by secularism and neoliberalism in case of stories like that of malala yousafzai the protagonist asserts her difference from the prevalent and supposedly restricting customs yousafzai emerges as an exception for she is an outspoken strong… a kind of shadowy sisterself to the american female if not the feminist reader she is the symptomatic case of being a victim of an oppressive culture waiting to be rescued to an enlightened land of liberty and empowerment on the other hand writers like asma gull hasan make strenuous efforts to prove their affinity with the progressive sisters of the west discussing the popularity of muslim womens autobiographical genre mahmood in her essay feminism democracy and empire islam and the war on terror elucidates that the popularity and ideological force of this literature owes largely to the ability of the muslim woman author to embody the double figure of insider and the victim this portrayal discredits the subjectivity of those muslim women who do not let themselves be classified via the attributes of liberty and individual empowerment that are the characteristic features of western feminism mahmood speaks out against this singular and reductive conception of religiosity that implies a narrow vision of gender enfranchisement blinding us to the power that nonliberal form of religiosity command in many womens lives malala the victimised icon malala because of the iconic stature that she enjoys internationally has come to assume an equivocal position of a miserable muslim woman and an empowered individual she is now seen as a victim of the societal mores she needs to be rescued from and simultaneously as an affirmation of the enlightened values of the land she has sought shelter in malalas injuries invoke sympathy for the helpless victim and derision for the society and its values which failed to protect her such nuances as those that are linked to her rescue imply that it is only a secularist society that can vouchsafe the rights of women when she was in pakistan her own country malala lived sans agency freedom or choice however in her salvaged position she appears as an apostle of human rights figures like ayan hirsi ali mukhtaran mai farah ahmed and last but not the least malala gain their ascendancy in international circles by reaffirming the rampant clichés about the suppressed figures of muslim women malala as abulughod remarks stands as an instance of sanctimonious championing of distant women a plucky individualist who gets credence in her rescued harbour by maligning her own culture as shelina khojamoolji remarks about malala that she embodies a transnational secular modernity exemplified by her emphasis on the autonomous self enactment of choice advocacy for freedom and arguments for gender equality malalas memoir contains a substantial critique of a culture she considers backward for instance she writes that the women of the village had to hide their face whenever they leave their homes and they could not meet or speak to men who were not their close relatives she dilates upon the custom of keeping the women illiterate since she doesnt need an education to run a house this reflection culminates in a seemingly natural cry of despair and helplessness from a girl who was confused and sad to see the hard life of the women of swat thus she asks why were women treated so poorly in our country malalas intercession as a writer is very deftly placed the narrative voice is quite candidly reaffirming the suppressed stature of women in her culture and expressing her own dissatisfaction with it malala however has apparently overlooked many instances of pashtun women whose priority is to remain within their own norms and ethos and that too by their own choice their subjectivity unlike malalas is not contending for a break from the cultural ties in which their identity is rooted malalas own mother is one telling example she chose not to go to school although she had the support of a father and brothers who encouraged her to go to school and yet the age she was in playing with her cousins cooking cleaning and bringing up children appeared far more fascinating than a life of dull drab studies malala we are told is named after a great fighter resisting british imperialism the fact that malalai was a source of inspiration for people of afghanistan and the afghan king build a maiwand victory monument in the centre of kabul bears testimony to the fact that she is remembered and respected in history her case seems to be an indication of the space enjoyed by muslim women even when they are acting against their recommended roles malala however cleverly bypasses such events to specify those which are indicative of a conservative society for example she mentions in her memoir one girl who takes her life because the tribal customs do not permit her to marry the love of her life this event is described in detail another girl who was sold by her father to a much older man is also highlighted these tales of misery are accompanied by the writers explanation that in our society for a girl to flirt with a man brings shame on the family though its all right for the man yousafzai is dilating upon a disagreeable state of affairs but the unpleasantness is surprisingly only felt acutely by malala alone as she expresses her discomfort with an accepted practice in society she is told by her father of the even worse scenario in afghanistan where women were being beaten and locked up just for wearing nail varnish as she shivered to hear such atrocities committed by taliban malala cherishes her situation of being free as a bird here it can be argued that malala is acting in the role of an unofficial spokeswoman imparting an air of credibility to some of the worst type of prejudices and stereotypes that are rampant about islam malala seems to be quite aware of the response that such details are likely to accrue she is positing her own struggle as a voice of dissent and is thus rewarded for standing in opposition to the religious oppression of taliban one other significant point is that figures like malala are taken as essentially representing the oppressive status of islamic culture whereas in their liberation they stand for the enlightening virtues of a secular society which rescued and empowered them it is well known that malala has been brought up on the notion of being an exception contrasting her life with the lives of the other girls of swat she tells her readers that the day a girl is born is a gloomy day since her role in life is simply to prepare food and give birth this shocking condition is then juxtaposed with the following claim but i was differenti never hid my desire when i changed from wanting to be a doctor to wanting to be an inventor or politician this realisation of being a distinct individual gets consolidated with time and later malala made conscious efforts to substantiate her image as an agent of transformation in society an opportunity was thrown her way when a bbc correspondent approached her he wanted to do a program in the tradition of anne franks diary the jewish girl who used to give voice to the atrocities of nazis malala was quick to respond and started to air the outrages of the taliban in swat purportedly the aim was altruistic however the flip side of the picture is that malala was making acquaintance with a new world of dazzling lights and loud microphones she got lured into a fascinating domain as her thirst for visibility and attention increased making her sign one project after another significantly she used such platforms to express her discontent against the taliban but did not link this with the gruelling task of bringing any tangible change in the people of her area whether the people of swat saw any improvement in the situation because of these programs is another story but one thing is certain that this international attention boosted up the image of malala malala rose as it were like a phoenix out of the smouldering remains of her own destruction embodying the feisty girlpower inflected mode of contemporary postfeminism and humanitarianism this projection of the unrest and mayhem experienced by the people of swat gives malala leverage interestingly her own father ziauddin exhibited exceptional eagerness to build the unique status of his daughter he engaged her as shahan mufti puts it in a delicate dance he cites adam ellicks remarks about the obsession of malalas father about her visibility in media pushing their kid to become the next tennis star or beauty pageant winner what is ironic in this instance is that malala got so used to this media attention that when she was attacked she was actually expecting a microphone to be thrust to her face and instead saw a black colt45 this hunger to be in the limelight has a particular resonance with the secularist neoliberal paradigm it imbued her with a consciousness of her exceptional status her subjectivity was constructed around resistance to traditional mores with an emphasis on individual empowerment and freedom of choice she started viewing herself as an agent of change who could plead with foreign emissaries like richard holbrooke for girls right to education malala was just twelve years old then her pride at her exceptional status is obvious from such remarks i sat next to him it was through her appearance at such public platforms that she established her singularity however unfortunately she was in a highrisk environment because of the presence of the taliban and hence had to be bailed out to a safer place the dichotomy present in the rescue missions has been amply borne out by the lopsidedness of these missions some selected figures were provided sanctum by britain while others like kainat riaz and shazia ramzan the two girls who got injured along with malala were left to fend for themselves they were provided amenity only when their case was pled by none other than malala herself the skewed exegeses of these missions therefore have a political nuance they are employed and mediated according to khojamoolji for installing the white anglophone as representing full humanity malalas censure of the tribal practices and the codes and ethos of the taliban assumes a special significance in such a scenario she informs with condescension about the kind of education delivered in madrassas they learn that there is no such thing as science and literature that dinosaurs never existed and that man never went to moon malala by contrast has a fondness for justin beibers songs the twilight movies and skin whitening creamsitems not even remotely linked to her indigenous culture in her new home britain she undergoes a metamorphosis as it were emerging as an empowered and emboldened figure however significantly she has to be thankful for these qualities to her rescuers who have brought in such refinement and finesse in her personality as a consequence the freedom of choice that she is granted is not an innocuous activity rather she becomes a ploy in the hands of her supporters to market a specific brand of empowerment which is the hallmark of secular and neoliberal forces in promoting the transformation stories of these wretched young women the west expediently overlooks the sordid history of its own women who have been the victims of state violence it measures womens power and agency with the only yardstick they have of how much a subject is able to assert and sustain its individual free will against societal pressures cases like bibi aisha of afghanistan with her mutilated face have a special significance for the west since it brings home the oppressive patriarchal structure of islam the disfigured picture of aisha was published in times magazine in 2010 with the caption running what happens if we leave afghanistan it is in relation to such politics of representation that mahmood points to the limitations inherent in such a definition of agency and subjectivity it occludes and undercuts the women who prioritise familial bonds and for whom collective welfare rather than individual betterment is the target the emphasis on individual will and struggle restricts the concept of womens subjectivity to the binaries of subservience and subversiveness malala in her rescued status emerges as a representative case of the reinforcement of these binaries the kind of compassion that her injured body generates also creates contempt for the invader her heroism in rising against odds is in the words of khojamoolji the successful performance of an empowered subjectivity her rescue and her empowered stature in britain her adopted home imply that this privilege is only possible in a liberated environment mahmood postulates that agency is not essentially a synonym to resistance but a capacity for action that specific relations of subordination create and enable agentic capacity is entailed not only in those acts that resist norms but also in the multiple ways in which one inhabits norm agency should not be tied to emancipatory politics individual heroines with malala being the characteristic example are celebrated in secularist democracies because of their asserting their agency in opposition to their societies in the course of her memoir malala frequently refers to the tenacious life style of the women of swat of how t here were no proper shops no universities no hospitals or female doctors… and they could not meet or speak to men who were not their close relatives malala is pointing to a state of affairs where difference of code for men and women is normative in addition she refers to the veil wearing which is quite an obligatory norm in swat as constricting living under wraps seemed so unfairand uncomfortable from an early age i told my parents that no matter what other girls did i would never cover my face like that my face was my identity one is reminded of the case of mukhtaran mai 1 the western media notes with satisfaction an unveiled muslim girl shaking hands with dignitaries as an essential sign of a muslim girls liberated status nicholas kristoff for example is pleased to note in the case of mukhtaran mai that the world will not end if her scarf drops mahmood has the following remarks to offer about the forceful reaction of the west regarding the veil controversy the reason the veil elicits such strong response is that it continues to assert a kind of religiosity that is incommensurable with and inimical to those forms of public sociability that a secularliberal polity seeks to make normative she further notes the inconsistency in responses that is the visible endorsement when men wear religious symbols such as turbans or yarmulkes and a vehement rejection when women use veils typically an uncovered head is taken as an instance of a free and empowered woman these proclamations are an oblique affirmation of the preeminence of secular neoliberal modes of governance and by implication an undermining of religious approaches of life asma gull hasan the moderate muslim woman of the west rescue narratives like malalas which stand as a testimony to the oppressed stature of muslim women are counteraffirmed by memoirs of another kind the central figure in such tales however is not in the need of liberty and empowerment rather the protagonist already enjoys the benefits because she belongs to an enlightened society the main thrust of all such memoirs we argue is to retrieve islam from the enclaves of terrorism and extremism and demonstrate to the west how it is also a progressive and liberal religion ideally compatible with the modern ways of life mahmood in her essay feminism democracy and empire islam and the war on terror warns against the gradual but incessant process of reform from a variety of quarters for secularising and liberalising islam so that muslims may live an enlightened existence in this regard the memoirs coming from muslim women are viewed very positively by liberal political pundits because they are seen to be embedded within an emancipatory model of politics eliciting admiration from feminist readership admittedly these writers have to face the maligning campaign against islam as a religion promoting terrorism and therefore they are extraordinarily cautious in proving themselves different from the extremist brand of islam however their ambassadorial overtures to explain the true spirit of islam to a foreign audience is quite clichéd the memoir which has been selected for investigation with this angle in mind is asma gull hasans red white and muslim diasporic writers like her feel it obligatory to bail out islam from the constricting strictures of the taliban a selfexplanatory zeal is the highly distinguishing feature of these writers ironically they begin by acknowledging their own version of islam as the true one while the rest is dismissed as a cultural innovation hasans memoir is no different throughout her narrative an exclusive enthusiasm to hold at par the values of islam with that of secularism is observed in the first chapter of red white and muslim titled note to the reader hasan parallels the quran and the perfect ideals of the american society and calls them strikingly similar the irony of this stance is compounded by the fact that it is shared by other muslim writers of diasporic origins as wellalikaramali is one such example like her hasan is also full of praise for the enlightened ideals of american society she is proudly a part of claiming that we american muslims love our country favour secularism and see that it is reconcilable with islam what is significant here is that such claims tend to turn a blind eye to the complicit role of hegemonic powers in creating a pliant version of islam acceptable to the west which attempts to construct a generation of obedient muslims whose first loyalty lies with their countrymen therefore it should not be surprising when hasan comes up with such selfexplicatory notes in which she showcases her difference from the talibanised version of islam the islam that i practice is not the one depicted by osama bin laden or by al jazeera cable news or the fearmongers i am not a member of a secret society of terrorists nor do i plot the death of nonmuslims what islam is really about is so different from the many misconceptions these illustrative overtures achieve the twopronged aim of maintaining the distinct identity of a muslim girl albeit different from that of her oppressed sisters in various parts of the muslim world and yet these impress the audience with their oblique connection with her empowered friends in the west this unthreatening appearance has been termed by rey chow as selfmimicry which caters to what others desire to see rather than what one actually is judith butler echoes the same thought when she says that any narrative is grounded in how it will be received by the addressee in like manner hasans memoir is one of the typical examples of such memoirs which are teeming with the anxiety to establish the authors kinship with her inhabited land which in her case is america apparently these narratives proclaim that they reveal to the world the diversity of islam though in reality these are closely akin to misery memoirs in showcasing an islam which is much similar to the progressive secular ideals of the western world hasan in her account is faithfully eulogising the values of justice equality and individual rights values which are associated with the western world ironically she sees her own version of islam as the only authentic version and typically condemns the more conservative minority who are flaunting repressive principles and cultural tribal attitudes these according to her are only a handful muslims whose islam runs counter to the progressive values she describe s in this book hasan thinks that the dictum which asks women to be standing at the back rows of mosques or prohibits women from attending the funeral of their relatives is a patriarchal interpretation of the quran she avers that these emotionally destructive interpretations must be protested against the ugly head of islam must be snubbed and disparaged by the educated and enlightened women like her throughout her account she is at pains to draw parallels between the secular values which are the hallmark of american culture and her own religion and finds them to her satisfaction strikingly similar she feels herself blessed to be part of a country where muslims do not have to meet the hostile grounds that has been the lot of muhammad and first muslims hasans naïve claim that in america islam has the chance to fulfil the values it truly stands for without politics or patriarchy to hold it back seems to overlook the horrendous treatment muslim had to face in america and elsewhere in the aftermath of 911 her memoir remains poignantly silent as regards the stealthy campaigns of pew centre2 and its like whose aim is to collect data which consolidates the proofs of the incompatibility between the west and islam lamiya khandaker in her work politicizing muslims the construction of a moderate islam elaborates that the method of collecting data used by forums like the pew center is designed on negative tropes about muslims and therefore biased hassans enthusiasm to equate islam with the secular values of america seems to signal towards the fact that she like many other writers of her kind has accepted the supremacy of american culture causing her to opt for such defensive gestures however this zest for integration appears problematic in more than one way it signals towards the impossibility of one individuals claim to represent the entire ummah which is ironic in view of the fact that she does not accept the rights of others to do the same and calls their interpretation as cultural contamination in addition it also hints at her desperate attempts to present the least offensive version of islam to her foreign audience this lack of objectivity is glaringly obvious in her critique of what she deems to be the repressive values of islam against women quite understandably she attributes it to patriarchal interpretation the status of women in islam confuses and terrifies every one alike even me as a muslim a little later she remarks when the west asserts itself on muslim men muslim men assert themselves on muslim women in the absence of any reachable target her position testifies to mahmoods conclusion in her essay feminism democracy and the empire the autobiographical genre attesting to islams patriarchal ills equally typical is her stance towards veil and hijab according to her it is a conservative concept… sticky for majority of muslim women who do not wear hijab according to her the hijab clad women of ethiopia even though they were occupying lucrative positions in parliament seem to her as enduring an imprisonment without bars their shyness and modesty are misinterpreted as a natural corollary of their oppressive treatment at the hands of men hasan actually feels blessed to have been born in a truly free land where she does not have to experience misguided religious interpretations that is precisely the reason why she retaliates so fiercely against gangs of muslim men who objected to her uncovered head in her colorado lecture if you think i should wear hijab just because you tell me to then you dont understand islam at all hasan terms their attitude coercive proselytizing which islam is markedly against without going into the intricacies of the veil issue which has come to be regarded as a sign of oppression and patriarchal subjugation of muslim women what is noteworthy here is that hasan establishes the connection between donning the hijab with lack of agency and empowerment in her view it is only an uncovered woman who stands for agency if she opts for the opposite then she is conveniently bracketed as conservative and her choice is assumed to be imposed by a culture which has nothing to do with islam this position of hasan towards the veil echoes the stance adopted by amina wadud and asra nomani who are hailed in western circles for their liberated outlook julianne hammer terms them exotic only in ways that are appreciated in the american mainstream as a spicy addition to the melting pot of american society and culture the hallmark of this group is the free bashing of fundamentalists who according to them are guilty of endorsing such measures which are either obsolete or are cultural innovations sumbul alikaramali in her memoir the muslim next door the quran the media and that veil thing also remarks the following about fundamentalists the wahhabis the taliban and bin laden are all connected in that all come basically from the same moldthe conservative ultraextremist fundamentalist wahhabi mold this liberal and moderate group is distinguished by its rebellious and transgressive stance towards such injunctions of islam which are not palatable to the west or which do not fit within the secular modes of life these are the rebellious renegades of islam as mohja kahf calls them in their bid to introduce an enlightened version of islam they accept only their own version as the true islam all the while declaring other shades of islam as outdated and conservative they represent themselves as the antidote to other muslim women who are unacceptable for the secular neoliberal world conclusion this paper has questioned the representation of the subjectivity and agency of muslim women in two memoirs i am malala the girl who stood up for education and was shot by the taliban and red white and muslim my story of belief it has argued that the kind of subjectivity and agency the authors of these memoirs are either craving foras in the case of malala or are validatingas in the case of asma gull hasanis befitting only in a secular neoliberal paradigm in upholding individual empowerment and agency these representations undermine other forms of subjectivity and agency which opt for remaining within accepted societal and religious norms in their depiction and ratification of personal resistance and struggle both memoirs endorse a particular kind of neoliberal empowerment of women whereby a woman is considered free and agentic only in proportion to her capacity to resist as in the case of malala or to assert her independence of conservative modes as in the case of asma gull hasan a woman who opts for an alternative course of action for instance giving precedence to either her religion or her family is deemed backward and oldfashioned this kind of depiction in these memoirs is grounded in the normative liberal assumptions about human beings desire for freedom in this regard mahmood has one important question to ask have we lost the capacity to be able to hear the voices of muslim women that do not come packaged in the form of ayaan hirsi azar nafisi and irshad manji malala the nobel prize winner now enjoys an iconic stature in the west yet in this exclusive position she also stands as an authentication to the failure of her own society which could not protect her as a natural off shoot of this perception the rescuing party emerges as triumphant in addition this establishes and reinforces the universality of the secular modes of life which supposedly can guarantee a womans security and grant her liberty agency and empowerment it is her individualistic struggle and her candid embracing of neoliberal ideals of subjectivity and agency which is given endorsement but when the global north is celebrating its achievement by claiming to be the saviour of girls like malala one might dare to question how deeply rooted the consequences of this salvage mission have been has this liberation been the cause of eliminating justice inequality or poverty from the society what improvement has malala in her iconic position vouchsafed for the girls of her area swat a glimpse of recent history will amply establish the truth that other distressed girls have not been lucky enough to be given this exclusive treatment the approach of providing protection to some becomes all the more controversial because of the asymmetry that enshrouds it as fawzia afzalkhan puts it womens empowerment narratives … lend them to spectacular rhetoric of human rights that erases the possibilities of a meaningful transnational feminism that could actually challenge the causes of global inequality empowered figures like malala become at first the objects of pity for the world citizens and these are then changed into individuals of admiration as the ideal citizens of our neoliberal times countering the narratives of oppressed muslim girls are accounts of writers like asma gull hasan she is grateful for being in an enlightened part of the world which guarantees justice and equality to its citizens regardless of gender she belongs to a realm which promotes womens visibility and sets it as a benchmark for determining whether women are modern or backward in this regard mahmood also notes the entanglement of liberal feminism with secularliberal politics which results in terming those women who are associated in any way with religion as agents of dangerous irrationality…pawns in the great patriarchal plan therefore one finds a marked emphasis in hasans narrative of the perks of being an enlightened moderate muslim and how it is strikingly different from the conservative variant most muslim women hasan tells her readers are not conservative in their practice but are moderate it is the wahhabi leadership that imposes a conservative concept of islam she upholds an enlightened version of islam such as practised by sufis which implies to remain open to new experiences and encounters which all hold the potential for new enlightenment she postulates that she enjoys a privileged position because of her living in an enlightened part of the world and therefore sets for herself the task of clarifying the prevalent misgivings about islam however this effort is marred by a desperate attempt to forcibly adjust and align islam with the framework of a secular neoliberal paradigm at the same time she does not forget to maintain her distance and difference from her oppressed sisters in other spheres of the world in other words she endorses the schism of muslims being split in two distinct classes conservative and moderate the former is allegedly practising an obsolete version of islam that is polluted with cultural innovation while the latter is a moderate variety in full control of their destinies this depiction of muslim women by hasan lacks the nuanced perspective that could adequately describe their multifarious and interconnected lives in addition her narrative precariously hinges on the amount of visibility that a muslim woman enjoys in the society for her the covered woman or the housewife is not sufficiently empowered or agentic in this paper we have crossexamined the stubborn conviction of progressive liberalism with which it tries to manoeuvre the lives of those who are not ready to permit their lives to be manipulated by the secular and neoliberal ethos of individual choice and freedom it has signalled towards the need for muslim women writers to agree not to portray themselves in line with other peoples dictates when the secularist model is employed as a prism to judge the lives of muslim women they appear as necessarily oppressed and hounded this philosophy fails to recognise the norms which value collective living as opposed to cherishing individualistic objectives in many instances familial and shared goals are given primacy while sacrificing narrow personal aims the preeminence which the secularist and neoliberal paradigm gives to individual ambition is incongruous in a society where collective living and ethos are the rule an interesting alternative to these memoirs is the work of african muslim writers where the central characters exhibit their roles outside the rubric of public and political lives and are satisfied with developing a private spiritual engagement with religion this pursuit is driven by no other ambition than personal edification through an observance of certain religious practices notable among these writings are the works of zainab alkali hauwa ali and abubakar gimba therefore the secular neoliberal emphasis on individual choice and freedom as a necessary prerequisite for subjectivity and agency is misplaced thus memoirs by muslim women need to be more inclusive incorporating the absent and missing voices of those women who opt to work in a dynamic complementarity with men

this paper draws upon the theory of subjectivity of muslim women as enunciated by saba mahmood in her seminal work politics of piety grounding our analysis in her work we critically engage with two selected memoirs i am malala the girl who stood up for education and was shot by the taliban and red white and muslim my story of belief both books are written by muslim women who are from two different locations pakistan and america via their memoirs we probe into the kinds of representation the central characters exhibit and how these texts employ the ideas of subjectivity and agency our position is that the subjectivity and agency of muslim women as depicted and endorsed in these memoirs is more in accordance with secular neoliberal paradigm when a secularist model is employed as a yardstick to measure muslim womens agency it makes her appear subjugated or oppressed representations are then curtailed within two extremes that of a distressed damsel in need of liberation or a modern chic woman who is empowered and not much different from her enlightened sisters in the west in each case the coveted ideal is the secularist neoliberal model of what constitutes an agentic and free woman this portrayal we have attempted to argue leaves much to be desired it undermines the agency and subjectivity of women who opt for a more religious and more confined existence such women are deemed conservative and unenlightened because visibility in communal public places is not their preference thus this paper signals towards a need for a more nuanced portrayal of muslim women

introduction understanding the family caregivers decisional role preferences is important to ensuring communication quality of cancer care and patient and family satisfaction although the family can sometimes be a conflict source 1 they play an important role in ensuring patient decisional control preferences 23 hispanic americans are the fastestgrowing minority group in the united states accounting for 163 of the population in 2010 and projected to account for 244 by 2050 4 there is a lack of published data on family caregiver perceptions of patients decisional role preferences particularly among husa 567 due to differences in culture socioeconomic status religion and family roles decisional role preferences of hispanic latin americans and husas may vary as well 89 the information regarding decision role preferences of hlas is important because it may help us to understand the preferences of those who have recently immigrated to the united states culture and acculturation can be important determinants of healthrelated attitudes beliefs preferences and behaviors 10 understanding the preferences of both latin american and us latino patients as well as the influence of acculturation on patient preferences is vital given the fluid nature of immigration from latin america and because recent immigrants and cancer patients of latin american descent in the united states may have different preferences perceptions and expectations than those of other groups to better understand husas and hla family caregivers preferences regarding patients decisional control we conducted a multicenter crosssectional survey of family caregivers of advanced cancer patients referred to outpatient specialist palliative care services in the united states and in three latin american countries we hypothesized than hla family caregivers would be more likely to prefer passive decisionmaking approaches than husa family caregivers would our primary aim was to identify hispanic caregivers preferences of advanced cancer patients decision control our secondary aims were to compare hla and husa caregiver preferences and to investigate whether acculturation influences the decision making preferences of husa caregivers methods we conducted a prospective survey of 387 latino caregivers of advanced cancer patients referred to outpatient specialist palliative care services in argentina chile guatemala and the united states the study was conducted at the palliative care clinics of the hospital sótero del río in santiago chile tornú hospital in buenos aires argentina instituto de cancerología in guatemala city guatemala and the university of texas md anderson cancer center in houston texas usa approval of the institutional review board at each of the four centers was obtained and all participants provided written informed consent outcome measures sociodemographic variablesinformation was collected on caregivers age gender marital status employment status and education information was also obtained on patients age gender and cancer diagnosis karnofsky performance scale was used to assess patient performance status marin acculturation assessment tool the acculturation level of the usa caregiver was determined using the maat 11 this tool was previously widely used in the hispanic population and found to correlate highly with respondents generation length of residence in the united states age at arrival and ethnic selfidentification the maat which has a reported alpha coefficient of 092 is composed of 12 questions answered by ranking on a scale of 1 to 5 the answers are summed and averaged and the tool yields a score ranging from 1 to 5 with higher scores representing higher acculturation participants who scored 299 or less were considered lower acculturated and those who scored more than 299 were considered highly acculturated per the assessment tool scoring information control preference scalethe family caregivers preference for the patients decisional control was assessed using the control preference scale previously developed and validated by degner and sloan 1213 this scale was chosen because it is easy to administer reliable and extensively used to assess the preferred and actual roles in health care decision making in various settings in more than 3000 cancer patients 14 and has been successfully adapted for the family caregiver in other studies 15 although is not validated in this population literature shows that grade of information disease progression and multiple variables can influence the decisionmaking preferences of the patient 161718 the cps is not sensitive to those variables we made minor modification to this instrument to include family components the tool was translated into spanish by bilingual investigators and independently back translated by bilingual latin american natives to determine semantic and linguistic equivalence between the versions this questionnaire has a triadic form and a dyadic form the triadic form assessed the family caregivers preferences regarding the patients decisional control preferences involving the family and the doctor the item began in my opinion decision about my relatives care should be made the following way … there were 15 answer options and the caregiver had to choose one option which was later categorized as passive shared or active decision making preferences the dyadic form of this questionnaire was composed of three items each with seven answer options the caregiver had to choose one option the first question addressed the caregivers preference regarding the role of the doctor and patient in the decision role preference with regards to the doctors participation in the decisions about my relatives care… the second question addressed the caregivers preference regarding his or her role and the role of the patient in the decision making process regarding the care of the relative with regards to my participation in decisions about my relatives care … the third question addressed the relationship between the family member and the physician with regards to the relationship between myself and the doctor in the decisions about my relatives care… the decisional role preferences models were categorized as passive active or shared the first one may reflect caregivers perception of their wanting the patient to accept a paternalistic model whereby the patient prefers to delegate the decisional role to the physician or family in the second model the caregivers perception of their wanting the patient to have decisional role solely to herhimself or herself and in the third model the caregivers perception of their wanting the patient have the decisional control preference shared by the patient family and physician 19 statistical analysis descriptive statistics were performed to summarize the data fisher exact and χ 2 tests were used to determine associations between categorical variables differences between continuous variables were analyzed using t tests for normally distributed data and wilcoxon ranksum tests for nonnormally distributed data multivariate logistic regression was used to correct for age and education when comparing husa and hla groups with regard to decisionmaking preferences a p value 005 was considered significant analyses were performed using spss 160 software for windows results the median age of hla patients was 60 years which was significantly older than husa patients the median performance status of hla patients was 80 significantly higher than that of 60 for husa patients among caregivers the median age of hlas was 48 years and that of husas was 45 years hla caregivers had a lower education level than husa caregivers did table 2 shows the triadic decisional preferences of husa and hla caregivers shared decisional control was preferred by the majority of both groups the pattern of decisional control differed significantly among caregivers in the three latin american countries univariate analysis of caregivers preferences of the patients decision control revealed a significant difference by educational level with caregivers with lower education having a preference of patients passive decisional control caregivers preferences for the patients passive decisional control regarding healthcare decision making were more prominent among hlas than husas this difference was maintained after age and educational level were corrected for in multivariate analysis the acculturation level of caregivers in the united states was not significantly associated with decisional role preferences there were increased preferences for passive decision making in hla as compared with husa in all cases shared decisionmaking control was the most frequent choice for both husa and hla discussion in this study we found that most of the hispanic family caregivers wanted the patient to use shared decisional control we also found that compared with husa caregivers hla caregivers preferred that the patient had a more passive decisional role acculturation did not seem to influence decisional role preferences among husa caregivers prior studies suggest that young age and advanced education are associated with patients preferences for an active decisional role 20 our results showed that the family caregivers ducation level was significantly higher among husas than hlas in a univariate model but that the passive decisional role differences between the groups persisted after correction for education level in the multivariate analysis communication at a patients end of life is a therapeutic necessity for the family 21 in most sociocultural environments the role of the family in decision making is fundamental for satisfactory delivery of care for the patient 22 in our study most of the caregivers perceived that the patient should share decisional control with them other studies have shown that patients also prefer to share decisional control in korea 50 of the interviewed advanced cancer patients wanted to share their decisions with the family 23 and in the united states more than 90 of a sample of interviewed patients receiving dialysis wished to discuss decisions with their family 24 a recent systematic review highlighted the importance of family participation in decision making among african american families 25 shrank et al observed that nonhispanic white patients seemed to prefer one family member in particular when the family participates in endoflife discussions 26 whereas kelley et al found that most older latinos favored familycentered decision making and limited patient autonomy 27 in our study although a preference for more active decision control by the patient was observed among husa caregivers than hla caregivers more than half of both groups preferred share decision making davison et al in a canadian sample of 80 men with prostate cancer and their partners identify that the majority of partners wanted to play a collaborative role in treatment decision making 15 to our knowledge ours is the first study that focused on the latinos family caregivers point of view about the patients decision control current evidence suggests that the shared decisional role preference is the most acceptable model to the patient 2829 according to our current data most latino caregivers do not want active decision making but most of them want to share the responsibility implying that the decisionmaking process with hispanics physicians must include both patient and their caregiver our study has important limitations including the lack a comparison of nonhispanic group in the usa sample the hispanic population in the united states is very heterogeneous and important variations may have not been detected due to the limited sample size and the limited variability across acculturation levels no other american ethnicities were included in our control group and our sample was limited to one us hospital we also have found differences between hla caregivers by country despite similarities in language religion and culture but our study still suggests that husa and hla families differ considerably in their decision control preferences the lack of mexican comparator group could have a somewhat lowered the impact of the results of the study as a high proportion of hispanics in united states are from mexico 3031 future studies must consider multicenter and multiethnic socioeconomic samples when assessing family caregivers preferences for the patients decisional role understanding how to satisfy a familys preferences should also be considered lastly further studies are needed to determine if caregivers relationship to patient could be important variable in predicting decisional control preferences conclusion most hispanic family caregivers preferred patients to make shared decisions hla caregivers were significantly more likely to prefer a passive decisional role for the patients than husa caregivers were acculturation did not seem to influence decisional role preferences among husa caregivers because patients decisional role preferences can be challenging and many instances involves the preferences of not only the patient but also the family and physician the decisionmaking roles have to be determined for each case more research is necessary to understand this important topic husa family caregiver preferences of patients decision control by acculturation table 4 caregiver preferences of patients decision control between patient and physician patient and caregiver and caregiver and physician

backgroundunderstanding family caregivers decisional role preferences is important for communication quality of care and patient and family satisfaction the family caregiver has an important role in a patients decisional role preferences there are limited studies on family caregivers preferences of the patients decisional control at the end of life among hispanics aimsto identify hispanic caregivers preferences of the decision control of patients with advanced cancer and to compare the preferences of caregivers in latin america hla and hispanic american husa caregivers designwe surveyed patients and their family caregivers referred to outpatient palliative care clinics in the united states chile argentina and guatemala caregiver preferences of patients decisional control were evaluated using the control preference scale caregivers and patients sociodemographic variables patient performance status and husa patient acculturation level was also collected

introduction in the globalization era states have not lost their role but suffer from multiple deficits that can be overcome only leaning on the resources competences and skills that are possessed by citizens and internet users in this context transformations of politics both at the national and at the supra national level have been analyzed following mainly two intertwined research avenues the first focused on how internetenabled communications enlarge the space of the public sphere the second on innovative governance arrangements based on collaboration between state and nonstate actors yet these two analysis strands have seldom been joined together with the overall result that our knowledge on how internetenabled communications can be strategically employed to enhance democracy and participation of nonstate actors into policy making processes is still limited in this paper we argue that to overcome this situation a more systematic analytic effort is needed we argue that understanding internet users uses and politics in a monolithic way jeopardizes the possibility to grasp the complexity of innovation dynamics and therefore to evaluate successes and failure of participatory arrangements we therefore make a plea for grounding research into a multilayered framework that looks simultaneously at a the type of users b the type of internetenabled communication c the different facets of political processes d the multilevel nature of contemporary politics not only these four elements need to be studied singularly but existing interplays between them are crucial to understand how technological advancements can be effectively translated into political advancements beyond the current limits of scale representativeness and efficacy the first section of the paper illustrates briefly the main terms of the discourse on innovation of political processes in terms of enlargement of the public sphere and of innovation in governance arrangements starting from this background the second section specifies better the relationship between internet and politics thus introducing the main layers of the foreseen analytical framework finally we explore at a preliminary level the interplay between these different layers enlarged public sphere and governance experiments so far transformations of politics both at the national and at the supra national level have been analyzed following mainly two research avenues the first focused on how internetenabled communications enlarges the space of the public sphere the second more concentrated on innovative governance arrangements based on collaboration between state and nonstate actors internet communications have proved fundamental to undermine the centrality of the state as the sole protagonist of national and supranational political processes the space of flows enabled by the internet hosts a wider and easier circulation of ideas information and knowledge in empowering individuals and groups through knowledgebased resources in allowing the formation the display and the interplay of personal and group identities as well as the articulation of perceptions and claims internet becomes the backbone of a transnational multilayered and multilevel public sphere where a multiplicity of reflections and opinion circulate enmesh and get articulated within this enlarged public sphere actors of noninstitutional nature eg non governmental organizations transnational social movements but also individual citizens activate both at the national and at the transnational level and claim to be part of the game the vitality of this multilayered and multilevel internetenabled public sphere is crucial to overcome the multifaceted deficit that affects traditional political actors in this context several participatory governance experiments ie mixed interaction patterns between state and nonstate actors have been experimented over time both at the national and at the supranational level one recent case is provided by the so called multistakeholder approach according to which institutional entities business organizations and the heterogeneous universe of civil society are considered as peers and therefore hold the right to act on an equal foot into the political process and yet these innovation strands are limited by two types of problems in first place there are structural constraints to the full realization of the democratic potential of the internet the socalled digital divides the information overload that hampers the creation of useful knowledge the tendency to reinforce online existing social ties based on some degree of facetoface interaction ultimately as calhoun puts it which of the possibilities opened by the internet are in fact realized will depend on human choice social organization and the distribution of resources secondly there are political constraints in first place participatory arrangements are adopted at the supranational level while locally they still constitute a relatively uncommon practice moreover they relate to policy framing activities ie to the articulation of common visions while they are still far from being adopted within actual deliberation processes although policy framing is a crucial phase of policymaking two kinds of problem emerge first a problem of representativeness ie who are the actors actually participating second a problem of efficacy ie the impact of nonstate actors contribution in this sense open processes are far from being universal and the extent to which commonly shaped vision are translated into policy provisions seems to be still limited a multilayered analytic framework if the internet can be used to revamp states legitimacy and to achieve a greater proximity between citizens and institutions thus leading to new mechanisms of participatory policymaking processes this potential does not seem to be fully achieved today this not only depends on the structural and the political limitations we have just illustrated our knowledge of how to enhance democratic and participatory features of political processes through the active employment of internet communications rarely goes beyond the acknowledgement that politics depend on technology by shaping the means of political debate the arena the communication links the agenda to better understand a the extent to which participatory governance experiments actually translate into social innovation and b how internetenabled communication can be strategically exploited to fulfill this goal beyond current limits of scale representativeness and efficacy we argue that a more detailed and systematic analysis effort is required one relevant step in this direction consists in overcoming monolithic conceptions of internet users uses and politics in fact the their internal complexity that characterizes each of these elements would require not only an explicit acknowledgement but also a consistent and systematic approach of study we therefore propose to account simultaneously for multiple layers users internetenabled communication tools facets of the political process and the multilevel nature of contemporary politics not only these aspects have to be studied singularly in all their complexity but existing interplays between the four layers are crucial to understand how technological advancements can be effectively translated into political advancements multiple users and multiple publics internet pervasiveness in our daily contexts enhanced by communicative potential of web 20 tools should not overshadow three relevant factors i that internet access is far from being universal ii that competences are unequally distributed amongst online users iii that there are differences in the degree of activity and in the motivations that lead to active contribution online these critical aspects point directly to the problem of representativeness of contributions delivered by users user generated content cannot be thought as being representative only because it is generated by individuals indeed not all citizens access the internet and become content generators hence considerations on enhanced participation should be elaborated paying specific attention to authors their properties motivations but also and more importantly looking at their social online and offline ties and to their political culture ie the way in which they understand politics and the role of civic engagement thus online users are all legitimate inhabitants of the multilevel and multilayered internetenabled public sphere yet the heterogeneity of this space pushes for a more systematic and detailed review of the idea of the public in the internet age in a context where actions undertaken by public authorities are subjected to the scrutiny of actors that are neither directly related nor controlled by them the public becomes synonymous for accessibility to third parties in general in order to regain legitimacy state authorities must deal not only with their citizens but more broadly with a multiplicity of larger heterogeneous publics the use of the plural form is not casual we argue that the public however defined actually consists of several different publics the unitary feature of the public sphere is questioned as it is more reliable to envision a multiplicity of public spheres and counterpublic spheres that interact amongst themselves and with the state through complex relational patterns of cooperation and conflict multiple social media mainstream analysis looks predominantly to internetbased communication while leaving aside other more traditional media while this fact is justified by the tremendous impact of internet on communications it is now challenged by digital convergence that transform old media into a new generation of communication tool thus further enhancing interaction capabilities and yet even if we leave convergence outside of the picture and limit our analysis to internetbased communication there is the need to draw distinctions between different tools employed to communicate with others as each tool entails different modes of interaction a first obvious distinction should be made between web 10 and web 20 tools if the former have installed the culture of the public with the idea of contentpublishing the latter allow for true and enhanced participation into public discussions through individual content generation when inquiring about the relationship between participation and politics through the internet we argue that a specific vision on web 20 tools should be preferred and suitably articulated consistently we would like to refine the relationship between the renewal of political processes in terms of enhanced participation and the internet looking specifically at social media ie a group of internetbased applications that build on the ideological and technological foundations of the web 20 and that allow the creation and exchange of user generated content social media share the same platform and are aimed at the production of user generated content but they can be distinguished on the bases of interactions they allow although there is not a unique way to classify social media the inherent conceptual switch consists in associating different tools to different types of content creation and exchange multiple facets of political processes in the contemporary context where publicity is extended to its maximum political processes should not be thought exclusively in terms of policysteering activities rather they should be thought as dynamics conducting to the production of public purpose which is an expression of vision values plans policies and regulations that are valid for and directed towards the general public therefore steering of actual policies and regulations should not be understood as the sole final goal of privatepublic interactions if deliberative democracy constitute the idealtypical threshold for total collaboration between state and nonstate actors in participatory policysteering there are at least other four important political objectives that can be achieved through enhanced privatepublic partnerships relationship building gathering and exchanging information brainstorming and problem solving and consensus building each of these facets of the political process are crucial although characterized often in terms of soft power the power to shape and influence political agendas is far from being weak multilevel politics in a context where the local and the global are mixing up one another the distinction between domestic and foreign political affairs becomes blurred and yet political processes do structure differently depending on their principal dimension localnational international regional or supranational different levels of political processes entail the involvement of different actors resources and different political opportunities for publicprivate collaboration experiments it is then suitable to avoid categorization of political processes in terms of domestic or foreign issues and move towards a multilevel conceptualization of politics according to which processes can start locally and then scale to a higher level or conversely we might look at processes that start globally and isomorphically reproduce locally in both cases the initial level of deployment entails specific dynamics and the involvement of particular actors whereas scaling or reproduction mechanisms imply changes at the organizational and the cultural level intertwinements between layers in general different users generating their contents through different social media make up different publics and these in turn can differently exploit social media depending on the goal they want to achieve yet not all publics intervene in all matters and public authorities are not ready to take into account every single suggestion provided by nonstate actors we then argue that in order to evaluate properly success or failure in participatory arrangements the four layers need to be put in relation one another for example the scale of the process implies different requirements in terms of representativeness and openness also the goal of the process can further refine selection criteria and influence the choice of which social media will be exploited a process could be labeled a failure in terms of participation just because we did not properly set our terms of comparison a relational perspective focused on interplays between layers allows to perform this operation and to account for the complexity of real life cases conclusion if it is true that internet can enhance politics as it enables a wider and more democratic circulation of ideas it is also true that we have not succeeded in outlining systematically how social media can strategically be employed for social innovation none of the participatory governance experiments that have been tried out so far seems to meet initial expectations on enhanced democracy we believe that this depends on a generalized trend to understand internet users uses and politics as monolithic the considerations we elaborated towards the definition of a multilayered framework aim at overcoming this limit and at reaching a more genuine understanding of the complex relation between social media and social innovation

this paper proposes a preliminary conceptual approach for studying how social media ie a class of specific internetbased communication tools can be strategically employed to promote social innovation ie the actual consolidation of norms guiding democratic and participated policymaking processes to this aim we propose to overcome monolithic conceptions of internet users uses and politics thus grounding empirical studies on the joint observation of a the type of users b the type of internetenabled communication c the different facets of political processes d the multilevel nature of contemporary politics

shaping health and potentially of significant interest to social science and population health researchers is its plasticity or ability to be altered and specifically its responsiveness to the environment 3 yet despite rapid technological progress in description and sequencing gaps remain in our understanding of the broader environmental factors that shape interindividual variation in these microbial communities 4 particularly in regards to how social conditions may influence this variation we argue that fulfilling the promise ofmicrobiome research particularly the human microbiomes potential for modification will require closer collaboration between life scientists and social and population health scientists who can consider the interaction of multiple levels of environmental exposures the very nature of the microbiome particularly its plasticity and adaptiveness to the environment opens the door to a broader research agenda focused on how social conditions influence the microbiome for analytic purposes we focus on earlylife conditions socioeconomic resources and social relationships as case studies for the possibilities these collaborations may hold decades of experimental and observational evidence demonstrate that these social conditions influence morbidity and mortality at levels far exceeding individual behaviours such as obesity or even medical interventions such as antihypertensives for social and population scientists attention to the microbiome may help answer nagging questions about the underlying biological mechanisms that link social conditions to health and promote attention to policy and other upstream factors that drive changes in the microbiome at the population level in this perspective we first detail existing research on how social environments influence the gut microbiome focusing particularly on earlylife conditions socioeconomic factors and social relationships we then outline potential interdisciplinary collaborations across these three substantive areas detailing ways in which existing populationbased studies and methods could be employed to test novel hypotheses about the human gut microbiome in sum we detail key substantive and methodological advances that can be made if collaborations between the social and population sciences and life sciences are strategically pursued with a particular though not exclusive emphasis on the gut microbiome where the largest number of microbial communities in the human body can be found current research on social environments and gut microbiome the gastrointestinal tract is estimated to harbour roughly 90 of our indigenous microbes 5 there is increasing empirical evidence both from animal and human population studies that distal gut community patterns play an important role in a broad range of physiological functions of their host including immune system maturation metabolic and inflammatory processes and even the brain and behaviour via the gutbrain axis 6 indeed the gut microbiota is now implicated in a wide array of chronic diseases including type 1 and type 2 diabetes inflammatory bowel disease obesity cardiovascular disease and cancer which remain among the leading causes of morbidity and mortality in the developed and increasingly developing world 12 moreover there is a robust body of research demonstrating how diet and nutritional factors influence the gut microbiome which may prove a key pathway linking diet to health 7 the rapid acceleration of research including successful clinical interventions involving fecal transplants points to the general consensus that the gut microbiome could radically transform research and interventions to improve human health despite large advances however scientific knowledge of the gut microbiome especially the way broader environments shape its variability over the life course remains in its infancy research is still limited regarding how broader social environments and conditions shape exposures and ultimately influence its composition especially research employing human subjects this limitation is important because recent evidence showed that the environment rather than genetics predominantly shapes human gut microbial composition 8 how this environment is defined and measured has not yet been well developed yet a small but growing body of literature is looking at how our social environment shapes acquisition and exchange of microbes from the people we interact with to the environments in which we work and live 9 10 11 12 13 in the sections below we explore existing research that touches on how our social environments specifically earlylife conditions social relationships and socioeconomic conditions may shape the human gut microbiome 9 figure 1 outlines a general conceptual framework for potential pathways linking social environments and the microbiome over the life course some of which we highlight below earlylife conditions it is well known that birth and early life are critical periods for the acquisition and development of an individuals microbiome broadly prenatal and earlylife environments play an important role in developmental trajectories for both the immuneand stressresponse systems with implications for developing microbiota as well 14 15 16 since humans are born mostly microbially sterile it is necessarily through interaction with the social and physical environment around them that subsequent microbial colonization takes place specifically exposures such as mode of delivery and initiation and duration of breastfeeding influence its composition and these earlylife exposures are in turn shaped by ones social status 17 18 19 the quality of fetal environments such as proper nutrition is strongly patterned by income and education including in the developed world 20 21 22 this remains true after birth while 91 of mothers with a college degree breast feed in the united states that rate falls to 69 for mothers with a highschool degree these rates fall to 28 and 14 respectively for six months of exclusive breastfeeding 23 we are beginning to see evidence that the lack of healthy microbiome development in children can have severe and lasting consequences 24 for example evidence from fecal transplant studies in mice show that the microbiomes of undernourished children drawn from a sample in malawi negatively affect physical and cognitive development 2325 despite this evidence of how extreme malnutrition in early life in the developing world alters the developing microbiome we have little evidence from the developed world regarding how variation in earlylife socioeconomic resources influences the developing gut microbiome social relationships social relationships have long been linked to health and mortality including inflammation and immune response 22 indeed the evidence is that the influence of social relationships on health and mortality exceeds medical interventions such as quitting smoking and the use of antihypertensives like statins 26 given the robustness of this relationship and the links between social relationships and inflammation and immune functioning it is not surprising that research is now beginning to explore whether and how social interactions shape the microbiome in terms of existing research studies using primate models suggest that social relationships impact the composition of the gut microbiota through direct microbial sharing between individuals 27 28 29 30 tung and colleagues 29 for example found that social network and social group predicted the species in the gut microbiome of 48 wild baboons even after adjusting for other shared factors including kinship diet and shared environments suggesting the importance of direct physical contact during social interactions in transmitting gut microbiomes a few human studies have begun to document these relationships for example two recent studies found that individuals living together had more similar gut 18 and skin 1819 microbiota than did those living apart some even hypothesize that microbes can help explain the evolution of social behaviours 31 the effect of microbiota on the hosts central nervous system could operate via chemical signals that are used as social communication this manipulation could benefit fitness of bacteria such as reproduction and transmission and food cravings and preferences 3233 but despite some tantalizing evidence of the influence of social relationships on the gut microbiome studies in human populations remain relatively small in number nonetheless there is related evidence to support further exploration of connections between social relationships and the gut microbiome there is growing empirical support for links between social and physical environments humans sharing homes have more similar skin microbiomes compared with those not sharing a home probably due to skin shedding respiratory activity and skinsurface contact 34 when families moved their microbial signature followed them to the new home and individuals who left the home for several days saw a decline in their contribution to the home microbiome 34 these findings suggest a mechanism for social transmission of bacterial communities through the built environment which could apply to socially shared spaces such as schools work and public transportation in light of this as well as recent primate evidence that immigrant males share gut microbiome characteristics from both their birth and adult communities 35 lifecourse residential and migration histories could play an important role in human microbiome dynamics socioeconomic conditions extensive research shows that adult socioeconomic resources in addition to earlylife socioeconomic resources influence morbidity and mortality life expectancy difference at age 25 can differ by as much as 16 years between those with the lowest and highest levels of educational attainment 36 while there is little direct existing evidence linking adult socioeconomic resources to the gut microbiome the link is highly plausible 12 the gut microbiome is strongly implicated in metabolic and inflammatory disorders adult socioeconomic resources in turn pattern chronic inflammatory diseases and metabolic disorders ranging from diabetes to heart disease the prevalence of diabetes is twice as high among those with lower compared with higher educational attainment among those with diabetes and myocardial infarction the mortality risk is substantially greater for those with lower educational attainment and incomes 37 moreover there is a robust literature linking socioeconomic status to inflammatory markers such creactive protein more generally to some extent this pathway is linked via behaviours in the united states obesity prevalence is 28 for women with a college degree compared with 45 for women without a highschool degree 38 given the already robust evidentiary body linking diet to the gut microbiome dietary behaviours may be a key path linking socioeconomic status to the gut microbiome in addition to possible behavioural pathways that could link adult socioeconomic resources to the gut microbiome there is emerging evidence of the role of psychosocial stress in modulating the microbiome 333940 this is important because psychosocial stress is a key pathway between many social environments and morbidity and mortality outcomes 41 perhaps most striking is a study of bees that demonstrated that position in their social hierarchies influenced the gut microbiome with both diet and stress mediating these relationships 42 rodent models have convincingly shown that exposure to psychological stressors can alter the gut microbiome through neuroendocrine response the integrity of barrier defences and the internalization of microbes 43 in mice exposure to social stressors has been shown to alter homeostatic interactions between the intestinal microbiota and the immune system leading to increased susceptibility to enteric infection and overproduction of inflammatory mediators that induce anxietylike behaviour 44 states of isolation such as maternal neglect appear to influence the gut microbial composition in animal models 45 at least in part through stress 4346 for example in captive rhesus monkeys maternal separation stress induced reductions in lactobacilli in intestinal microflora and higher rates of opportunistic enteric infection 45 prenatal stress in mothers has also been shown to impact the microbiota of offspring in mice which in turn decreased the abundance of lactobacillus in the gut microbiota of their offspring 47 more generally there is some evidence that the effect of maternal stress on child anxiety and mental health disorders may be modulated by the gut microbiome 47 these alterations were subsequently related to changes in the offsprings metabolite profiles involved in energy balance as well as with disruptions of amino acid profiles in the developing brain 4748 we note that we have largely highlighted influences of social conditions on the microbiome there is however empirical evidence supporting the idea that the composition of the microbiome may modulate individual behaviours preferences and choices and thus potentially shape individuals social interactions and environments if confirmed this bacterial manipulation of the human host has perplexing implications for the evolution of phenotypical traits this is an active area of study mostly with animal models and has already sparked controversy regarding the likely sustainability of a strategy involving bacterial exploitation of their hosts 33 the need for better data overall the existing evidence provides a strong rationale for the potential importance of social conditions for the dynamics of gut microbial composition across the life course but thus far populationbased evidence to confirm these relationships is limited to move forward the significant challenge of data availability needs to be addressed while animal models have been invaluable in understanding the mechanisms underlying gut microbial composition and function including the possible influence of social conditions they are constrained by some important limitations some of which are general issues with animal models and some of which are specific to the study of the gut microbiome first the basic biological variance between mice and human models may limit the potential to translate what we learn about mice to humans 4950 second even if we overcome this challenge animal studies are constrained in their ability to examine how more complex social phenomena such as human social relationships and networks influence the gut microbiome while we can draw useful parallels similar to basic biological differences the social and cognitive differences between humans and animals constrain comparisons existing human studies also have some important limitations especially if the goal is to explore how social environments influence the gut microbiome early human gut microbiome studies were constrained by small nonrandomly selected samples for example the human microbiome project directed and funded by the national institutes of health to map the healthy human microbiota in 2012 was conducted on a single nonrandom sample of 256 individuals from st louis and houston most of whom were researchers and students 51 despite the small number of nonwhites in the hmp sample comparisons were made across race and ethnicity with the investigators reporting that a wide variety of taxa gene families and metabolic pathways were differentially distributed with subject ethnicity at every body habitat representing the phenotype with the greatest number … of total associations with the microbiome 51 these incidental findings of strong associations with race and ethnicity suggest the need to characterize the microbiome in diverse populationbased samples yatsuneko et al also highlighted the need for diverse samples showing strong geographical differences in microbiome structure and function for residents of the united states compared with the amazon in venezuela and rural malawi 52 more recently there have been attempts to collect much larger samples 53 but these attempts fall far short both of population representativeness and measurement of the macroenvironment voluntary crowdsourcing models such as the american gut project or ukbased mapmygut have been shown to be particularly nonrepresentative for example only 6 of respondents in the american gut project are obese compared with a 37 adult obesity rate overall in the united states 54 as interest in the microbiome grows larger studies are including microbiome collection key examples include the belgian flemish gut flora project and the dutch lifelines study 5355 both studies include rich detail in regards to biological anthropomorphic and general health data however they contain more limited data on social environmentssocioeconomic family work and community compared with social and demographicbased population health studies moreover participants were not randomly selected but rather were recruited through media campaigns thus introducing selection and sample bias the twinsuk study one of most prolific human studies of the gut microbiome thus far was designed with a specific biomedical focus on the heritability of common diseases with only superficial attention to the social environment the disproportionately female and white volunteer sample does not reflect the race ethnic and socioeconomic diversity of the overall uk population 56 57 58 59 60 61 62 63 importantly the highly selected nature of these samples limits variation in both the microbial exposures and phenotypic outcomes of interest reducing their analytical potential and ultimately their scientific generalizability what are the implications of nonrepresentative samples in this emerging science one related cautionary tale comes from the neuroscience of brain development this research has largely been conducted on nonrepresentative convenience samples of volunteers leading some to argue that these study findings may be skewed 64 a recent study supports this contention researchers compared representative and nonrepresentative samples of children in an imaging study focused on brain development findings in data that better represented the population were markedly different to those in the unrepresentative sample showing a very different pattern of how differing regions of the brain develop as children age 65 while this scenario may or may not repeat itself for existing microbiome and health research it will be important to be aware of the heterogeneity of associations across different populations and how and why this variation may arise collaborations with population health sciences given existing limitations in this section we detail ways in which existing populationbased studies and methods could be employed to test novel hypotheses about social environments and the gut microbiome but to start we want to emphasize the broader potential methodological contributions that population health scientists might make to this field one of the central challenges of human microbiome research much like basic social science research is how to demonstrate causal relationships while animal models provide a straightforward platform in and of themselves they are not sufficient to fully explore the social determinants of the gut microbiome observational human microbiome studies however can suffer from familiar issues related to unobserved confounding and causal inference collaborations between life science and social and population health researchers however can draw on a long history in the social sciences of methods to improve causal inference in observational data including familybased designs natural or quasiexperiments as well as populationbased field experiments 66 opportunities for such research designs require microbiome data from ongoing preferably longitudinal studies with rich social environmental and phenotypic data on participants as the largest cost in obtaining data from a large representative population is drawing the sample frame and the initial enrolment of participants we argue that adding the microbiome to existing population surveys is the most costeffective approach relative to designing new studies from scratch many longrunning populationbased studies follow families which would allow for testing for intergenerational effects most large longitudinal populationbased surveys also already collect biological data ranging from blood to saliva this would allow microbiome analysis in conjunction with highquality health data while also leveraging the experience of these studies in getting their participants to provide these types of more sensitive data 67 an ideal study design to investigate some of the pathways alluded to above should satisfy three conditions first as most population studies aspire to be it should be representative of a target metapopulation rather than based on highly selected samples that preclude more than modest generalization of inferences second it should be flexible enough to maximize opportunities to make genuine causal statements rather than being a source of association measures which in most cases cannot be elevated to the status of estimates of causal effects which are uncontaminated by omitted variable biases and confounding or selection mechanisms of various types third because many of the relations portrayed in fig 1 are a function of lags and delayed impacts the ideal study should be longitudinal and a source of information on events that unfold over multiple stages in the life course of individuals earlylife conditions over the past 10 to 15 years research on the developmental origins of adult health and disease has produced robust empirical evidence suggesting that prenatal and early postnatal exposures have a strong influence on early growth and development and under some conditions have significant delayed impacts on adult health outcomes 68 69 70 71 72 the first three years of life are crucial for colonization of the gut microbiome 5273 this points to the configuration of the microbiome as one pathway through which early conditions may operate calling for social and population health scientists working under the dohad paradigm to explicitly include investigation of the microbiome over the life course both bodies of research confront remarkably similar problems such as the existence of critical and sensitive periods accumulation of damage and synergies over the life course path dependencies and reversibility properties 41 74 75 76 77 it is likely that these problems to which dohad and microbiome researchers have arrived independently might have common solutions moreover both groups are pointing to epigenetic modifications as an important mechanism through which embryonic and prenatal exposures on one hand and composition of the microbiome on the other may sometimes operate 72 78 79 80 81 while there are many examples of potentially fruitful joint research an area that offers promise of very immediate rewards concerns the effects of early nutritional status and nutritional shocks on growth development and adult health outcomes barkers seminal research 68 implicated fetal nutritional impairments as an important determinant of adult chronic conditions including obesity coronary heart disease and type 2 diabetes whereas a large literature in population health sciences investigates the effects of infant and child nutrition on diseases in adult mortality and disability until recently this body of research made no reference to the relation between nutrition and the microbiome new research suggests that a paradigmatic shift is in order a study of malawian malnourished infants showed via fecal transplantation in mice that gut microbial immaturity is causally related to child malnutrition as immature microbiota transmit impaired growth altered bone morphology and metabolic abnormalities 83 this could be a smoking gun as it shows that the microbiome is one mechanism that mediates the association of prenatal or neonatal malnutrition and later morbidity and mortality if replicated it provides a heretofore unknown and modifiable pathway establishing relations involving the microbiome may also be required to fully understand other processes identified by dohad such as those relating early exposure to acute stress and later mental health 84 85 86 childhood poverty and adversity to late onset of chronic illnesses 87 88 89 exposure to shocks such as influenza natural disasters wars to a broad array of chronic ailments 90 or recurrent childhood or adolescent infectious diseases sustained inflammation and later heart and circulatory disorders 91 92 93 94 but how can we explore these questions one approach involves exploiting quasiexperimental conditions generated by famines including the dutch famine 95 and the great chinese famine 96 which produce quasirandomly selected subpopulations exposed and unexposed to a treatment studies of the dutch famine have uncovered in samples of midlife and older adults that those exposed to the famine in utero compared with those in utero in the months just preceding the famine have everything from higher mortality rates from cardiovascular diseases to differences in dna methylation 97 98 99 linked to metabolic health and transgenerational impacts on metabolic health differences in dna methylation explained a significant portion of the differences in metabolic health between those with and without exposure to the famine in utero data on the gut microbiome could be added to these existing cohorts with people currently in their 60s and 70s this could elucidate relations conjectured by dohad though less common randomized control trials or field experiments are also being conducted to measure the impact of social interventions on health outcomes in larger populationbased samples for example a newly launched randomized cashtransfer experiment is enrolling 1000 infants to track how a randomly assigned increase in income affects cognitive development in poor children 100 a wealth of longitudinal and quasiexperimental research points strongly to the influence of poverty on maternal stress and mental health as well as the infants cognitive development in early life the addition of data on the gut microbiome would allow for the testing of the role of the gut microbiome as a mediator in these relationships as already previously detailed studies showing connections between the gut microbiome maternal stress and cognitive development would suggest these are pathways worth exploring furthermore there are a growing number of studies that involve controlled interventions that monitor large populations over extended periods of time thus studies built around cashtransfer programmes such as progresa in mexico have become an ideal study design that many other lowto middleincome countries are following thus generating massive datasets on a multiplicity of conditions and outcomes 101102 in addition international organizations such as the world bank the international food policy research institute the interamerican development bank and the world health organization periodically initiate studies that involve a multiplicity of social protection interventions and are designed to facilitate causal inference experiments involving cash transfers or those based on nutritional interventions could add a module to collect information on pregnant women maternal health and nutrition periand postnatal birth exposures microbiota composition and various childhood outcomes lastly although the empirical evidence is still too fragile to confirm them dohad and related theories pose conjectures involving transgenerational effects of some significance to the extent that these may be contingent or directly influenced by changes in the microbiome there will be ample room to test evolutionary biology hypotheses about the development of phenotypical traits with strong impacts on reproduction and longevity thus large population studies with the characteristics described above will not only be useful to population health scientists but also could have potential large spillover effects benefitting the growth of other disciplines socioeconomic conditions social and population health scientists have spent decades gathering and analysing data that demonstrate that socioeconomic markers such as education income and wealth matter a great deal for adult health and mortality as we detailed earlier 103 evidence linking behavioural factors such as obesity and psychosocial stress to both the gut microbiome and socioeconomic health disparities provide a plausible basis for testing whether adult socioeconomic resources influence the gut microbiome 141539101 to date however there is virtually no work exploring the potential of gut microbial composition as a biological mechanism linking adult socioeconomic status to morbidity and mortality outcomes existing populationbased longitudinal studies that have documented the influence of income and educational attainment on morbidity and mortality are large in number and increasingly include a wide array of more basic biological data collected from saliva blood and even urine hair and nail samples 104 the addition of microbial data then would be a natural extension these studies follow large populations of cohorts for extended periods of time and are a source of very rich information examples include the health and retirement study and its sister studies around the world the national study of adult and adolescent health and the british cohort studies although these studies are not designed to be experimental changing exogenous conditions sometimes induce a quasiexperimental setup that can be exploited for example the hrs in the united states has provided rich information on the effects of the great recession on individual health status changes 105 the hrs in addition to many other populationbased studies has been used to test the influence of changes in schooling laws as a source of exogenous change on health with outcomes ranging from diabetes and strokes to later life cognitive decline and mortality 104105 many studies including the hrs and addhealth now include genetic data which allow for a mendelian randomization approach drawn from genetic variants linked to educational attainment to test the causal influence of educational attainment on health 106 107 108 many of these studies could be replicated to test the influence of these exogenous changes on microbial composition for example combining animal experiments with insights from the kinds of observational human data detailed above may offer an especially unique methodological strategy to strengthen causal findings there is of course already precedence for this for example a wellknown study found that the transplantation of gut microbiota from obese humans to lean germfree recipient mice transfers an increased adiposity phenotype relative to transplants from lean donors 79 this approach relies on hybrid humananimal studies to produce a robust causal design they first find associations between phentoypes and the composition of the gut microbiome and then they use animal models to further test the causality of that associational relationship for example we know the chronic inflammatory conditions like diabetes are more deadly for those with low compared with high educational attainment even after accounting for body mass index 37 fecal transplants drawn from those with type 2 diabetes but who varied in their educational attainment and were comparable on characteristics like body mass index could then be transplanted into mice to see how the gut microbiota influenced morbidity and mortality outcomes in these models is the gut microbiome a biological mechanism that can help clarify why lower levels of educational attainment are so harmful for health social relationships social and behavioural scientists have also shown that quality quantity and duration of intimate contact and social relations are important for health potentially as a buffer from stress across a wide array of empirical designs ranging from animal models to human longitudinal studies and randomized controlled trials the relationship between social relationships and health and mortality is the most well documented among specific social conditions that influence health and mortality 111 indeed a recent review found that social relationships are a stronger predictor of mortality than smoking 111 limited social interactions may contribute to reduced diversity in gut microbial communities among older persons or the socially isolated another plausible biological mechanism for the strong associations of social relationships and health as already detailed there is some evidence from primate models that social relationships perhaps in part via direct microbial sharing exerts an influence on gut microbial composition indeed a recent study demonstrated that the oral microbiome infiltrates the gut microbiome supporting evidence for microbial exchange via salivary mechanisms 112 this area is ripe for study in human models to further test and elucidate pathways between social interactions gut microbial composition and morbidity and mortality outcomes our recent data collection in the wisconsin longitudinal study took a step in the direction of integrating social and biological approaches to the gut microbiome this cohort of nearly 10317 1957 wisconsin highschool graduates their spouses and a subsample of siblings 113 has been followed for the past 60 years and includes extensive social and phenotypic measurement of everything from highschool records education and occupation histories to childhood conditions health status cognition disability mortality and genetic data fecal samples from a randomly selected subsample of 436 participants were recently collected targeting a mixture of sibling and spousal pairs in their mid70s 67 because the subsample includes siblings as well as spouses most of whom have been married and lived together for nearly their entire adult lives we were able to compare microbiome composition among those who share environments due to living arrangements across most of their adult lives to those who share only early upbringing conditions we found 114 that shared environments in adult life had a stronger influence on microbial composition in later life than did shared earlylife environments this provided a mechanism to test the relatively plasticity of the gut microbiome in populationbased data we also found that the similarity between spouses compared with unrelated individuals was entirely driven by married couples who reported they had a very close relationship in short the shared gut microbial composition of married couples who rated their relationship as somewhat good was similar to that of unrelated individuals modest as it may be this finding alone is important as it generates new questions and problems first it is somewhat unexpected given extant empirical evidence that points to the early colonization and stable character of the microbiome 3 second it confirms other findings in epidemiology according to which environments shared by siblings explain only a small fraction of adult outcomes 115 finally one puzzle to resolve is whether or not the impact of shared environments by spouses on the microbiome is part of a chain of events that accounts for withincouple similarity in chronic illness 116 conclusion we believe these early days of microbiome research offer exciting opportunities for collaborations between the life sciences and the social and population health sciences a time when theory and measurement in both realms is still developing and before disciplinary conventional wisdom has the chance to solidify for social and population health scientists the study of the microbiome may help elucidate currently unknown biological pathways that link social conditions to health and mortality and provide a target for intervention for biologists collaborations with social and population health scientists can enhance knowledge of a new range of environmental factors that may influence microbial composition and in turn health insights from the social and behavioural health research can also help contextualize existing findings for example the robust evidentiary base linking diet and the gut microbiome should be considered in the context of broader population health research that documents how structural conditions ranging from economic resources to neighbourhood environments constrain nutritional choices individuals make both fields will benefit from the joining of social science and basic biological methodological approaches embedding animal models in the context of populationbased studies provides a novel approach to improving causal methods for social and population scientists having access to large population representative longitudinalbased studies with highquality phenotypic measures can vastly expand the quality of research produced by biologists success will ultimately be measured by the ability of scientists across all disciplines to understand how the microbiome influences human health and social trajectories and how social and medical interventions may use this knowledge to improve both individual wellbeing and population health note this figure is not intended to be a comprehensive overview of all possible causal relationships it suggests where social and population health scientists are best positioned to contribute to microbiome research focusing particularly on the possible pathways between social conditions and the gut microbiome competing interests the authors declare no competing interests

the microbiome is now considered our second genome with potentially comparable importance to the genome in determining human health there is however a relatively limited understanding of the broader environmental factors particularly social conditions that shape variation in human microbial communities fulfilling the promise of microbiome research particularly the microbiomes potential for modification will require collaboration between biologists and social and population scientists for life scientists the plasticity and adaptiveness of the microbiome calls for an agenda to understand the sensitivity of the microbiome to broader social environments already known to be powerful predictors of morbidity and mortality for social and population scientists attention to the microbiome may help answer nagging questions about the underlying biological mechanisms that link social conditions to health we outline key substantive and methodological advances that can be made if collaborations between social and population health scientists and life scientists are strategically pursued we are an amalgamation of cells both human and microbial and there is growing evidence that the trillions of microbes that inhabit the human body collectively referred to as the human microbiota have profound implications for human health 1 this complex human ecosystem belies the traditional dichotomy between good and bad bacteria giving way to a more nuanced consideration of changing and interacting networks of microbes the microbiome is now considered our second genome with potentially larger importance than the genome in shaping human health 2 what makes the microbiome potentially so pivotal for

introduction economists organizational scholars and sociologists 1 2 3 have advanced strong theoretical and empirical arguments that social scientists should increase their focus on the role of workplaces in generating earnings inequalities recent research has discovered that in multiple countries rising earnings inequalities have been associated with between workplace polarization in wage rates 4 5 6 underlining the importance of developing robust analyses of workplace inequality processes the main empirical contribution of this paper is to develop and explore a set of available organizational explanations for rising between and within workplace inequality focusing on the role of employment dualization 4 workplace and industry skill segregation 5 and firm fissuring 7 a second contribution is to develop an original research design to examine workplace inequality dynamics we take advantage of fifteen years of german administrative data on a large random sample of workplaces and all of their employees germany is the largest economy in europe and the fourth largest in the world it is also an important case in that earnings inequalities have risen rapidly both between and within workplaces 46 our estimates 6 are that by 2010 total inequality rose a remarkable 31 over its level in 1995 within workplace earnings dispersion increased 227 while between workplace earnings dispersion surged by 568 the most prominent explanation for rising inequality in germany focuses on institutional shiftsparticularly the birth of new nonunion firms and the rise of parttime laborboth of which potentially undermine the bargaining power of labor more generally 4 we directly model the impact of both establishment births and parttime labor on rising within and between workplace inequality in addition we explore a novel explanation of institutional change that focuses on corporate strategy and firm fissuring in which firms with market power outsource production roles particularly those of lower skilled labor leading to rising between firm skill segregation 57 we see these two explanations as complementary declining institutional protections make it easier to outsource while outsourcing can also lead to declining collective worker power there has been very little research that makes the direct connections between organizational processes and rising between or within workplace earnings inequalities in this paper we review what has been speculated on and what is known in this regard and derive a collection of hypotheses that are consistent with the variety of underlying mechanisms identified in the literature some of these hypotheses are at the societal level and tend to receive fairly strong support others are at the workplace level and while our evidence is mixed it generally confirms that changes in skill composition and rising dualization in job structures are important contributors to both between and within workplace inequality dynamics while these exercises are far from definitive we see them as strongly suggestive of which mechanisms deserve to be more fully explored in the future we find that between workplace inequality dynamics are associated with industry level wage polarization the birth of new low wage workplaces and reductions in occupational skill complexity we also confirm the dualization hypothesis that the rise of parttime work increases the bargaining power of fulltime labor within workplaces while decreasing average wage rates even among fulltime workers between workplaces disconfirming our expectations within workplace inequality is higher in both high and low wage establishments and rises when earnings both fall and rise stable and average pay establishments are the most internally egalitarian previous research early research using linked employeremployee administrative data for multiple countries found that most earnings inequalities were within rather than between workplaces 89 recent research in contrast has discovered that a great deal of rising inequality is a between firm phenomena 4 5 6 10 our recent study using administrative data for fourteen countries finds that in twelve countries the share of total inequality that is between workplaces was rising that in six the between workplace inequality component is now larger than the within establishment component and that these trends were associated with declining institutional protections of low wage labor 6 past research has found that increased between workplace earnings inequalities produced about 60 of growing west german male wage inequality twothirds of which was associated with increased occupational skill segregation between workplaces 4 as likely explanations for these trends the authors point to the birth of new nonunion firms as well as labor market reforms which permitted german employers to create parttime and fixedterm employment contracts and to outsource jobs to labor contracting firms we directly examine establishment births and the rise of parttime jobs we do not observe outsourcing or fixedterm contracts directly but discuss their likely influence rising inequality has also been linked to changes in organizational structure the disintegration of large dominant vertically integrated firms implies rising national inequalities as high wagelow inequality firms shrink as employers relative to low wagehigh inequality firms 11 this process it is argued has been encouraged by the shareholder value movement which has shifted large firm goals from employment production and market share to a focus on core competencies lean production and return on investment this aspect of financialization encourages dominant firms to externalize as much of production and administration as possible leaving the economic rents associated with their market and brand power for ceos shareholders and fewer high wage employees while simultaneously creating subordinate lowwage trading partners 7 consistent with this account in the us the largest firms accumulated larger shares of the value produced in the economy even as their share of employment shrank 12 from this theoretical vantage between workplace earnings polarization is produced by some firms becoming more powerful in their market positions and so accumulating larger shares of national income while simultaneously reconfiguring organizational boundaries to outsource routine production and support functions moving from vertically integrated to marketbased sourcing of intermediate products and services examples of these externalization processes include manufacturing giants spinning off labor to cheaper dependent supplier firms 13 branded companies subcontracting out most low skill labor while absorbing the profits associated with the brand 7 global commodity chains in which routine production are sourced from low wage economies by firms in high wage countries 14 and growing large firm market power 1516 there is little evidence at this point linking these processes to rising inequality there is evidence however that outsourcing tasks to low wage industries leads to reduced wages for the outsourced tasks in germany outsourcing jobs to service industries is estimated to reduce pay by 10 to 15 percent even though the work is done by largely the same people at the same site 17 in the us estimated wage declines were 47 for janitors and 824 for guards outsourced from manufacturing to service industries 18 there is also evidence that us firms are simplifying their divisions of labor over time 19 also for the us recent research suggests that growing occupational homogeneity among employers is particularly acute among low wage workers and that increased workplace occupational homogeneity can explain a large portion of rising us earnings inequality between 2002 and 2016 20 if these processes are operating in germany we would expect that much of the rise in german between establishment inequality will be a function of polarization in incomes associated with the industrial location of production and of growing occupational skill segregation between firms if high earningshigh skill firms externalize low skill and noncore jobs to firms in other industries this should intensify industry pay polarization when a manufacturing firm externalizes its human resources cleaning and food service functions those jobs relocate to firms in other often lower wage industries similarly simplifications in occupational divisions of labor at the firm level via the outsourcing mechanism should intensify between workplace inequality while reducing within workplace inequalities in high income firms although germany has a history of industrially coordinated labor markets it has been moving since the mid1990s toward a more decentralized and globally oriented industrial relations system 2122 solidaristic bargaining across industries has given way to dualized bargaining structures between industries weak unions and low collective bargaining coverage characterize low wage typically service sectors while strong unions in exportoriented manufacturing preserve their workers high wages these shifts are associated with both gender and contract status employment segregation within and between firms these dualization processes have also been hypothesized to be associated with the rise of new low wage nonunion employers in germany 4 this discussion leads to a linked set of hypotheses that obtain at different levels of analysis including economywide trends over the study period betweenworkplace differences in levels and withinworkplace changes in those levels over time we refer to differences in levels in terms of more or less or greater or lesser with respect to changes over time we use the words rising and declining or increasing and decreasing we begin with four linked sets of hypotheses industry hypothesis h1 economy wide between industry wage polarization should increase new establishment hypotheses h2a new workplaces will have lower mean wages and lower skill profiles than existing workplaces h2b new workplaces will have lower internal inequalities and lower skill complexity than existing workplaces occupational structure hypotheses h3a economy wide total between workplace variance in skill levels will rise h3b economy wide total within workplace skill complexity will decline h3c between establishments a higher skill level will be associated with a higher mean wage within establishments an increasing skill level will be associated with an increasing mean wage h3d declining workplace skill complexity will be associated with decreased within workplace inequality dualization of the labor market can happen within as well as between workplaces the rise of fixed term contract work and parttime work are prominent practices in germany the german hartz reforms of the early 2000s which loosened regulations on both parttime and fixedterm contract work is predicted to increase the incidence of firms building their labor process around parttime labor 22 others have speculated that growing parttime labor will undermine the bargaining power of labor more generally 4 but do not specify if this is a within or between workplace prediction somewhat in contrast other scholars have stressed the utility of these types of precarious work to protect the wages of the remaining fulltime core workers 2324 for between workplace inequality we follow the reasoning in 4 that parttime work undermines the bargaining power of labor for within workplace inequality we follow the reasoning in 22 23 24 and hypothesize that the rise of parttime work will produce dualized workplace structures that strengthen fulltime employees earnings claims hours dualization hypotheses h4a economy wide between workplace variance in parttime work will rise h4b firms with more parttime work will have lower fulltime wage levels net of occupational skill levels and complexity h4c rising parttime work will increase within establishment fulltime worker wages finally the literature on the outsourcing of low wage employment by high wage firms 7 leads to the expectation that both high and low wage firms will have declining internal inequalities as they specialize in high and low skillpay production regimes in addition the observation that high wage firms also tend to be low inequality firms 11 leads us to the expectation of particularly low inequality in high wage firms wage dualization hypotheses h5a both rising and declining workplace mean earnings will be associated with declining internal earnings inequalities h5b high wage firms will tend to have the lowest levels of internal inequalities additional explanations some scholars of rising between workplace inequality have interpreted the rising between workplace trend as reflecting individual level skill segregation between firms 5 our hypotheses follow previous research on germany 4 and the fissuring literature 7 in emphasizing occupational rather than individual skill segregation one prominent theory of organizational inequality emphasizes that gender and citizenship can operate similarly to education channeling the distribution of rewards in workplaces although this approach also prioritizes the role of occupational divisions of labor 2526 we include educational age tenure gender and citizenship composition in our models as potential additional drivers of organizational inequalities materials and methods we analyze a random sample of administrative data drawn from the social security records of the german federal employment agency linking employees to their workplaces over time although the data were anonymized prior to analyses they are highly confidential under german law and must be analyzed in a secure data facility with a license from the german institute for employment research ueberblickaspx this data and similar data sets are available for scientific analysis upon filing an application aspx apply the basis for the data is the integrated notification procedure for health pension and unemployment insurance which came into effect in 1973 and was extended to cover eastern germany in 1991 employers are required to submit notifications at least once a year to the responsible social security agencies concerning all of their employees covered by social security and earning more than a minimum wage threshold which was 450€ in 2015 these data are of very high quality as they are used to track income and employment for social security and tax purposes excluded from the data are beamtea class of permanent civil servantsas they do not participate in the national social security system in the early 1990s beamte were 67 of all employees declining to 52 in 2011 in addition freelancers and the selfemployed who are also not covered by national social security are not present these make up about 11 of the labor force in 2009 up from 9 in 2005 like beamte they tend to earn more on average than employees in the social security system 27 although they are much more heterogeneous and include many low earners thus our sample misses two types of relatively advantaged workers as a result we probably underestimate the levels of earnings inequality although the impact on trends is unknown as beamte are declining and the selfemployed are rising the data were sampled by the institute of employment research from the integrated employment biographies sample combining individual records of employment and benefit recipient history see 28 for a description of the source data our sample covers roughly 5 of the german employee population and 20000 establishments with at least one year of existence between 1994 and 2010 although national data are available starting in 1991 the east german administrative data only become reliable in 1993 the period of great growth in german earnings inequality happens within our observation period as we use a lagged imputation strategy to deal with earnings top coding our estimations start in 1995 workplaces are observed via an establishment id and are for the most part unique standalone workplaces when a firm owns two or more workplaces operating in the same industry in the same municipality they are reported under the same id when a workplace is sold to another firm it will get a new id we treat such workplaces as new establishments see also 4 these data include both private and publicsector establishments from all industries our sample mirrors the dynamic population of german establishments sampling occurred in two steps in the first 20000 establishments were selected proportional to their number of jobyears between 1994 and 2010 smaller and shorterlived establishments are selected with decreasing probabilities we limit the maximum of the sampling probability to 03 as otherwise large workplaces would be drawn nearly completely into the sample violating our confidentiality agreement compared to more typical sampling strategies this method prioritizes jobs as employment spells rather than people or organizations as discrete units in a second step all employees of the selected 20000 establishments were drawn from the ibes for large establishments the number of employees was limited to 1000 randomly selected employees again to conform to confidentiality restrictions all analyses use sampling weights to increase the weight of larger establishments and under sampled employees to correspond to their population frequency prior to aggregation to the workplace level this weighted sample reproduces all individual and organizational population characteristics after aggregation we drop any workplace that averages less than 20 employees per year observed this produces a sample that is representative of all german workplaces larger than 20 employees and all of their employees between 1994 and 2010 compared to the entire economy the only population level shift of note is that our 20 employee sample has a 04 year longer average workplace tenure than the full economy average we then aggregate all indicators to the workplace level focusing our analyses on organizational variation in the mean and standard deviation of logged daily earnings of fulltime employees most workplace characteristics are calculated on fulltime workers only the one exception is the workplace distribution of parttime employees which is calculated from all employees thus while we mainly focus on earnings inequality levels and trends among fulltime employees we examine if the growth of parttime employment influences fulltime earnings both between and within workplaces per hypotheses h4b and h4c dependent variables both of our dependent variables are aggregate versions of the log of real daily earnings for fulltime employees earnings includes all earnings from the employer in the year including bonuses and overtime divided by days worked we are missing the exact hours worked and it is primarily for this reason that we limit our analyses to fulltime employees between workplace inequality is measured as workplace mean logged daily earnings hypothesis 1 predicts that rising between workplace inequalities will be linked to rising between industry wage polarization hypotheses 2a 3c 4b and 5b also relate to between workplace inequalities and are estimated regressing mean workplace earnings upon organizational level predictor variables within workplace inequality is observed as the standard deviation of daily earnings within workplaces and this is the measure responsive to hypotheses 2b 3d 4c and 5a the key limitation of the earnings measure is that it is topcoded at the maximum income subject to german social security withholding we improve on an existing topcode imputation strategy by using workplace as well as individual level information and prioritizing information from the two years previous to the topcoding of the wages to impute the income of higher earners predictor variables industry is measured with the threedigit standard industry scheme and is used to predict economy wide change in between and within workplace inequality trends we only have a hypothesis with regard to the former but include the latter for comparative purposes although there are some changes in industry coding in this period they do not impact our estimates we observe the birth of new establishments as any workplace which appears after the first year of the time series we hypothesize that new workplaces will tend to pay lower wages than existing workplaces and also have lower skill complexity than existing workplaces it is also possible that new establishments have lower wages simply because they are more likely to be economically marginal to partially account for economic marginality we also include an indicator of any establishment that exits the panel prior to the last year if we are actually seeing a shift to low wage firms the wages of new firms should also be lower than that of the firms that died this is not a time varying indicator of course these are imprecise measures since exits can be produced by other factors such as being acquired by another firm occupational skill is measured with threedigit occupations ranked in terms of their mean wages converted to percentiles of the national income distribution this measure is empirically very similar to an occupational socioeconomic status or prestige measure 29 others have shown across multiple countries that the consistent underlying dimension associated with occupational socioeconomic status is skill in production 30 previous work has used a similar measurement strategy for linked employeremployee data 429 the measurement of occupational skill as income percentile is not tautological only a third of individual earnings variance in germany is between occupations 31 and the conversion to percentiles further reduces the association with individual earnings economy wide between workplace variance in occupational skill is predicted to rise while occupational skill levels are hypothesized to be associated with higher and increasing wage levels occupational complexity is measured with the within workplace standard deviation of these occupational ranks economy wide within workplace occupational complexity is hypothesized to decline decreased occupational complexity is also predicted to be associated at the workplace level with increased between workplace inequality and decreased within workplace inequality we calculate the workplace proportion of parttime workers to test three linked hypotheses that establishment variance in percent parttime will increase and that parttime labor forces will decrease between workplace fulltime wages while increasing within workplace fulltime wages we measure workplace heterogeneity for parttime versus fulltime composition as well as other categorical status attributes with the gibbsmartin index of heterogeneity h ¼ 1 à x n o¼1 p 2 o where p o is the proportion of employees in an establishment within a category and n is the number of categories control variables standard economic 4 theory leads us to expect that individual skill levels and individual skill heterogeneity should drive between and within workplace earnings inequalities respectively organizational inequality 25 theory would agree but stress the additional possibility that gender and citizenship distinctions may also be influential we include as compositional control variables the levels and heterogeneity of tertiary degrees age tenure sex and citizenship heteroegeneity for continuous variables is measured as their workplace standard deviation categorical heterogeneity is measured with the gibbsmartin heterogeneity index as defined above we also control for industry in final models analytic strategy we focus first on the economy wide hypotheses and follow with hybrid multilevel regression models predicting variation in between and within workplace inequality hybrid multilevel regression models combine the advantage of fixed effects multilevel and crosssectional models the fixed effect model focuses on change while the crosssectional model describes stable relationships thus we can account for the impact of timeinvariant measured and unmeasured higher level characteristics in the analysis of change while allowing for the estimation of timeinvariant effects in the cross sectional analysiswe introduce the logic of each empirical analysis as we undertake it industry hypothesis analysis in our first analysis we examine h1 that between workplace earnings inequalities are increasingly tied to between industry earnings differentials the dependent variable is workplace mean earnings we estimate yearly crosssectional models regressing workplace mean earnings on fixed effects for threedigit industry codes we then focus on the level of variance explained by industry as captured in the r 2 statistic h1 predicts an increase in explained variance over time we experimented with 2 and 4 digit industry distinctions as well but 3 digit distinctions captured both earnings variation and trends better than the simpler and roughly equivalent to the more detailed operationalization for the sake of comparison we also regress workplace internal inequalities on industry with the same yearly r 2 focused strategy but with no prior theoretical expectations we interpret table 1 as providing strong support for h1 that between industry wage polarization is intensifying in 1995 38 of establishment mean wage variation was between detailed industries by 2010 that had risen to 49 the association of industry with workplace mean wage grew a remarkable 285 in only fifteen years we also report the parallel analysis for within workplace inequality within workplace inequality is more weakly associated with industry and shows no temporal trend within industry workplace inequality is not becoming more similar over time descriptive analyses and economy wide hypotheses in table 2 we examine three hypotheses as part of an initial descriptive analysis we also use this table to establish if other workplace characteristics changed during this period and so are potential competing explanations for the national trends we are trying to understand table 2 also provides descriptive statistics for the entire panel for all variables used in the multivariate analysis that follows the first two columns of table 2 describe the pooled sample the next four the first and last years of the panel and the last two changes in the mean levels and between workplace standard deviation for all variables it is these last two columns that we use to examine hypotheses h3a h3b and h4a we begin with these three hypotheses and then go on to describe other aspects of the changing german economy all three hypotheses are confirmed the german economy became more skill and parttime segregated between workplaces while the average workplace simplified its division of labor we ask in hypothesis h3a if the economy wide between workplace variance in skill levels rose in 1995 the standard deviation across workplaces in mean occupational skill was 191 this rose by 52 to 201 by 2010 using a twosample variance comparison test the null hypothesis of no change can be rejected at below the 0001 level between workplace skill variance rose between 1995 and 2010 confirming hypothesis h3a hypothesis h3b predicts that economy wide within workplace skill complexity will decline in 1995 the standard deviation of workplace skill complexity was 201 declining to 188 by 2010 this 647 drop produced a two sample t statistic of 109 rejecting the null hypothesis of no change at well below a 0001 probability level and confirming hypothesis h3b our final economy wide prediction is that the between workplace variance in parttime work will rise in the average 1995 workplace 127 of jobs were parttime this rose to 20 in 2010 over the observation period the proportion jobs parttime grew by 575 the standard deviation across workplaces grew by 272 strongly confirming hypothesis h4a this large change in employment composition is highly statistically significant while the hypotheses associated with our core analyses about economy wide restructuring around industry occupation and job precarity were all supported other aspects of german establishments were also changing some dramatically both mean tenure and the percent of the workforce with tertiary degrees rose strongly as did between workplace tenure and education segregation the same is true although less dramatically for age human capital between establishment segregation is a plausible alternative explanation of rising between establishment inequality to job restructuring in contrast gender and citizen segregation between establishments declined suggesting that these are unlikely to be explanations for between workplace inequality trends in the multivariate models that follow we treat these compositional variables as statistical controls to examine the robustness of our core hypotheses multivariate analysis approach we now turn to workplace level analyses of the association between establishment births the occupational and parttime organization of work and between and within workplace inequalities these analyses estimate the potential influence of organizational covariates on mean logged earnings and the standard deviation of logged earnings for the panel of german workplaces the vast majority of both between and within earnings inequalities are a stable function of workplaces for mean log earnings 962 of variance is at the establishment level for the standard deviation of log earnings the stable establishment component is smaller but still substantial at 782 reflecting this stability we have pursued a hybrid multilevel regression modeling strategy the between coefficient of the hybrid multilevel regression examines the impact of independent variables of interest on the dependent variable taking the mean level of selected measures for each workplace across the panel 32 the within coefficient employs a workplace fixed effect estimation strategy focusing on change across time both models are estimated simultaneously with a maximum likelihood estimator time varying control variables influence both of these estimates although we do not discern separate between and within components of those effects only establishment entry and exit variables are time invariant and their influence is limited to the between estimate the randomintercept model which provides the basis for the estimations of the hybrid models can be written as loge wt ¼ d 0 þ dx wt þ bc w þ φ t þ � w þ � wt where log e wt are the log daily workplace earnings x wt indexes a vector of observed timedependent variables illustrating workplace change over time while c w presents a vector of observed timeindependent higherlevel variables at the workplace level φ t are the year fixed effects and � w � wt represent the error terms similar to a fixed effect strategy a hybrid model also refers to change in y as a function of change in x over time fixed effect models control for time invariant omitted variable bias including eg geographic location these models can be written as loge wt ¼ d 0 þ dx wt þ φ w þ φ t þ � wt where φ w φ t are workplace and year fixed effects while � wt presents the errorterm the hybrid models combine the features of both multilevel regression strategies by estimating a random effects model including within effects technically this is achieved by decomposing one or more variables at the lower level into a between effect using the mean of the variable and a within effect capturing the deviation from the mean in accordance to the demeaning procedure used for fixedeffects models 32 hybrid models for the mean of earnings can be written as loge wt ¼ d 0 þ dx wt þ bc w þ g 1 b w þ g 2 w wt þ φ t þ � w þ � wt where the additional term b w refers to a vector of between components and w wt to a vector of within components the equation for the standard deviation of earnings models are identical robust standard errors adjust for within workplace clustering all observations are weighted by workplace fulltime job size in order to generalize models to national inequality trends as always our models are vulnerable to omitted variable bias and so can best be seen as indicators of potential causality rather than strict causal tests this is less the case for the within workplace fixed effect analyses but even there changes in behavior such as in managerial practices or capital investment in new technologies are missing and potentially influential perhaps the most serious missing indicator is the absence of a measure of workplace collective bargaining coverage the rise of new nonunionized establishments 4 and dualization in union wage bargaining 22 may permit the formation of new low earnings establishments assuming that establishments are born unionized this omitted variable is effectively controlled by the inclusion of establishment birth and death in the crosssectional analyses and by design in the fixed effects specification but it does limit our ability to comment on the magnitude of this institutional shift effect because unionization in germany is strongly associated with industry and we control for industry in final models that model is the least at risk to bias from the lack of workplace unionization measures more generally with the exception of occupational skill and parttime measures we lack information on other dynamic organizational processes such as outsourcing and subcontracting production tasks which we expect to influence the between workplace outcomes as such our models can give us estimates of the impact of increased between establishment occupational skill dispersion on workplace inequality but not the underlying mechanisms which produce changes in occupational skill composition we rely on the initial analysis of industry linked earnings polarization and economy wide shifts in occupational and parttime structure to provide partial evidence as to the union dualization and fissuring processes to the extent that shifts in skill and parttime composition are systematically associated with other dynamic organizational processes estimates may be biased though the direction of bias is unknown we also lack a measure of fixed versus permanent contract frequency in the workplace in germany collective agreements do not allow for unequal pay for fixedterm and permanentcontract workers although in practice temporary workers occupational titles may be downgraded to allow for lower payments 3334 since legally it cannot influence earnings but socially it might influence the mean occupational skill of a workplace this source of omitted variable bias can be expected to be largely absorbed by the estimated influence of skill composition upon earnings thus estimates of occupational skill effects can be seen as primarily about shifts in the division of labor but potentially may also incorporate the impact of the rise of fixed term contracts we organize our multivariate analysis through four sequential models we treat model 1 as the baseline it includes only a fixed effect for year in model 2 we introduce the variables indexing which establishments were born and died during the observation period model 3 adds variables indexing levels and variability in job structures model 4 introduces the set of employment composition variables as controls because industry does not appear to be a fixed trait we also include it as a statistical control in model 4 we see the contrast between model 3 and model 4 as providing upper and lower bound estimates of the impact of our hypothesized job structure variables on earnings inequalities our fifth hypothesis predicts that within workplace inequalities would fall in both high and low wage establishments thus when analyzing within workplace inequality we introduce the logarithm of mean earnings as a potential explanatory variable if a process of internal skill homogenization based on outsourcing and new firm business models is occurring at the top and the bottom of the establishment income distribution we expect reduced inequality in these establishments this effect of mean wage if it exists should be at least partly mediated by declining occupational complexity we introduce this variable in model 2 and observe its attenuation after occupational variables are added in model 3 prior research has documented in crosssection that larger establishments pay higher wages but also that the size premium has declined during this period of outsourcing and downsizing 35 in preliminary models we explored the influence of organizational size on both mean earnings and earnings variance a crosssectional establishment size premium in germany was observed in ols models but not in the fixed effect model specification as a result we do not include organizational size in our models modeling workplace mean wage levels and change table 3 reports variable and model estimates from the hybrid multilevel model for workplace mean wages if we focus first on model estimates reported at the bottom of the table we confirm that the vast majority of variance in workplace mean wages is between establishments thus change in between workplace wage inequality is primarily a function of the birth and death of establishments with different structural characteristics we also note from the baseline model that mean workplace inflation adjusted earnings in germany barely changed over time rising slowly through 2001 and declining thereafter to get a rough sense of the relative impact of each variable we calculate effect sizes by multiplying estimated coefficients by the standard deviation of variables reported in column 2 of table 2 we now turn to examine four hypotheses models 2 and 3 examine hypothesis h2a that new establishments will have lower mean wages and lower skill profiles than existing establishments we see that new establishments have 93 lower mean wages than establishments that exist throughout the observation period they also have 52 lower earnings than the presumably economically marginal establishments that exit the panel prior to 2010 adding job structure variables in model 3 attenuates the lower wage coefficient of new establishments by 17 h2a is supported new establishments have lower mean wages and this is in part because they are being founded with less skilled job structures hypothesis h3c predicts that higher workplace skill levels will be associated with increased between and within workplace inequality more skilled workplaces have higher mean wages with a 11 rise in mean wage predicted per percentile gain in occupational skill level the impact of changing skill levels on change in within workplace mean wage is also highly significant but only about half as strong both effects are only marginally attenuated by the introduction of employment composition and industry controls in terms of effect sizes associated with a standard deviation rather than a unit increase a standard deviation higher workplace mean skill level is associated with 18 higher mean earnings for the fixed effect coefficient we find that a one standard deviation rise in skill level implies an 11 rise in that workplaces mean earnings as expected workplace skill levels have the strongest effect on wage levels of any variables in these two sets of models we did not have hypotheses about the impact of occupational complexity upon mean wage levels or change we find however that higher occupational complexity is associated with high mean wages a result consistent with classical political economy notions about the productivity advantages of detailed divisions of labor in contrast rising occupational complexity is associated with declining mean wages in the fixed effect estimation however the between effect of skill heterogeneity has an effect size of 001 workplace mean wage and the within effect is only 0002 so while statistically significant these are not large effects hypothesis h4b predicts that establishments with more parttime work will have lower fulltime wage levels net of occupational skill levels and complexity hypothesis h4c reflects the expectation that rising parttime work will be associated with a positive effect on within establishment fulltime worker wages both dualization hypotheses are supported net of occupational skill levels and occupational complexity more parttime workers are associated in crosssection with lower wages for fulltime workers but rising parttime labor forces strengthen fulltime workers wages in the fixed effect estimation the latter effect is partially mediated by employment composition the effect sizes for both variables is moderate at 002 or a 2 rise in workplace mean wages for a 17 rise in parttime labor we lacked hypotheses on the impact of parttime versus fulltime heterogeneity on mean wages we find across workplaces that when establishments approach fifty percent parttime fulltime workers tend to be paid higher wages however this same process is associated with declining within workplace fulltime wages we see these results as strengthening the interpretation that dualization has shortterm positive effects for fulltime workers but over the longer term undermines their bargaining power the between effect of parttime heterogeneity has a moderate effect size of 003 while the within effect is only 001 for a one standard deviation increase in terms of control variables a rising share of tertiary educated older longer tenure male and citizen workers are all associated with higher average workplace earnings even net of controls for occupational skill and skill heterogeneity the strongest effect sizes among these variables are for sex and education we did not have expectations linking heterogeneity measures to mean earnings all of those effect sizes are relatively modest below a 2 change in workplace mean wage looking across variables it is clear that the strongest contribution to between workplace mean earnings and to within workplace mean earnings change derives from the skill level of the organization surprisingly the next strongest effect size derives from the sex composition of the workplace followed by the educational level of the workforce and then the new establishment effect all other covariates display relatively weak influences on earnings levels and change in these models within workplace inequality in table 4 we explore the correlates of within workplace earnings variation focusing first on the baseline model rho statistic at the bottom of the table we see that about threequarters of variance in within workplace inequality is a stable attribute of establishments the time trend reported in the baseline model confirms that average within workplace inequality has been rising across the study period we next examine three formal hypotheses relating to within workplace inequalities the first hypothesis predicts that new establishments will have lower internal inequalities and lower skill complexity than existing establishments net of workplace mean earnings and inconsistent with hypothesis h2b new establishments have the same internal earnings inequalities as existing workplaces after controls for job structure industry and status composition new establishments have significantly higher inequalities than existing workplaces in contrast workplaces that exit the panel had lower internal inequality although this seems to be primarily a function of job structure we also hypothesized that declining workplace skill complexity would be associated with decreased within workplace inequality for both between and within workplace models of internal earnings inequalities we observe strong positive relationships between skill complexity and the level and change in within workplace inequalities since the economy wide trend is toward declining workplace occupational complexity hypothesis h3d is supported the effect sizes are somewhat larger than most others for within workplace inequalities at 03 for between and 02 for within estimates our final set of hypotheses focus on the relationship between workplace wage levels and internal inequalities hypothesis h5a states that both rising and declining workplace earnings will be associated with smaller internal earnings inequalities while hypothesis h5b predicts that high wage establishments will tend to have the lowest levels of internal inequalities we produce marginal effect plots adjusting for model covariates to examine these nonlinear patterns we focus on model 3 estimates but the full model estimates are quite similar both hypotheses must be rejected workplaces with rising and falling wages display strongly rising internal inequalities although the magnitude of this effect is stronger for low wage workplaces the pattern is similar in crosssection although the pattern is more symmetrical within workplace wage homogeneity is most likely to be found in establishments with little or no shifts in their mean wages and in the middle of the establishment wage distribution low wage and high wage establishments are better characterized as within workplace inequality generators as expected the various status heterogeneity measures are also associated with higher within workplace inequality looking across these measures of internal heterogeneity gender and occupational complexity have the largest effect sizes followed closely by both education and tenure while the results for education and tenure are consistent with a standard human capital model the results taken together suggest that german within workplace inequality is not simply a result of variance in individual human capital levels but that occupational divisions of labor and gender are both at least as influential the expectation that occupational skill variance would be the primary driver of within workplace inequality is not confirmed at least in these dynamic models education tenure gender and occupation all appear to be roughly equivalent drivers of german internal workplace inequality dynamics in the study period discussion following the increasing political and scholarly interest in rising earnings inequalities we focus on germany a nation with particularly steep increases in both between and within workplace inequality we depart from prior work in three fundamental ways first we foreground workplaces as the sites of income pooling and distribution second we connect the empirical recognition of rising between establishment inequality to the organizational fissuring and dualization literatures on the reconfiguration of larger firms through the creation of dualized job structures and the externalization of labor costs associated with outsourcing subcontracting and the rising market power of firms in oligopolistic industries finally we directly model organizational characteristics and dynamics on shifts in both between and within workplace inequalities confirming our first hypothesis we find rapidly rising between industry polarization in mean workplace earnings outsourcing tasks from high to low wage firms increased market power of dominant firms and collective bargaining dualization are the theorized causes of this predicted industry linked earnings polarization while none of these mechanisms are directly observed the industry analysis helps to establish the degree to which they are potentially reasonable explanations this industry approach does not capture the consequences of some forms of organizational reconfiguration including within industry and global outsourcing or the externalization of labor via independent contractors we also directly estimate the association between a series of organizational factors and both between and within workplace inequalities reflecting that most of the variability in between and within workplace inequality is a stable establishment attribute we model these impacts in a hybrid hierarchical linear modeling framework in hybrid models a conventional fixed effect approach models change within establishments while a pooled panel crosssectional approach models the between establishment variance more than 90 of between and 75 of within workplace inequality is captured in the pooled panel analyses confirming hypothesis h2a we find that between workplace inequality is strongly tied to the birth of new low wage workplaces and that these workplaces tend to have lower skill levels and lower skill complexity than more stable establishments there is however no evidence that new establishments have lower internal inequality and the sign actually switches to positive in the fully controlled model thus hypothesis must be rejected in part new establishments do have lower skill complexity but they have higher not lower internal inequalities not surprisingly we also find that occupational skill levels are strong predictors of workplace mean wage and occupational complexity of internal inequalities as we saw table 2 between workplace occupational skill variability grew by 52 and within workplace occupational complexity declined by 65 in this period we see these results as quite consistent with the more general fissuring account of work reconfigurations workplaces are becoming internally more skill homogenous and more skill polarized from one another and these trends are tied to both the birth of new establishments and industry earnings polarization we confirm the speculation that the rise of parttime jobs might be undermining the bargaining power of fulltime labor 4 but demonstrate that this is primarily a between establishment phenomena within establishments rising parttime labor is associated with an increase in the wages of fulltime labor a result consistent with the dualization literature 2122 consistently research shows that in germany the use of temporary workers increases the job security of permanent fulltime workers 33 thus dualization appears to have two faces within establishments parttime and perhaps temporary contract work increases the wages and stability of the remaining fulltime workers at the same time the bargaining power of all workers is reduced at the establishment level the hypotheses linking establishment mean wage and internal inequalities were strongly rejected low and high wage establishments as well as establishments that both reduce and raise wage levels over time are markedly more internally unequal than establishments in the middle of the wage distribution and those that exhibit stable wage levels from a mechanical point of view one might expect that high wage establishments should have higher inequalities simply because the social space to make distinctions rises as an organization moves away from the floor of minimum wages that inequality is also high in low wage establishments suggests a high level of exploitation in those establishments this empirical observation certainly deserves further exploration both in germany and elsewhere past research found that educational sorting was not associated with rising between establishment inequalities for west german men 4 in contrast we find that shifts in the educational composition of workplaces are associated with both rising between and within workplace inequalities although effect sizes were consistently smaller than occupational skill effects we saw in table 2 that the degree of educational segregation between establishments grew by 30 substantially faster than between workplace skill segregation since occupational skill and educational sorting are the demand and supply side of the same coin we see these results as consistent with the fissuring expectations but we cannot from these analyses adjudicate between educational or occupational structure segregation as the primary driver of rising between workplace inequality an additional strong empirical result has to do with the gender composition of the workforce rising female employment is associated with lower mean workplace earnings net of individual and occupational skill levels but since female employment levels do not change much over the observation period and between workplace gender segregation actually declines this cannot be a major driver of rising inequality between establishments in contrast to gender citizenship composition while statistically significant had very small effect sizes this is consistent with prior work that shows that citizenship is a weak status distinction in german workplaces 36 conclusions the fundamental contribution of this paper is to redirect research on growing national inequalities towards observing the firm level processes that generate market income distributions about twothirds of germanys rapid growth in income inequality was produced by increased between workplace earnings inequalities this pointedly underlines the importance of organizational wage polarization as an emergent inequality generating phenomena our past research 6 has shown that this pattern is not confined to germany but exists in twelve of fourteen highincome countries examined this research confirms that in germany that a variety of organizational factorsindustry wage polarization the birth of new low wage workplaces occupational restructuring and the rise of labor market dualizationcontribute to rising inequality both between and within workplaces in germany we see the results in this paper as offering confirmation of predictions from literatures on employment 422 and union bargaining 24 dualization and on workplace fissuring 7 while there is good evidence that german establishments are becoming more skill homogenous and that this drives between workplace inequality the suspicion that this leads to lower internal inequalities must be rejected internal inequalities are strongly exaggerated in low and high wage establishments and in establishments that restructure toward high and low wage divisions of labor we also found two sets of results that led us to reject hypotheses inequality is higher and rising in both declining and rising wage workplaces we also find that new firms tend to have higher internal inequalities net of internal divisions of labor industry and status composition together these two sets of results suggest that dynamic tendencies are toward more internal firm inequalities clearly change whether the birth of new firms or changes in firm pay levels is empirically consistent with rising internal workplace inequalities what the mechanisms are behind these dynamics is not at all apparent and deserves further theorization and empirical investigation we have only scratched the surface of these processes future research should further explore both organizational and institutional mechanisms including those that we do not observe in this paper such as the role of firm market power in both generating high wage jobs and creating a fissured economy the role of outsourcing independent contracting global supply chains franchising and other strategies to externalize production while capturing economic profits should be examined as well why both high and low earnings workplaces are also high inequality is a finding in search of an explanation we do not expect any universal pattern to be discovered in future research but rather that more proximate mechanisms will be more or less prominent in different institutional and historical settings 26 more generally however we see these two sets of global mechanisms as linked declining organized worker power makes it easier for firms to pursue externalization of labor while that strategy further weakens collective labor organization see 37 for this argument applied to germany this paper focuses on the variance in logged earnings analyzed separately as between and within workplace components while this is standard in the literature on firm wage effects 4 5 6 8 9 10 it prioritizes inequalities around and below the mean future research might pursue a more distributional approach either calculating wage ratios or moving to a quantile regression framework at a more theoretical level this paper confirms the utility of exploring organizational wage setting processes a focus that is now emerging in economics sociology and organizational sciences 1 2 3 the paper also shows that a singular focus on traditional human capital explanations of both workplace inequality levels and change is much too narrow explanations need to be developed within a more organizationally focused analyses of the division of labor which admit the potential impact of gender and other status processes the birth and death of establishments with different inequality profiles and the institutional contexts in which they operate 23 24 25 26 this study used thirdparty data which are highly confidential under german law data are available from the german federal employment agency and provided by the institute of employment research to researchers who meet the criteria for access to confidential data access to the data is available under licence through the german institute for employment research this data and similar data sets are available for scientific analysis upon filing an application deenfdzdataaccessfdzscientificusefiles aspx apply the authors did not have any special access to this data supporting information s1 file imputation strategy for top coded income data curation silvia maja melzer formal analysis silvia maja melzer

germany has experienced sharply rising earnings inequalities both between and within workplaces working from prior literature on rising employment dualization and the fissuring of workplaces into high and low wage employers we explore a set of organizational explanations for rising between and within workplace inequality focusing on the role of employment dualization skill segregationcomplexity and firm fissuring we describe and model these hypothesized processes with administrative data on a large random sample panel of german workplaces we find that rising inequalities are associated with polarization in industrial wage rates and the birth of new low wage workplaces as well as increased establishment skill specialization and the growth of parttime jobs in workplace divisions of labor we conclude with recommendations for future research that directly examines more proximate mechanisms and their relative importance in different institutional contexts

introduction appearing in the middle of the twenties century sociolinguistics is regarded as one of the branches of the modern linguistics and it studies the language in the context of society as well as social factors analyzing the works of prominent scholars such as lyons j and hudson ra one may assume that language is evolved formed and may be disappeared in the society also each lexical unit of that very language is the indicator of the life of a certain language community from this point of view professional names are considered to be the most flexible elements of the evolving language the main results and findings names of professions their linguistic as well as extralinguistic characteristics have been discussed by scholars such as jespersen o labov w and others but from the sociolinguistic point of view they have not been sufficiently studied yet many scientists believe that the names of professions highlight the historical picture of the formation and development of individual thematic groups the evolution of which is manifested in the emergence of new business and industry terminological systems and is reflected in the replenishment of the modern english vocabulary random choice of examples of job names demonstrate the variety of the structural etymological and derivational features based on their object of activity and the way of doing the activity professional names are combined into two subgroups names of professions related to the production of something including the names of specialists who carry out a stepbystep process of manufacturing any materials in order to obtain a finished product or part of it construction of buildings and structures breeding of animals plants for the purpose of food production architect farmer woodworker welder chef faller animal breeder butcher meat cutter fabricators etc names of professions related to the maintenance of something or someone containing the names of persons who are professionally engaged in ensuring the functioning of equipment devices structures processes carry out the operation repair of something interaction with other employees as well as the provision of various services to the public clergy marriage therapist barbers animal trainer childcare worker archivists teachers trainers curators etc social factors play great role in subgrouping the names of the professions these processes are determined by the sociocultural vectors of social development confirming the idea that it is the social factor that determines a set of cognitive entities representing a set of knowledge about the surrounding world and the features of its functioning the connection of language with the peculiarities of the development of society is expressed in the formation of new lexical layers the above statement implies the title of this article the purpose of which is to demonstrate the projection of the sociolinguistic factor on the processes of emergence acquisition and updating of the industry term system the relevance of the article is due to the increased scientific interest in research in the field of industry linguistics in recent years and the need to study professional languages in order to develop the theoretical foundations of their functioning in a special field today the constantly changing economic situation leads to a new reality which in turn becomes a referential intermediary building a phenomenal duality assuming on the one hand the transformation or complete disappearance of one sphere of human activity and on the other hand the emergence as well as rapid development of new areas the latter fact naturally becomes a catalyst and an extralinguistic determinant influencing the development of the language system the world of professional work is constantly changing but this is happening especially rapidly in the xxxxi centuries and if earlier centuries passed before new types of professional labor activity appeared requiring all new designations then in the xxxxi centuries changes in the content of labor activity occur in several decades and sometimes even in a short time interval of several years and following the dynamic changes in professional activity lexical units related to the names of persons by profession are also rapidly changing so using the examples presented below one can observe the changes that have occurred in the field of professional titles in the english language in the xxxxi centuries augmented reality manager talent manager data detective and etc it should be noted that a relatively small number of lexical nominations pass into the category of archaisms while much more neologisms appear regarding the names of professions in a certain sector this imbalance is caused by the rapid development of production scientific and technical sphere sociopolitical changes in the life of people as well as cultural relations with other countries around the world which result in the emergence of numerous neologisms scientific and technical information and computer technologies the internet and telecommunications have rapidly burst into the life of modern man with their development numerous new names have appeared related to working on a computer computer programs the concept of virtual space unity developer vr game engineer mixed reality artist technical 3d artist etc most of the neologismsborrowings from the english language are components in the composition of complex nouns such a change in content and structure is probably related to the global process of cognitive complication of both the picture of the world and the ways of its cognition however the scholar mcmahon stresses that it does not happen deliberately we should never lose sight of the fact that languages are spoken by people for purposes of communication consequently speakers change languages although that is not to say that they are necessarily conscious of doing so or that they intend to make changes modern society is developing rapidly and consequently the lexical system of the language is in constant motion which is the most sensitive among other subsystems of the language to social changes representing an open class of lexical units the names of persons by profession are subject to constant quantitative and qualitative changes that occur over time under the influence of numerous external factors some lexical units come into the language together with new or borrowed objects and phenomena others on the contrary begin to be used less often and gradually disappear from linguistic use thus reflecting the laws of the existence of human society and its culture the stability or on the contrary the shortlived nature of these lexical units is different but at the time of their appearance and use by society they more or less reflect the nature of the changed situation for example today we do not come across with the names of professions such as mirshab qushbegi muftiy pattachi as they have disappeared or replaced by other words conclusion in conclusion a comprehensive study of profession names will allow on the one hand to penetrate deeper into the social factors that have effect on the evolution of lexical systems and on the other to predict tendencies in the development of subsystems of professional names from the point of view of linguistic and sociolinguistic approaches

the article discusses the professional names from the point of view of sociolinguistics in the article subgroups of naming professions are given due to the requirements of the language community social factors are taken as the main cause of the appearance and the disappearance of the professional nameskalit sozlar sotsiolingvistika ijtimoiy omillar kasb nomlari arxaizmlar neologizmlar leksik birliklar annotatsiya maqolada professional nomlar sotsiolingvistika nuqtai nazaridan muhokama qilinadi maqolada til jamoasining talablaridan kelib chiqib kasbhunar nomlarining kichik guruhlari berilgan kasbiy nomlarning paydo bolishi va yoq bolib ketishining asosiy sababi sifatida ijtimoiy omillar olinadi лингвистические и социолингвистические характеристики названий профессий в контексте шахноза темирходжаева студент магистратуры узбекский государственный университет мировых языков ташкент узбекистан

introduction indonesia is a vast country and is a legal state of national development which covers all aspects of the life of society nation and state with the aim of creating a just society the law defines what must be done and what cannot be done the legal targets to be aimed at are not only people who actually act against the law but also actions that might occur and to the state apparatus to act according to the law such a legal system is a form of law enforcement laws created by humans have the goal of creating an orderly safe and orderly situation likewise criminal law which is one of the laws made by humans the law exists because of circumstances where a person wants to feel legal protection and is entitled to a comfortable and peaceful living environment because that is a form of human rights that exist in this country which is guaranteed enforced to all correctional inmates in correctional institutions with the aim of disciplinary punishment as a form of administrative sanction to improve and educate correctional inmates who commit disciplinary violations law enforcement is needed in handling violations of disciplinary regulations for correctional families in practice the procedures for implementing administrative sanctions for inmates of corrective correctional centers are focused on correctional officers who must be obliged to reexamine inmates in accordance with the flow of the mechanism for disciplinary violations with the aim of finding out the violations that have been committed in this case the sense of justice and security in the correctional cell takes precedence if a prisoner has committed an offense before then the officer will provide appropriate sanctions and of course the sanctions given will be heavier than the disciplinary punishment ever imposed on him but only sentenced to only one sentence compliance with the rules that apply in prisons and state prisons is one of the indicators in determining the criteria for good behavior towards convicts and detainees when a sentence has been imposed in accordance with the existing criminal justice system in indonesia a person who has been deemed guilty through the criminal justice process and has been legally and convincingly proven to have committed a crime must carry out his sentence or sentence in a correctional institution or often referred to as lapas where in this case correctional institutions function as a place for someone who has been found guilty in criminal law which is commonly called a convict to serve his sentence in a correctional institution or often called a correctional institution apart from being a place to serve punishment the function of a correctional institution is a place to provide guidance for inmates so that they become good human beings better and no longer repeat their mistakes because after all the inmates are human beings who deserve to be respected and treated according to human dignity and even though they have made mistakes it is precisely in this place that they are fostered to become better human beings for the betterment of this nation in this case prisons have a very important role where prisons have a role to provide guidance for their assisted citizens issn print 20866852 and issn online 25985892 penitentiary is a place to provide guidance to convicts in indonesia correctional institutions known as prisons are established in every capital city regency or city where the guidance is carried out on convicts penitentiary is one of the components in the criminal justice system in indonesia which is tasked with carrying out coaching for inmates as a form of crime prevention efforts and is the end of criminal justice according to paf lamintang imprisonment is a crime in the form of limiting the freedom of movement of a convict which is carried out by closing the person in a correctional institution by requiring that person to comply with all the disciplinary regulations in force in the correctional institution which are associated with an disciplinary action for those who have broken the rules barda nawawi arief also explained that the effect of the prison sentence was not only the loss of independence but also had negative consequences for things related to the deprivation of independence itself among convicts not only that but also gives a stigma to society and results in degradation lowering of dignity and selfesteem in essence as mentioned above correctional institutions are places where convicts are placed so that they can be accepted back into society in a good and conscious way so that they can be of use to themselves their families society home and nation however in reality there are still many convicts who remain inside and outside the penitentiary and it is not uncommon for inmates to commit violations or fraud in correctional institutions both against wardens and inmates such as fighting hunting killing buying and selling drugs thinking about the function of punishment is not just an aspect of prison but is a rehabilitation and social reintegration of correctional families which is called the correctional system the function of punishment itself is to prevent the commission of criminal acts by enforcing legal norms for the protection of society socializing convicts by providing issn print 20866852 and issn online 25985892 guidance to become good and useful people resolving conflicts caused by criminal acts improving the quality of correctional assisted residents to realize mistakes correct themselves and not repeating criminal acts so that they are accepted again by the community play an active role in development and live normally as good and responsible citizens law enforcement is needed in handling violations of disciplinary regulations for correctional families the purpose of disciplinary punishment as a form of administrative sanction is to improve and educate correctional inmates who commit disciplinary violations therefore every correctional officer who has the authority to punish must first thoroughly examine correctional inmates who commit disciplinary violations penitentiary inmates must also obey the rules and regulations that must be maintained while living in the penitentiary disciplinary punishment is a punishment imposed on convicts or detainees as a result of committing an act that is considered to violate the rules of a correctional institution or detention center violations committed by correctional families are in the category of serious disciplinary violations which are punishable by exile for a period of 6 days and can be extended for a maximum period of 2 x 6 days as well as being revoked rights such as not getting remissions leave before release visitation rights assimilation and parole the imposition of disciplinary punishment is given to prisoners who are proven to have violated the rules of the lapas order in this case the prisoners who are suspected of violating the order must be subjected to an initial examination by the head of security before being sentenced to disciplinary punishment however prior to being sentenced to disciplinary punishment convicts may be subject to disciplinary action the disciplinary action itself is in the form of temporary placement in an exile cell for a maximum period of 6 days in accordance with the provisions of article 15 of regulation of the minister of law and human rights number 6 of 2013 when a correctional familie who under his guidance violates lapas rules which is already in the process of being examined by the head of security it has been proven that the inmate has indeed violated the rules the head of lapas has the authority to impose disciplinary punishment on correctional assisted citizens who violate lapas security and order regulations which he leads it is very easy to say about the development of strong and evenly distributed laws throughout society but it cannot be denied that in the process of developing strong laws there are still many obstacles the community is frustrated with this situation the existing human rights seem unable to help them situations like this make people have no other way out so they commit crimes that have an impact on the inclusion of these people in correctional institutions in principle all convicts who are serving a sentence lose their independence after being decided by a court decision which has permanent legal force and then the convict is placed in a correctional institution as a convict and there he is processed again according to applicable law so that later he can return to living in society this is in accordance with the purpose of criminal law itself namely to fulfill a sense of justice in society by implementing and enforcing the rules of criminal law for the sake of creating justice benefit and legal certainty the imposition of a sentence on a person by placing him in a correctional institution basically sees that punishment is a tool to uphold order in society criminal is a tool to prevent the occurrence of a crime with the aim that the social order is maintained so that by being put in a correctional institution in fact there are many obstacles in this institution such as the deplorable conditions of the penitentiary and also the constraints of the inmates themselves who do not comply with the applicable rules even though the coaching is carried out for the benefit of the inmates themselves so that the mandate of article 2 of law number 22 the year 2022 regarding corrections can be implemented namely providing guarantees for the protection of the rights of prisoners and children improve the quality of personality and selfreliance of inmates so that they are aware of mistakes improve themselves and not repeat criminal acts so that they can be accepted again by the community can live normally as good citizens obey the law are responsible and can play an active role in development and provide protection to the public from repetition of criminal acts in general crime can be interpreted as a form of suffering that is intentionally imposedcaused by the state against a person or people under the law because his actions violate the prohibition of criminal law specifically this prohibition in criminal law is considered a crime the application of discipline to convicts who are in correctional institutions is based on the applicable regulations namely regulation of the minister of law and human rights number 6 of 2013 concerning rules of correctional institutions and state detention centers the provision of disciplinary punishment to convicts is based on the fact that convicts violate the rules of conduct that apply in correctional institutions so that in order to restore the convicts condition so that they return to good and orderly conditions punishment is given in the form of disciplinary punishment for a maximum of 6 days and postpone or abolish certain rights within a certain period of time based on the results of the tpp trial jurnal wacana hukum dan sains universitas merdeka surabaya this work is licensed under a creative commons in the case of imposing disciplinary punishment if a convict violates the rules the convict will first be examined by the head of security then the results of the initial examination will be submitted to the head of the detention center or head of the prison for further examination in subsequent inspections the head of detention center or head of correctional institution forms an examining team to examine the results of the initial examination this examining team is tasked with examining detainees or convicts who are suspected of violating the rules the results of the examination are then set forth in the minutes of examination detainees or convicts are given the opportunity to read the minutes of the examination before the convict signs the minutes issn print 20866852 and issn online 25985892 prior to being sentenced to disciplinary punishment convicts or detainees may be subject to disciplinary action namely in the form of placement in solitary confinement for a maximum period of 6 days security and control is an absolute requirement for the implementation of coaching programs in every penitentiary therefore a safe and orderly atmosphere is always conditioned by various strategic means of monitoring preventing and preventing as early as possible disturbances to security and order that arise both inside and outside the penitentiary therefore the correctional institution officers must supervise the prisoners so that there are no violations of the correctional institution rules in an effort to create conditions for correctional institutions that are safe and orderly security measures are carried out based on the principle that prevention is better than taking action security officers detect every symptom as early as possible that causes disturbances to security and order if in a penitentiary there is a disturbance of security and order the security officers will immediately take steps to protect it by trying to stop the incident of disturbance of security and order disciplinary punishment is a form of enforcing discipline for convicts who commit disciplinary violations therefore a safe and orderly atmosphere in penitentiary needs to be created however to ensure the orderly implementation of life in correctional institutions it is necessary to have rules that must be obeyed along with a mechanism for imposing disciplinary punishment by every prisoner the role of disciplinary punishment in the surabaya class i penitentiary is very important because it is not only to create a sense of security and order in the correctional institutiondetention but also so that every convict can obey and comply with every obligation and prohibition in the surabaya class i penitentiary as for the obligations that must be obeyed by through the rules regarding obligations for convicts themselves it cannot guarantee that anything that is clearly obligatory for convicts to obey is actually violated or difficult to implement so this is where it is necessary to have restrictions or prohibitions that convicts may not do and must comply with every prohibition in class i penitentiary in surabaya of the many obligations and prohibitions regarding rules that must be obeyed and obeyed by every convict it cannot guarantee that the inmates who have been fostered will definitely obey the rules and not commit crimes again the problems that often arise are caused by the convicts the application of disciplinary punishment should be a deterrent effect for convicts who commit violations so they dont violate the order again but the reality cannot stop convicts from continuing to commit violations and carry out severe penalties because of mistakes that have been made in prison the theory used in the surabaya class i correctional institution for the imposition of sanctions used is the imposition of administrative fines because it is not only a reaction to a violation of norms that is aimed at adding a definite sentence but also a mandatory one research method the type of research in this study is sociological juridical legal research namely research based on literature studies which include primary legal materials and secondary legal materials primary legal materials are carried out by reviewing laws and regulations related to the legal issues being studied and secondary legal materials in the form of books journals and documents as well as related studies related to the titles that have been determined by the author case approach the legal approach is carried out by identifying and discussing the applicable laws and regulations which are related to the problems in this study results and discussion activities of prisoners while they are in class i penitentiary in surabaya in surabaya class i penitentiary every convict gets his rights because rights must be obtained by every convict these rights are regulated in article 9 of law number 22 of 2022 activities of prisoners in correctional institutions vary ranging from the fields of religion education skills and sports activities in surabaya class i penitentiary include religious field in this religious field every prisoner can worship according to their respective religions starting from islam christianity and hinduism places of worship in surabaya class i lapas can be classified as proper places of worship and it can be said that every believer of a religion can carry out his worship comfortably and peacefully for convicts who are muslim there are many religious activities that can be participated in to fill the time while serving their sentence activities for islamic religious convicts include religious teachings reading and writing the koran banjari this activity is carried out in the morning and evening according to the schedule of each activity 302 issn print 20866852 and issn online 25985892 and for nonmuslim prisoners they can also worship properly because in surabaya class i prison there is a church that is very suitable for worship so convicts can worship without thinking about a place to worship education field the field of education both within prisons and in the world is very important therefore established for the education of prisoners the teachers were also brought in from outside so that the quality of education in the prison was also in accordance with the education in the community skill field every human being must have their own talents and skills and also have expertise from that basis the surabaya class i prison provides a place or place for its inmates to channel their skills including of the many places or containers each convict may or has the right to choose according to his respective field or for inmates who want to have skills that previously did not exist at all they can learn and later when they return to society they can become human beings who are useful for other communities agriculture and farming the class i penitentiary in surabaya has a large area starting from the building and land used in class i lapas surabaya there is land used for farming and gardening this activity is under the auspices of bimker or work guidance so every convict who really likes farming and gardening can distribute or carry out activities on the agricultural land and plantations that have been provided by communicating with bimker issn print 20866852 and issn online 25985892 sport is an activity that almost every human being likes because sport besides being entertainment for oneself also functions for human health itself maybe from that basis the surabaya class i prison appreciates in the field of coaching especially in the field of sports this appreciation is shown by the existence of sports venues in the prison these sports venues include what is meant by a violation of punishment is an action that is carried out in violation of the rules or against the rules that apply in a correctional institution and detention center the punishment referred to is the laws and regulations that regulate the security and order of prisons and detention centers namely permenkumham number 6 of 2013 which contains rights and obligations as well as rules of procedure prohibiting prisoners assisted by prisons and detention centers issn print 20866852 and issn online 25985892 there are several actions that are considered as disciplinary violations in the surabaya class i penitentiary seen from the form of violations divided into three levels namely minor disciplinary violations moderate disciplinary violations and severe disciplinary violations the types of violations can be classified based on levels which will be explained in detail as follows 1 minor disciplinary violations in the form of e repeatedly commits acts that fall into the category of minor disciplinary punishments more than once f doing actions that are based on tpp meetings are included in actions that can be subject to mediumlevel disciplinary punishment p repeated acts that fall under the category of mild disciplinary punishment q doing actions that are based on the consideration of the tpp meeting is included in actions that can be subject to severe disciplinary punishment from the description of the levels and types of disciplinary violations above there are several serious disciplinary violations namely 1 attempted murder 2 using electronic communication devices 3 consuming narcotics 4 gambling 5 unrest escape from prison for inmates who commit acts of violation above severe disciplinary punishment is imposed by surabaya class i penitentiary officers based on a decision letter from the results of the tpp trial the tpp trial that was held at the surabaya class i it can be classified that there are several types of punishment that can be imposed on inmates who violate the disciplinary rules of the correctional institution according to the type of level of violation committed namely light violations will be subject to light disciplinary punishment moderate disciplinary violations will be subject to moderate disciplinary punishment and serious disciplinary violations will be subject to severe disciplinary punishment with the legal details as follows 1 light level disciplinary punishment including a give a verbal warning b give a written warning register book f is a book to record violations of the rules and regulations of a convict and detainee with the aim that the convict is registered as a convict who may not receive remission in the current year or the following year in contrast to its implementation in the surabaya class i penitentiary severe disciplinary punishment is imposed on inmates who commit gross violations during the period of exile decided at the tpp session exceeding the period of exile stated in permenkumham article 9 paragraph based on an interview with mr ari prasetiono se kplp staff it is known that the period of exile sentences imposed for convicts exceeds the 2x6 period of exile in the surabaya class i correctional institution the punishments applied to convicts who commit serious disciplinary violations are punished with exile with a term according to the decision of the tpp trial results and the penalty for revocation of rights is also added besides not getting remission not getting family visits conditional leave assimilation leave before release and parole in the current year and the following year the inmate also lacks the amount of clothing and food menu if the prisoner has not changed during the exile period the penitentiary officer will add to the sentence until the prisoner shows a change in attitude and good behavior specifically positioned to supervise the inmates in the isolation isolation room but officers always control what activities are carried out by the inmates while in the isolation room every decision that has been made has been considered to the fullest extent possible this is because the class i penitentiary in surabaya places convicts sentenced to exile in an isolation room that is not cell staff the seclusion room facility provided is an ordinary residential block room even though the room is located separately from the residential block of correctional inmates and the room is specifically for a quota of one person but the condition of the room is not closed which is cell staff so the punishment imposed beyond the time period specified in the permenkumham with the aim of creating a deterrent effect for the inmates so that they do not repeat the violation and become preventive as a precaution so that other inmates are not provoked and motivated to commit violations too any punishment given to people who violate rule of law prior to the implementation of the addition of severe disciplinary punishment every year the number of prisoners who committed a large number of violations with various types of violations as mentioned above committed violations both minor moderate and serious level its just that some of them have been provoked by the inmates who have just moved to commit violations and only a small number of the old inmates have repeated the violations they committed caught redhanded by the guard of the residential block for prisoners who commit repeated violations they are subject to the severe disciplinary punishment that applies at the class i penitentiary in surabaya by the head of the tpp session the sentence imposed can be adjusted according to the number of times the prisoner repeats the violation if after adding a severe level of disciplinary punishment the convict continues to commit repeated violations the prisoner is recorded in the transfer expedition book and then transferred to another correctional institution because they are considered cannot be fostered by the guidance that applies in the surabaya class i correctional institution and is unable to adapt to the surabaya class i penitentiary environment so the head of the special tpp session adopts a policy so that the assisted citizen is transferred to another correctional institution outside the surabaya class i penitentiary the application of disciplinary punishment is a form of coaching in the surabaya class i penitentiary for inmates who violate the rules conclusion the in carrying out the application of disciplinary punishment by officers to inmates at the surabaya class i penitentiary it has been carried out as it should because the number of disciplinary violations has decreased from the previous year the application of disciplinary punishment has been effective in reducing disciplinary violations that occurred in the surabaya

the implementation of disciplinary punishment for convicts who violate the order is based on minister of law and human rights regulation no 6 of 2013 concerning rules of correctional institutions and state detention houses in relation to convict development studies in class i correctional institutions in surabaya the approach method used in this research is a juridicalsociological approach from the results of this thesis research it is concluded that administrative sanctions for correctional families violate article 4 of the regulation of the minister of law and human rights of the republic of indonesia number 6 of 2013 namely violations in the form of minor violations moderate violations and serious violations applied to all correctional inmates in correctional institutions with the aim of disciplinary punishment as a form of administrative sanction to improve and educate correctional inmates who commit disciplinary violations law enforcement is needed in handling violations of disciplinary regulations for correctional families in practice the procedures for implementing administrative sanctions for inmates of corrective correctional centers are focused on correctional officers who must be obliged to reexamine inmates in accordance with the flow of the mechanism for disciplinary violations with the aim of finding out the violations that have been committed in this case the sense of justice and security in the correctional cell takes precedence if a prisoner has committed an offense before then the officer will provide appropriate sanctions and of course the sanctions given will be heavier than the disciplinary punishment ever imposed on him but only only one sentence

introduction basically every human being in his life will face risks the risks every human faces are not the same but these risks can threaten life or property one of the mental risks faced by every human being is the possibility of getting sick where risk is uncertainty that can lead to gains or losses in relation to insurance what is meant by risk is the risk that can cause defeat humans are expected to be able to manage risks one of them is the risk of getting illness one way to overcome the risk of getting sick is with health insurance because the purpose of health insurance is to transfer the risk of illness from the insured to the insurer where the insured is the party that transfers the risk while the insurer is the party that accepts the transfer of risk namely the insurance company health is very important for humans because with healthy conditions humans can carry out their activities properly with the population of a nation whose health is well maintained the nation will have optimal human resources in development law number 36 of 2009 concerning health explains that the indonesian government is fully responsible for fulfilling the right to a healthy life for every citizen including the poor and disadvantaged responsibility government including the component of providing health services that are easy inexpensive and accessible to all people in need because of that health development is one of the governments work targets in health development everyone will be aware have the ability and willingness to improve the degree of health based on the national medium term development plan for health the government started by increasing access and quality of health services to achieve this target the government provides health insurance for all citizens countries especially the poor the badan pusat statistik report shows that 68 out of 100 residents in indonesia have health insurance in 2021 the percentage reached 6836 last year the majority of indonesias population has health insurance in the form of bpjs health pbi in 2021 health insurance provided to recipients of this contribution assistance was owned by 3846 of indonesias population in 2020 health insurance developed in indonesia is part of the national social security system which is administered using compulsory social health insurance mechanism based on the law on the national social security system article 19 paragraph of 2004 the national health insurance is organized on the principle of mutual cooperation participation is mandatory contributions are based on a percentage of wages and are carried out on a nonprofit principle that has an impact on the communitys economy society does not need to pay high costs for health and can be used for other needs methodology in writing scientific papers this time research uses library research systematic review with a database search strategy using google scholar this database search uses several related keywords namely community concern health insurance and willingness to have health insurance papers selected to be used as the database for writing scientific papers are written in indonesian and english with a maximum issuance period of 5 years the selected papers are ensured to have complete relevant text with the topic discussed and an international standard serial number to guarantee the quality and quality of the content of the written work the criteria selected for the writing of this scientific paper is the implementation of human resources specifically for health facilities meanwhile papers that are not included in the criteria usually have a time of publication older than 5 years do not have a complete text and do not have an issn number the author uses the prisma systematic review method which includes identification screening inclusion and eligibility based on the findings of the paper which are then analyzed papers that meet the criteria will be analyzed so that data related to the level of public awareness of the importance of having health insurance can be obtained the presentation used for all findings regarding the level of public awareness of the importance of having health insurance uses narrative paragraphs after data regarding the level of public awareness of the importance of having health insurance is obtained conclusions will be drawn based on the results of this data the level of communitys sense of importance in ownership of health insurance results and discussion results discussion one of the indonesian health insurance institutions the social security administrator in indonesia known as badan penyelenggara jaminan sosial wants to expand jkn membership throughout indonesia encourage community participation and strengthen compliance through improvement efforts to encourage public participation to achieve universal health coverage require all indonesian citizens to be registered as jkn participants therefore to ensure that all indonesian citizens are registered as jkn participants and become jkn holders all sectors ranging from health insurance companies health services regional governments and city governments are encouraged to participate and work together in supporting all indonesian citizens to be registered as a jkn participant with proof of card ownership the level of communitys sense of importance in ownership of health insurance depending on several factors including age education and knowledge economic status and social factors age health insurance ownership is partially influenced by age as it is closely related with an individuals susceptibility to illness the risk of falling sick particularly with degenerative diseases tends to increase as one gets older a previous study in china also informed similar findings indicating that advancing age is linked to a higher risk of experiencing illness the health challenges that people encounter are becoming more complicated as their life expectancy rises the the level of communitys sense of importance in ownership of health insurance tendency for degenerative diseases is growing as the number of senior individuals grows education and knowledge education was the most dominant variable in 2019 and 2020 the analysis from results shows that the higher level of education the higher probability someone to have health insurance how education and knowledge can play a role such as understanding the importance education may help someone to understand the importance of health insurance in managing healthcare costs and accessing necessary medical services with knowledge about the potential risks associated with healthcare more likely to recognize the need for insurance coverage to protect themselves and their families awareness education can help someone become aware of the different types of health insurance plans available including employer provided plans government programs and individual market options understanding the various options empowers individuals to make informed decisions about the type of coverage that best suits their needs health literacy health insurance involves navigating complex terms and coverage details with higher levels of education someone may have better health literacy skills enabling them to comprehend insurance policies and make informed choices regarding the coverage furthermore low knowledge of public on health insurance is what causes someone to not take part in health insurance economic status the most dominant variable in 2018 was per capita expenditure income is one of the important factors influencing consumer demand for goods and services the higher individual income will present the amount of individual budget for consumption the higher of income the greater individual budget for having any health insurance its easier for someone to spend money on other needs such as improving quality conclusion it can be concluded from various literature results that we found that the urgency of having health insurance is very important for the community to have bearing in mind basically human nature cannot be separated from the risks that will be faced in his life both risks that can lead to gains and losses there is also one risk that causes losses namely the possibility of getting sick of course under these conditions it cannot be denied that these losses are life threatening therefore there are various things that must be learned and understood from the importance of health insurance for the community through a program provided by the government namely the national health insurance the main benefit for the community is to have a sense of ownership of the program to get health insurance in the form of health services both medically and nonmedically so that it is hoped that the community can be more massive in its productivity in order to improve welfare thanks to we would like to thanks apt riswandy wasir phd and arga buntara skm mph as the lecturers for public health english course who have provided guidance the level of communitys sense of importance in ownership of health insurance

humans are expected to be able to manage risks one of them is the risk of getting illness one way to overcome the risk of getting sick is with health insurance health insurance developed in indonesia is part of the national social security system which is administered using a compulsory social health insurance mechanism society does not need to pay high costs for health and can be used for other needs in writing scientific papers this time research uses library research systematic review with a database search using google scholar papers selected to be used as the database for writing scientific papers are written in indonesian and english with a maximum issuance period of 5 years complete relevant text with the topic discussed and an international standard serial number issn one of the indonesian health insurance institutions the social security administrator in indonesia bpjs wants to expand jkn membership throughout indonesia however the level of a communitys sense of importance in ownership of health insurance depends on several factors including age education and knowledge economic status and social factors there are various things that must be learned and understood from the importance of health insurance for the community through a program provided by the government namely the national health insurance jkn the main benefit for the community is to have a sense of ownership of the program to get health insurance in the form of health services both medically and nonmedically

open access injections and use of pills as other birth control methods genderbased violence especially amongst female students is a particular concern as some of them are dating older men evidence shows that they are unable to negotiate condom use because their male partners are older and tend to have many casual partners south africa has responded through numerous interventions including condom distribution programmes and hiv education there have also been a number of wellpublicised hiv awareness campaigns using a variety of media including khomanani love life soul city and soul buddy the 2012 national communication survey on hivaids evaluated these national campaigns and found that they were having a positive effect particularly on students aged 1524 years with an increase in condom usage hiv testing counselling and male circumcision however research interventions which included large trials have shown mixed results with regard to the reduction of risk behaviour students aged 1524 years in south africa continue to have poor health outcomes because of their highrisk behaviour there is an urgent need to find interventions that may prevent and reduce youth risk behaviour we thus developed implemented and evaluated a contextbased behavioural riskreduction intervention in umgungundlovu district municipality kwazulunatal province aimed at reducing risky sexual behaviour use of alcohol and other drugs and violence enacted by learners purpose of the research the purpose of this study was to assess the effects of a behavioural riskreduction intervention on sexual risk behaviours substance abuse and violencerelated behaviours of grade 10 learners assigned to receive a behavioural youth riskreduction intervention compared to those who did not receive such an intervention methods the study was conducted in 16 public coeducational high schools in umgungundlovu district municipality south africa from 2014 to 2015 this district comprises seven local municipalities six of which were selected the office of the premier of kwazulunatal requested to exclude msunduzi local municipality as it felt that the said municipality was already saturated with projects we invited high schools to participate in the behavioural riskreduction trial only public high schools were eligible because of the existence of the operation sukuma sakhe facilitators and we randomly selected 16 of the 45 high public schools in the district to ensure comparability of intervention and control groups schools were stratified and pairs of schools were randomly selected from the same stratum one randomly allocated to intervention and another to control sample size owing to financial constraints this study focused only on grade 10 learners the sample size of 2000 grade 10 students from 16 schools was calculated to detect a 19 reduction in the proportion of students engaging in risky behaviours between intervention and control groups we set a study power of 80 and a significance of 95 probability a design effect of 7 was included in the calculation to account for the randomised clustered design of the trial instrumentation a questionnaire based on the sayrbs comprising the following variables was used and piloted prior to being completed by the learners demographic profile violencerelated behaviours substance abuse sexualrelated behaviours circumcision hiv and aids a pilot study was conducted amongst grade 10 learners in schools which did not form part of the main study and 22 learners completed the questionnaires demographic profile these questions comprised age sex living arrangements and information about the head of the household to investigate the risk behaviour of participants the sayrbs was used the sayrbs is a schoolbased survey used to monitor priority health risk behaviours that contribute to the leading causes of death disability and social problems amongst youth violencerelated behaviours these were adapted from the sayrbs the measures of whether students carried a weapon and a gun were as follows during the past 30 days how many days did you carry a weapon such as a gun knife or club on school property and during the past 30 days on how many days did you carry a gun these were scored as 0 no days 1 12 days and 2 34 days substance abuse the measures of cigarette alcohol and marijuana use were limited to the past one month time frequency and quantity were measured questions included were as follows on how many days did you smoke a cigarette how many cigarettes did you smoke on an average per day how often in the past one month did you have at least one drink of alcohol how often in the past one month did you have five or more drinks of alcohol how many number of drinks did you have in a row and how many times did you smoke marijuana on average per day the questionnaire used the local term dagga instead of marijuana sexualrelated behaviours having highrisk sexual intercourse was measured by the following two items did you drink alcohol or use drugs before you had sexual intercourse the last time you were having sex and did you or your partner use a condom during sexual intercourse the last time the following questions were added at the followup after 4 months in order to investigate the effectiveness of the then current hiv testing campaign and circumcision for hiv and aids the questions were adapted from the sayrbs measures of hiv testing and perceptions and comprised the following have you ever been tested for hiv do you think you might be hivpositive when it comes to hiv do you feel you are circumcision having been circumcised was measured by the following item have you ever been circumcised hiv and aids the measures of hiv testing and perceptions comprised the following have you ever been tested for hiv do you think you might be hivpositive and when it comes to hiv do you feel you are procedures all 16 participating schools were allocated to the intervention and control groups using stratified random sampling general information sessions about the study were facilitated for the principals school governing bodies and all grade 10 students in all 16 high schools this process provided an opportunity for the recruitment of potential participants information sheets and informed consent forms were sent to parents or guardians of all grade 10 students and were collected before the actual enrolment process during enrolment all the learners who were willing to participate signed informed consent and assent forms this study was approved by the university of kwazulunatal ethics committee and the department of education gave permission to conduct the study in the school ethical issues such as confidentiality anonymity and voluntary participation were discussed with parents or guardians and students during the enrolment process all students in both arms of the intervention completed a baseline and followup survey 4 months after the intervention using a questionnaire that was completed in the classroom about five students did not participate because of the nonavailability of parental consents and there were no other refusals in this study intervention arm after each school completed enrolment and the baseline survey a behavioural riskreduction intervention was implemented if a school was in the intervention group two facilitators per school delivered sessions which took place during the life orientation periods the duration of the sessions lasted from 45 min to 1 h and comprised the following topics knowing yourself peer pressure decisionmaking healthy and unhealthy relationships contraceptives teenage pregnancy condom use hiv aids and sti prevention alcohol and drug abuse violence and genderbased violence child support grant human rights and responsibilities in sexual health the sessions were designed to include brainstorming group discussions roleplays reflections and demonstrations all the eight schools of intervention group agreed for two sessions per week and the intervention was implemented in all these schools within 2 months we assessed the process of implementation of the intervention by requesting that the facilitators record each session by giving students an attendance register to sign for each session control arm there was no intervention in the control schools they continued with their lo learning area which is a compulsory learning area for all learners attending public schools statistical analysis and evaluation we matched preand postquestionnaires by students identification the questionnaires were coded to ensure confidentiality we recorded question responses using the likert scale categorised into three groups no risk moderate risk and high risk at baseline the intervention effect was measured by the difference between learners responses on the pretest and posttest questions this difference was dichotomised into positive and negative behaviour a generalised estimating equation model was used to compare the groups this model adjusts for the possible correlation of students within schools and baseline characteristics such as age significance was set at p 005 for all the analyses we used stata 13 statistical software to analyse the data ethical consideration ethical approval to conduct the study was obtained from the university of kwazulunatals biomedical research ethics committee in south africa results and findings a total of 16 high schools and 1558 grade 10 learners participated in the trial with eight schools per group all were analysed at followup table 1 shows the characteristics of participants the ages of the learners ranged from 13 to 23 years the old age of some learners was a result of kwazulunatals policy not to exclude older learners from rural schools students from the intervention group were older than the control group male and female learners were equally represented more than onethird of learners were residing with their mothers and extended families whilst only 28 were living with both parents over half of the heads of the households had been to high school but surprisingly household heads in the control group were more likely to have posthigh school qualifications and be professionals table 2 shows the baseline prevalence of risk behaviour in intervention and control groups measures were confined to 30 days of the learners in the intervention group 115 carried a weapon and 61 carried a gun and in the control group 73 and 36 had carried a weapon and a gun respectively one third of the learners reported alcohol consumption with 13 in the intervention and 12 in the control groups reported having binge drinking of the learners in both groups 268 versus 220 reported smoking cigarettes and 126 versus 107 had smoked marijuana at least once in the past 1 month respectively a quarter of the sexually active learners 42 versus 34 reported drinking alcohol before having sex and 40 of the learners had not used a condom at their last sexual intercourse of the learners 60 in the intervention group and 51 in the control group reported testing for hiv in the past 1 month behavioural change there was a decrease of 11 between baseline and followup amongst the learners in the intervention group reporting carrying of a weapon during the previous 30 days compared to the 7 decrease in the control group although there was a decrease in the use of tobacco and alcohol in the intervention group this was not statistically significant the 10 decrease in the use of marijuana in the intervention group was similar to that in the control group similarly decrease in the open access use of alcohol before sex was similar to that of the control group condom use before sex increased substantially by 20 in the intervention compared to 17 in the control group but this was not statistically significant the odds of learners in the intervention group not carrying a weapon in the previous 30 days were one and a half times greater than that of those in the control group there was also a trend towards a reduction in carrying a gun there were no statistically significant differences between the groups for smoking alcohol consumption and binge drinking use of alcohol before sex decreased and use of condom at last sexual intercourse increased in both groups hiv andor aids and circumcision the prevalence of hiv testing by learners in the postsurvey was 530 for the intervention group and 433 for the control group although the results are not statistically significant we found that more learners in the intervention group compared to the control group reported having been newly tested for hiv after the intervention had been completed a similar finding was for the sexually active learners where 94 learners in the intervention group compared to 66 learners in the control group had tested for hiv but this was not statistically significant many of those learners who did not test for hiv did not perceive themselves to be at risk of hiv only 16 versus 19 of these learners perceived themselves to be at risk or somewhat at risk namely 21 in the intervention group versus 30 in the control group a number of learners perceived themselves not to be at risk but most learners of the intervention group and the control group were unsure whether they were at risk of contracting hiv circumcision to reduce hiv transmission the overall prevalence rate of medical male circumcision in the postsurvey in both groups was 65 amongst circumcised learners there was no significant difference between intervention and control groups perceptions as to their risk of being infected with hiv limitations the intervention programme did not have the desired effect on learners risk behaviours with the decrease in substance use and sexual risk behaviours occurring in both intervention and control groups although the intervention was intensive the 2month period may have been insufficient for the wide and complex range of topics covered a further limitation was that the learners questionnaire responses were selfreports of their behaviours the process evaluation indicated that no other interventions had taken place in the schools but media access by students was widespread and this was not monitored and may have influenced the study results although all grade 10 students were invited the proposed sample size of 2000 was not attained discussion since behavioural risk and school violence surveys were conducted in south african schools violence has been reported to be high our intervention appears to have reduced the number of days students carried weapons to their schools with the intervention group indicating a significant reduction in the number of learners carrying weapons to school compared to the control group there have been numerous interventions aiming at reducing the risk behaviours of young people but most of the studies on the existing interventions which focus on sexual risk behaviours such as sexuality education alcohol and drug abuse and genderbased violence showed mixed results in south africa interventions targeting violent behaviours such as physical fighting and carrying weapons amongst learners are limited in south africa the department of basic education has developed an antibullying policy to be implemented across public schools but it is not clear whether it is being implemented as bullying continues to be high amongst high school learners the other risk behaviours that were targeted by the study are similar to youth risk behaviours targeted by south african researchers and other countries however the context in south africa differs in that youth seeking their independence and wishing to enjoy themselves are often limited by their social circumstances south africa has one of the highest gini coefficients indicating societal inequality worth mentioning is the increase in hiv testing that was found in the present study overall a general decrease in risky behaviours in both intervention and control groups was observed the intervention was developed to take into account the context in which youth facilitators from the area were trained to implement the programme in the schools the envisaged strategy was that their being employed by the kwazulunatal premiers office would enable them to continue to work in the schools to reinforce the programme efforts to reduce students risk behaviours however in the year that this school programme was implemented the youth facilitator programme was discontinued for internal budgetary reasons the intervention programme although intensive was only for 8 weeks and lacked a followup component to reinforce the intervention messages we observed that selfregulation through a motivational continuum from extrinsic and intrinsic motivation in students is necessary the study afforded students an opportunity to reflect on and internalise their perceptions of their risk and the consequences of antisocial behaviours such as violence including their taking necessary measures towards prevention of hiv and sti infections teenage pregnancy and prevention of alcohol and drug abuse changing behaviour is complex and the health promotion messages need to be reinforced so that students are able to personalise these messages and reduce their risk behaviours amongst students condom use has increased from 14 to 60 over the past decades which although insufficient demonstrates that consistent messages could make inroads towards more healthpromoting behaviours education is compulsory in south africa and the life skills component of lo curriculum presented in all grades in public schools offers an opportunity for reinforcing key messages as students move up the grades data availability statement data sharing will be available on request competing interests the authors have declared that no conflicts of interest exist disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors

globally youth risk behaviour including risky sexual behaviour drug abuse and violence is a public health concern and south africa is no exception a range of behaviours place youth and in the context of this study south african youth at risk although numerous interventions have been conducted to mitigate risktaking young people continue to practise unsafe sex binge drink and use illicit drugs and are involved in violence the latest south african survey on youth risk behaviours reports that adolescents initiate alcohol use prior to the age of 13 years and that men were more likely than women to use alcohol engage in binge drinking to have driven or walked under the influence of liquor and engaged in physical fighting burton leoschut 2013ashisana et al 2015 furthermore in south africa although the human immunodeficiency virus hiv infection rate is decreasing youth are severely affected by hiv violence and unplanned teenage pregnancy district 2012 national department health 2012mkhwanazi 2010 it is also widely acknowledged that the high prevalence of hiv and other sexually transmitted infections and rate of teenage pregnancy are fuelled by highrisk behaviours harrison et al 2010a evidence shows that substance abuse has detrimental consequences for youth scottsheldon et al 2013yach et al 2015 the results of the south african national violence survey reported that of the 47 learners who smoked marijuana at school 31 reported witnessing learners who were high and 27 reported knowing learners who were drunk at school burton leoschut 2013a this is undesirable in a teaching and learning environment and particularly concerning as alcohol abuse has been associated with violent behaviour peltzer davids njuho 2011 the prevalence of violence in south african schools has been reported to be high schuld 2013 one in four learners reported knowing learners who brought weapons such as firearms knives and other sharp objects to schools burton leoschut 2013award et al 2012 these learners may carry weapons to initiate or threaten other students or for selfdefence the prevalence rates of students reported carrying weapons vary across the country burton leoschut 2013a learners from kwazulunatal province were aware of learners who had brought a weapon to school and 82 stated that they were threatened whilst at school burton leoschut 2013a another concern is the lack of contraceptive use bhana et al 2010catalano gavin markham 2010 in the third south african youth risk behaviour survey sayrb 2011 learners reported condom use 451 as the main method to prevent pregnancy this was followed by contraceptive background youth behaviour in south africa continues to be a public health concern primary prevention interventions remain a prerequisite for promotion of improved social and health outcomesthe aim of the study was to assess the impact of a behavioural youth risk reduction intervention among grade 10 learnersthe study was conducted in kwazulunatal high schools at umgungundlovu district municipality methods we conducted a cluster randomised controlled trial at 16 kwazulunatal high schools where learners completed a selfadministered questionnaire assessing youth risk behaviours schools were divided into two arms intervention and a control arms resultsthe intervention reduced learners reports of carrying of a weapon to school in the past 30 days but did not significantly reduce other assessed risk behaviours although the intervention appeared more likely to reduce learners risk behaviours when compared to the control group such as carrying weapons risky sexual behaviour and alcohol and drug abusethis study was unable to show statistical significance for these outcomes

introduction the recent study initiatives emphases of china media and selfreporting social media are increasing fear and melancholy due to the outbreak of novel coronavirus disease 2019 worldwide media plays an essential role in spreading awareness for some currently occurring issues such as covid19 which is becoming the source of disease spread worldwide covid19 epidemic evolved from china and after some days this disease became severe grave in the social economic and health systems of the world according to kufel the role of social media on covid19 coverage is pretty unacceptable while talking about electronic media such as television that shows news about covid19 still news coverage and transmissions are without solid proof from medical professionals social media users frequently use famous social media applications such as wechat weibo toutiao facebook youtube and whatsapp there are no special programs arranged to inform encourage or motivate the morale of the public and protect them from mental stress in this global crisis everyone has become an expert about covid19 only to comment on their public posts instead of using this media platform to help miserable people many social media users used this platform only to spread fake news about covid19 still at the same time there is thinking that television transmissions regularly use alarming and shocking words social media news disseminates most of the talks about death and dissatisfactions about life and hopes as it sometimes seems that there is a jungle of deaths and more and more deaths are coming soon the media is spreading fear and stress instead of encouraging providing accurate information and aiding knowledge among social media of citizens is called upon to take responsibility frenkel et al indicated that once the who complained that social media organizations have been spreading false information over covid19 worldwide few social media groups used their platforms to spread incorrect data and tried to remove it a recent study described the effect of media on the health of people muwahed stated that social media had affected the shocking crisis over some countries while many people have been greedy for buying foodstuff and household things because of the widespread fear of covid19 merchant and lurie investigated that social media is responsible for panic and creates a fear of shortage of foodstuff in the surrounding a universal situation is leading in which social media organizations have taken steps to remove fake posts about covid19 besides victor reported that people saw empty store posts on social media spreading fear of food shortages in addition kelvin and rubino noted that social media put everyone at risk of having a ratio of one to another they heard surprising news about why people posted on social media as soon as possible furthermore it has been distinguished that the publication of misleading information on social media networks where almost all media channels are exposed to diseases has harmful effects on general public health and mental health victor claimed that this is an age of digital information today chinese population cannot get facts about covid19 and social media users share fake news information photos and videos similarly the indian government said the highest social media application corporations such as wechat weibo toutiao youtube facebook tiktok whatsapp and twitter to break in their journey of publishing fake information because it spread anxiety and fear to the public this fake news highly impacted the younger generations that use social media the 21st century has seen a change in the way that the public embraces online communication technology the new upgrading media terms became an essential source of public discussion nonexperiments criticisms health disease and treatment in the same way wongkoblap et al noted that human beings are spending a lot of time on social media and have seen many infected panic attacks in several countries during the covid19 epidemic spreading anxiety similarly jee indicated that everyone is a pseudoprofessional who tries to raise his or her voice and transfer messages to almost all covid19 respectively ittefaq et al explained that we empowered social media to create fear around covid19 because we all distributed anxiety fear news and socialized among the public because coronavirus has spread worldwide there is misinformation about it there is no difference between social media corporations to stop its spread wechat weibo toutiao facebook google and twitter said that they were removing misinformation about the coronavirus as quickly as possible it worked with the who and other government organizations to ensure that human beings have found correct facts however new york times brings out for example dozens of movies photos and written posts shared on every social media platform that is believed to be cracking these posts are no longer limited to english many languages have started from hindi and urdu to hebrew and persian reflecting the viruss spreading cycle as it has traveled worldwide security researchers also say that hackers set up wornout websites that claimed to contain fake data on almost coronavirus these sites were honestly virtual traps intended to steal nonpublic information or break gadgets of people who came to them spreading false and malicious material about the coronavirus has been a perfect reminder of the war of attrition fought by researchers and internet groups even if corporations have decided to protect this fact they are frequently raided by liars and thieves on the internet ahmed et al observed many ways to disseminate facts and information to the community today with the upgradation of social media studies show that the fear of an illness and any resulting behavioral changes may be passed on through a virus there are historical instances of people fearing mass contagious illnesses based on media reports such as when london had a massive plague in 1665 it was linked to stories in the newspapers which forced officials to close the printing presses studies also have indicated that media coverage of past outbreaks of pandemic diseases has led to a rise in worry extensive research should be done on the mechanisms by which the media incite fear and other emotions in the face of a pandemic additional studies should be conducted to determine the specific factors that increase the likelihood of certain persons these symptoms emotion contagion is one area where a little study has been conducted this research aims to measure the impact of social media on the performance of employees of industries during covid19 this research also identifies the toxicities of speech freedom about the pandemic and curbing dissenting political views on social media the commoner does not know about the facts and figures for a specific situation when an individual speaks out in an extreme case one presents their mental state and psychological effect on the reader the pandemic phenomenon reflects health issues other than a pandemic which reduces the performance levels of employees this overreach is destined to evoke an intense reaction and severe to alienate the general public from its telecommunication approach at a time when a unified stance is essential literature review employee performance as a dependent variable in this study the performance of the workers is taken into consideration it is the performance of workers in an industry that industrialists are most concerned about since the profit or loss of a sector is directly linked to the performance of employees the outbreak of covid19 had a significant impact on employee performance in a variety of ways such as lockdown frightening news about the pandemic limited working locations and stringent operating procedures among others the basic rationale for selecting this variable is real as the success of the industries and the performance of the workers are very complementary to one another because the economy is in such bad shape the luckiest individuals are included among those working the performance of workers increases the productivity of the industry and the achievement of goals and objectives on time as a result of the epidemic human resource managers were pressed to continue with the recruitment selection processes employee engagement and training and development initiatives in this catastrophic global lockdown scenario the oil industry is humiliated for the first time as a barrel of oil drops to less than zero for the first time in its history the management of safety performance and the management of safety information are inextricably linked to one another in many ways physical workplaces have been transformed into virtual workplaces suitable for the services industry but not the manufacturing sector after using partial least squares structural equation modeling and the inputprocessesoutcomes framework bartsch et al discovered that service workers were able to live virtually with little difficulty contrary to expectations individual job autonomy and team cohesion had little impact on the work performance of services workers this was unexpected and workrelated covid19 worry and social media fear in late december 2019 when china reported a mysterious illness in wuhan city called covid19 some cases were registered due to this illness the infection has spread around the world and has become a pandemic disease the telecommunications institution plays an essential role in the awareness of people about the effects of the disease still at the same time media became a source of spreading fear and anxiety among their users the social media platforms gave their users different instructions about preventing this virus such as washing their hands wearing the mask and keeping distance among themselves but at the same time social media became a source of fear dissemination during covid19 according to lee this news of covid19 became one of the deadliest public disastrous news in human history all developed and developing countries trying to cope with the epidemic and save the health of human beings should take essential preventive measures such as lockdown contact tracing patients green health code and quarantine until now the impact of this virus has been severe in emerging countries such as china there was a lack of medical setup public health literacy to respond to the crisis in addition the outbreaks spreading misinformation from social media among the people create fear and anxiety the misinformation calamity for emerging economies is also tricky due to the lack of health infrastructure lack of deontological expertise in health hospitals lack of trusty media and health knowledge among the public the who rules on pandemics help people avoid this sudden condition in figure 1 the relationship and direction are influencing the scaling of variables the information about the covid19 is spreading greater than the virus itself leading to fullsize public panic worldwide social media alternatively is a realistic platform for spreading public health messages to the audience ida et al brewer has published on bbc news that the general public has been shocked and horrified to hear all kinds of information about covid19 causing them to land in a state of depression additionally pennycook et al claims that panic is spreading among social media users simultaneously in a conversation on social media people almost rely on social media to get information and facts about covid19 some countries use news filters that are why social media presents some points but not all correct records after the emergence of covid19 and the migration of countries beyond mainland china people turned to social media to get more information about the virus in just 24 h according to pennycook et al there were 19 million mentions of the covid19 cases on social media and news sites worldwide similarly shimizu stated that many nations were no longer aware of the spread of covid19 or failed to provide the information they needed because of this people trusted information they could find on social media khan and naushad contend that a global changing condition impacts in disclosure of fake news and misinformation about covid19 which is alleged to be the beginning of a virus based on misinformation lab theory contained in social media accordingly frenkel et al are confident that media reporting has highlighted covid19 as an utterly exclusive threat as opposed to people that have caused panic and created tension victor described that social media plays three crucial roles in spreading information about covid19 in most countries firstly a factor about the occurrence of the virus was posted on social media secondly facts about the epidemic appeared on social media as misinformation fake news and misleading thirdly social media has caused widespread anxiety fear and depression worldwide during the outbreak of covid19 it seems that pleasure anger and worry are all socially infectious types of emotion research has shown that when it comes to strangers especially the spread of negative emotions figure 1 theoretical framework individuals who have greater levels of emotion contagion tend to respond more strongly to distressing experiences that so those who are sensitive to the emotions of others may be more vulnerable to the covid19 epidemic even though most research on emotion contagion has focused on human interactions a recent study has shown that digital communication may be a conduit for emotional contagion the fact that social media is very popular in the contemporary world and that many people get their news from social media emphasizes the significance of this since it has spread worldwide this sickness has gotten a great deal of attention in the media previous research has shown that more media exposure will result in increased anxiety about covid19 however this increase among concerns may be much more severe in individuals who are very susceptible to emotional contagion hence we suggest the following hypothesis h1 social media fear significantly influences employee performance h2 covid19 worry significantly influences employee performance moderating role of covid19 vaccine workers are the foundation of any business and the primary duty of any organization is to ensure that its workers are safe and secure particularly during this difficult period of a pandemic outbreak with the covid19 pandemic in full swing it is clear that companies must take their responsibilities to safeguard workers seriously and that the widespread distribution of covid19 vaccinations is necessary to preserve their health even in the face of widespread vaccination reluctance according to a recent study businesses of all sizes must act responsibly to ensure that no harm is done care for their employees and allow the government to do its job in protecting people additionally every company should make concentrated efforts to meet employee needs and desires costeffectively to improve the performance of the company exposure of workers to covid19 may be reduced by providing safe and healthy working circumstances such as appropriate protective equipment and training and personal hygiene practices such as hand washing and coughing etiquettes the first step is to gather current information about their situation a variety of approaches may be used to reduce direct humantohuman interaction throughout the job process ensure that employees are aware of the coronavirus and the immunization program by providing them with appropriate information distribution governments and corporate sectors must safeguard the health of their workers during this difficult period but this crisis also presents a chance for our economy to reach a watershed moment the vaccine of covid19 is used as a moderator variable between the performance of the employee covid19 worry and social media the vaccine is performing two rules at a time in this research first it will point out the psychological impact on the employees of industries who are afraid of covid19 due to media second it will also measure the effectiveness of vaccines because the immune system of the human body is related to mental health the accurate effect of the vaccine is not only dependent on the vaccine but also characterized the vaccinated person the psychological factors ie stress depression and loneliness which are created by exaggerating spreading fear by media may affect the immune system of respondents the vaccine of covid19 is the best moderator variable that can elaborate the intensity of the relationship between the dependent and independent variables the inflammatory markers of vaccines rise within hours due to innate immune response in normal human beings but its effect and reaction period are prolonged for stressed people again the fake news of social media restricted the general public from accepting the vaccine of covid19 the useful information and encouraging vaccine material are rare on social media than negative and discoursing materials hence we proposed the following hypothesis h3 covid19 vaccine moderates the relationship between social media fear and employee performance h4 covid19 vaccine moderates the relationship between covid19 fear and employee performance as per previous literature most research is available on social media fear and covid19 but the performance of employees and vaccines are still undiscussed in this section the theoretical information is categorized for two purposes ie an indication of previous research and direction and the current inclusion of this research work the independent variable is explained in detail with cited references but vaccine and employee performance have only declared the moderator and dependent variables due to unavailable literature methodology this study designed a questionnaire according to the hypotheses stated above the participants in this study were experienced users of social media platforms in china a selfadministered questionnaire was used to collect data from respondents the research analysis was based on service sector employees and data were collected from 630 respondents via a structured questionnaire a pilot study with 100 participants was carried out since providing recommendations revisions were made to the final questionnaire to make it more understandable for the respondents of the study to ensure the content validity of the measures three academic management experts analyzed and made improvements in the items of constructs the experts searched for spelling errors grammatical errors and ensured that the items were correct the experts have proposed minor revisions to social media fear and employee performance items and advised that the original number of items be maintained this study used an online community to invite social media users to complete the designated online questionnaire system online questionnaires have the following advantages sampling is not restricted to a single geological location lower cost and faster questionnaire responses a total of 650 questionnaires were returned from respondents there were 630 appropriate replies considered for the final analysis data were analyzed through ms excel and statistical package for the social sciences software measures the study used items established from prior research to confirm the reliability and validity of the measures all items are evaluated through fivepoint likerttype scales where 1 denotes strongly disagree 3 denotes neutral and 5 denotes strongly agree we used 10 items adopted from a prior study by bartsch et al to get responses about employee performance covid19 worry and social media fear were measured with eight items adapted from the study of pennycook et al finally the covid19 vaccine was measured with seven items adapted from the prior study of murphy et al results demographic characteristics of respondents this study analyzed the data through the spss primary data were collected from 630 respondents and demographic characteristics 1 data collection for this study was performed using a questionnaire in this study we analyzed the impact of social media fear on the performance of employees through the moderating role of the covid19 vaccine before testing the structural model the measurement model was analyzed in terms of construct reliability convergent validity and discriminant validity according to our assessment of the reliability of the indicators there are 25 indicators with outer loading greater than 070 a total of 10 indicators of social media fear were used all showing a reliable factor loading as indicated in table 3 the covid19 vaccine is measured through eight items which also show factor loading greater than 070 the employee performance is measured through seven items and all the outer loading greater than seven is significantly reliable hypotheses show the influence of independent variables on employee performance table 2 shows that the independent variable covid19 worry and social media fear have a negative impact on employee job performance with beta value is negative and tvalue is 2093 social media fear significantly impacts the covid19 vaccine with a beta value of 0202 and 6140 this confirms that the independent variable included in the model has a positive and significant impact on employee performance based on the tvalue independent variable has a positive and significant impact on employee performance at p ≤ 005 table 4 tests the variables by employing the htmt discrimination validity test which measures the heterotraitmonotrait discriminant validity the results presented that the values are very far from 1 not even near to 080 the values are confirmed that there is no multicollinearity in selected variables table 5 contains the results of regression analysis and presents the values of r 2 and adjusted r 2 the linear regression results have measured the proportion of variations in selected dependent variables toward independent variables with 0867 the decreasing trend of adjusted r 2 indicated that the predictions would not improve more according to expectations table 5 shows the moderation effect of the covid19 vaccine first we assessed the direct relationships before looking at the moderation effects the results revealed a negative relationship between social media fear and employee performance which gives positive support for h1 of our study the moderation hypotheses of the covid19 vaccine in the path between social media fear and employee performance are tested using the twostage continuous moderation analysis the moderating effect of smf cv ep indicating the moderating effects are statistically significant at the 001 level this supports h2 of this study table 6 presents the summary of table 3 with understandable and clear manners the hypothetical approaches are strongly supported by the analytical process discussion in this study we used a large sample of social media users we tested the theory that employees who are more sensitive to emotion contagion would experience more anguish and display symptoms during the covid19 pandemic in china individuals with heightened fear or who are more affected by the emotions of others were more likely to have greater degrees of fear sorrow anxiety and stress according to covid19 results these details are covered in more detail in the section below although the variations in sensitivity to covid19 worry and fear of social media were found to be small generally we observed that those with greater vulnerability to contagion were more likely to exhibit worry about the virus and maladaptive reactions this result is consistent with other research which showed that those with a greater capacity for emotional contagion tend to have a more pronounced stress reaction to stressful experiences because of the current covid19 epidemic the community as a whole is under stress those who are very sensitive to others emotional states are likely to be more vulnerable to feelings of worry additionally we examined the potential that general social media usage and media consumption regarding covid19 in particular might be significant in predicting the degree of anxiety around covid19 additionally we examined the possibility that the covid19 vaccine might serve as a moderator in these interactions consumption of media regarding covid19 was shown to predict the degree of anxiety associated with covid19 significantly but this connection was not reduced by emotion contagion one previous study discovered that the degree of emotion contagion moderated the stress response following exposure to a traumatic film still this study was conducted in the laboratory and used a highly controlled stressor whereas our measure of media exposure on covid19 was retrospective and uncontrolled as a result it is conceivable that a substantial moderating effect might have developed under more controlled circumstances as our further research showed we discovered that the relationship between covid19 worry and fear of social media and employee performance was influenced by the covid19 vaccine making it greater for an employee who was more susceptible to social media fear the connection between social media fear and employee performance is likely exacerbated because of the increased susceptibility to infection with the virus that causes covd19 despite this warning it is important to remember that the study was based on the primary analysis of crosssectional data meaning no causal conclusions can be drawn further studies are also required to examine this in clinical populations study limitations study limitations must be considered while evaluating current findings for our study we first gathered all of our data online using a crosssectional design where subjects answered questions at a particular moment in time consequently our findings do not allow us to prove causality this is because we cannot tell if media exposure raises anxiety or whether those with anxiety gravitate toward news and therefore spend more time on social media to properly predict the potential effects of a global epidemic more indepth research might follow those who exhibit high and low degrees of fear to see how social media is used and the stress levels that develop in reaction to the danger similarly additional factors that explain the connections between observations are regarded as possible third variables unfortunately we did not measure neuroticism in our survey which is an interesting area for future study moreover all the data were obtained via selfreport surveys and they may have been influenced by shared method variation since they rely on selfreporting future mixedtechniques studies such as interviews would diversify the measuring methods used while the data were restricted to the sample of social media users they were at last assembled to validate these results further research should be conducted in other samples such as those working in other settings with fear who are especially susceptible to pandemic disease risks and those with a higher proportion of male participants some of the findings from recent studies have had modest but statistically significant outcomes and thus they need to be looked at again to see whether they have clinical relevance conclusion the study concludes that social media was responsible for spreading covid19 fear among people in china meanwhile during this health crisis of the outbreak of covid19 trust between citizens and the state had declined which is why official statements news and information provided by the ministry of health and government agencies met the needs of people therefore they rely heavily on social media platforms to obtain information about viruses the nature of social media panic among people depends on gender age and level of education it can be seen that social media has played a crucial role in spreading the fear of the spread of covid19 in china and other countries according to media experts and academics we believe that we and chinese comminutes now have an essential role in the future we must educate media users about good things reliable information and a way of thinking critically since younger people are also getting a lot of information through the internet and then spreading it to their family and friends a university is an ideal place to design courses and symposiums that can help students and teachers figure out how to find search for and evaluate health information in someones case during epidemics the scope of the investigation varies but those affecting the research process are important there was a lack of literature on social media about covid19 so this study relied on novel research available but was very limited in addition conducting research required data so data collection was another hurdle due to the lockdown period because of the data collection we had difficulty finding participants who wanted to respond and participate 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 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

in the age of digitalization social media has played a significant role in quickly spreading the news about current affairs from december 2019 to now coronavirus disease 2019 covid19 with its several mutated shapes has more transmissible potential catastrophe and has become a severe phenomenon issue worldwide the international spread of the epidemic has created fear among people especially employees working physically in different organizations the present research aimed to measure the impact of social media on its users in the china the social media users more often were influenced by shocking news instructively and destructively the research analysis was based on service sector employees and data collected from 630 respondents via a structured questionnaire this research was confirmed the negative impact of fear on social media on the performance of employees this research was also confirmed the moderation impact of the covid19 vaccine on the relationship between social media fear and employee performance this research recommends that the china censor board checked the news and its validity to reduce the fear of covid19 among employees this research will become a roadmap for organizations and media controllers to understand the impact of social media during an intense situation the telecommunication sector will reduce psychological disease and enhance the work capability of employees by controlling unnecessary and unapproved material about sensitive issues

introduction there has been a recent upsurge of interest in selfreported measures of wellbeing by official statisticians and by researchers in the social sciences this is in part due to influential reports including by stiglitz sen and fitoussi the organization for economic cooperation and development and the national academy of sciences that have provided the rationale for supplementing standard economic measures of societal wellbeing such as gdp with peoples subjective selfreports research documenting determinants of subjective wellbeing has primarily focused on evaluative measures of wellbeing such as life satisfaction and the cantril ladder which are the wellbeing measures most often used in large national surveys yet evaluative measures are only one aspect of subjective wellbeing a component that reflects peoples judgments about their current situation which is framed in a context of their values and aspirations experiential wellbeing is another component of the wellbeing of individuals and groups experiential wellbeing is intended to assess peoples everyday emotions their joys miseries and pains which have been shown to be only modestly associated with evaluative measures as will be discussed later experiential measures that incorporate timeusage require greater respondent participation than evaluative measures which has discouraged their widespread adoption in population surveys identifying determinants of subjective wellbeing has also captured the interest of scientists because determinants could be useful for developing interventions to enhance wellbeing and reduce suffering or for providing information to policy makers about their constituencies in this paper we focus on the measurement of experiential wellbeing using the american time use survey wellbeing module a survey administered by the us bureau of labor statistics that has collected information on experiential wellbeing using a timeuse data collection methodology with a sample representative of the united states the paper has two goals our first a methodological goal is to describe the atus wbm in considerable detail and the opportunities that arise from these data for a finegrained examination of experiential wellbeing our second a substantial goal is to use the atus data to examine relationships between experiential wellbeing and two variables age and income that previously have received much attention in the prediction of evaluative wellbeing regarding methodological issues pertinent to the atus in the next section of this paper we describe how experiential wellbeing has been measured and highlight the methodological strengths of the technique compared with others to put the particular qualities of the atus into context as an approach for measuring experiential wellbeing regarding the substantive goal we illustrate the qualities of the atus wellbeing data for understanding how age is associated with wellbeing this question has far reaching implications for developing life course theories and for identifying consequences of the aging process for example how increased disease rates associated with aging affect us we also examine the effects of income on subjective wellbeing a topic that is of considerable interest for economists some of whom view wellbeing as a proxy for utility a core construct in economics as well as for those many noneconomists who believe that wellbeing has little to do with money in a subsequent section of the paper we then provide brief reviews of prior literature about evaluative and experiential wellbeing and their relationships with age and income and then move onto quantitative analyses using the atus wellbeing data the last section of the paper presents analyses that test the associations between the two predictors and experiential wellbeing measured in the atus wbm methodological considerations in assessing experiential wellbeing for interpreting the experiential wellbeing findings one needs to seriously consider how it is assessed experiential wellbeing concerns peoples levels of their everyday emotions which can include not only positive emotions but also negative experiences such as pain and suffering the assessment of such labile emotional states presents challenges techniques of asking respondents how they generally feel or how they feel over long periods of time run the risk of bias because answers to such questions are likely to reflect peoples beliefs and expectations rather than actual experience to obtain more accurate assessment of experiences researchers have resorted to techniques that reduce recall bias by asking about current experiences using methods such as experience sampling and ecological momentary assessment these techniques provide detailed and precise information about experience but because they are burdensome for respondents and costly to implement for researchers the techniques are better suited to small intensive studies rather than largescale studies intending to provide population estimates two solutions have been developed to overcome this problem the first solution is to obtain overall experiential ratings of yesterday the method is simple and relatively quick the technique is virtually the same as endofday diaries which have been in use for many decades but answered from the following day questions like please rate your overall pain for yesterday are used unlike most diary protocols though the yesterday ratings are typically only done for a single day providing a singleday snapshot of experiential wellbeing the assessments require only a few minutes and can be done anytime on the day following the targeted day overall yesterday ratings have been used to collect experiential wellbeing data in the galluphealthways wellbeing index and have been used in a recent british office for national statistics survey of wellbeing a second solution for collecting accurate experiential data in largescale studies has been to combine wellknown techniques for measuring timeusage which has respondents parse the day into many episodes defined by activities with other ratings of the episodes this technique is called the day reconstruction method and has been implemented by asking respondents to define episodes of their waking hours of yesterday and then to return to each episode and rate several affective adjectives and pain for the period the process of recalling and reflecting upon yesterday in this comprehensive manner is intended to help respondents recreate the feelings they actually had during those periods as opposed to relying on their general beliefs about occasions data from the drm has been compared with data collected with momentary assessment methods which are often considered the gold standard and the correspondence between the methods is good supporting the validity of the procedure more recently a telephone interview version of a drmlike interview has been developed and run by the bureau of labor statistics in their subjective wellbeing module which was added to the ongoing atus atus has been monitoring the timeuse of americans since january 2003 participants are selected from the current population survey and are interviewed for the atus within 25 months after their household has completed the current population survey interviewers in the atus have respondents parse yesterday into discrete episodes and immediately code the activities in each using a three tier coding system as with the drm the interviewers then obtain experiential wellbeing information about episodes however whereas the drm collects wellbeing ratings for all episodes of the day this was not feasible in the atus due to time and resource limitations instead the computerassisted telephone interview program in the atus randomly selected three episodes per person for the wellbeing ratings providing a partial drm corresponding to the drm and to overall yesterday diaries the atus experiential wellbeing data is collected for a single day illustrating the atus wellbeing module age income and experiential wellbeing with few exceptions what we know about experiential wellbeing and its association with age and income are mainly from surveys of global yesterday assessments only a few studies have drawn upon the experiential wellbeing data from the atus to examine constructs and relationships that are well established through evaluative wellbeing measures while it is not practically feasible to conduct a momentary data collection study with thousands of participants if only because there are many important activities where people cannot respond the availability of the blss atus data provides a way of collecting data that is similar to that obtained with realtime momentary assessments combined with time use information it also enables a deeper understanding of experiential wellbeing because activities which are strongly related to daily affect can be considered in the analyses furthermore because the atus is based on the current census it provides a representative sampling of the people in the united states age and subjective wellbeing researchers have long been interested in how subjective wellbeing changes with age early theories suspected that developmental trends in wellbeing would parallel those of physical functioning with both reaching their highest point in young to middle adulthood and declining thereafter in addition older age was viewed as a period when people would question their purpose in life as they faced the reality of increasing losses and eventual mortality which should lead to lower life satisfaction in older age but these theories have not been supported by empirical evidence the socalled paradox of wellbeing is that older people evaluate their lives as better than those at younger ages especially so when compared with middleaged people the specific form of the age trend in life satisfaction is not entirely clear but the predominant finding is that it is ushaped over age at least in rich englishspeaking countries with a nadir in satisfaction occurring in the late 40s to mid50s several lifespan developmental theories provide possible explanations for findings of improved wellbeing with older age one prominent theory selective optimization with compensation argues that as people age they invest their resources in goals more selectively and draw on the expertise accumulated in life to compensate for inevitable limitations and to optimize performance and wellbeing socioemotional selectivity theory suggests that older people are more likely to prioritize emotional goals and invest more resources into meaningful social relationships and that they derive increasingly greater life satisfaction from these selective investments however the majority of studies examining agerelated trends in wellbeing have focused on evaluative wellbeing or have used retrospective assessments of wellbeing that tend to be associated with peoples implicit personal theories turning to experiential wellbeing only a few studies have investigated age effects the available evidence suggests improvements with age for several aspects of experiential wellbeing such as daily negative affect and stress but it also shows a complex pattern of age differences across different dimensions of experiential wellbeing one study was based on the galluphealthways wellbeing index which is comprised of several hedonic adjectives that are dichotomously rated for whether or not there was a lot of the emotion yesterday this study showed strong age gradients for almost all of the adjectives assessing experiential wellbeing for example the proportion of the respondents who said they experienced a lot of stress yesterday was fairly stable from age 18 to late 40s and then plummeted during the period 50 through 70 years of age worry and anger had similar declining gradients though with a more modest drop sadness did not vary much by age happiness and enjoyment displayed modest ushape gradients a later paper using the gallup organizations world poll also showed age gradients for experiential wellbeing and the pattern varied according to the area of the world studied for example stress and worry showed an inverted upattern for high income englishspeaking countries whereas there was an ascending or flat pattern over age for countries of the former soviet union and eastern europe very recently dolan et al analyzed data from the 20122013 atus wbm and found a modest ushaped agetrend for happiness and an inverted upattern for negative wellbeing taken together these results highlight the need to examine a range of specific dimensions of experiential wellbeing to obtain a nuanced characterization of lifespan developmental trends in wellbeing income and subjective wellbeing with regard to income there is some controversy about its association with evaluative wellbeing with some scientists presenting a case for a strong linear association between evaluative wellbeing and the log of household income others suggest an alternative perspective basing associations on income relative to those living in surrounding neighborhoods and others claim an association only at the lower levels of the income distribution from a theoretical perspective it has been argued that global evaluative wellbeing questions are potentially prone to exaggerate the importance of higher income for better subjective wellbeing this is because standard survey questions that ask respondents how satisfied they are with their life overall may focus peoples attention disproportionately to their material wellbeing when they respond to the question on the other hand people with greater income tend to devote considerable amounts of time to work and other activities that may be unpleasant but such typical aspects of everyday life tend not to be salient in memory when answering evaluative wellbeing questions whereas they may have a pronounced effect on experiential wellbeing this suggests that experiential wellbeing may be much less positively impacted by higher income than evaluative wellbeing a recent study based on the experiential wellbeing questions in the galluphealthways wellbeing index supports this supposition in 2010 kahneman and deaton analyzed data from over 450000 interviews from those data and showed a positive linear relationship between better experiential wellbeing and the logarithm of income until a income level of about 75000 was reached thereafter the there was no association with income this income association differed from that with the evaluative measure in the same study which had a linear rise with the logarithm of income but did not plateau at higher incomes the claim that experiential wellbeing ceases to rise after some level of income has been achieved suggests that beyond that point the joys of daily life are not enhanced and the miseries are not diminished by more money is intriguing thus confirming the association in the present study using another dataset which has its own strengths and weaknesses is timely recently kushlev et al used data from the 2010 atus wbm to examine the association between income and two affective adjectives happy and sadness consistent with prior work they found that greater income was associated with less sadness but that income had no relationship with happiness they furthermore explored the possible correlates of these associations by examining demographic variables and activities but these variables did not explain the observed associations in this paper we extend the analysis of income to all of the atus wbm adjectives to provide a more complete picture of the association of income with experiential wellbeing in summary we will examine the relationships between two variables that are central to the social and behavioral sciences age and income with experiential wellbeing using recent data from the american time use survey not only will we determine if the same gradients are observed as have been previously shown using yesterday assessments of wellbeing we will be able to determine if the gradients are impacted by the daily activities reported by individuals at different ages and at different income levels that is when their effects are statistically controlled and these associations will be tested with a random sample of individuals from the current population survey conducted by the census bureau procedure and materials the data were collected by the blss atus project in 2010 with addition of the niasupported wbm extensive information about the methodology is available on the bls website including sample selection procedures details about the computer assisted telephone interview and the training of the interviewers wording of questions and skip patterns and demographic information about the sample respondents were interviewed over the telephone and asked to provide a detailed time diary of the previous day in a series of questions the interviewer asked what were you doing how long did you spend activity what did you do next starting at 4 am of yesterday and ending at 4 am on the interview day thus episodes were defined based on the temporal sequence of yesterdays activities the wbm was completed after the time use episodes were collected and three episodes were chosen at random with the exception that the following episode categories were eliminated from consideration sleeping grooming personal activities dont knowcant remember and refusalnone of your business also to qualify for selection an episode had to be at least 5 minutes in duration after the completion of data collection the bls realized that there was a programming error in the selection of the three episodes for the wbm it excluded the last episode of the day from being selected we believe this adds only a very small error to analyses presented here but do recognize that researchers interested in activities occurring late in the day will need to deal with this selection bias items for the wbm were similar to those the day reconstruction method and had the following form using happy as an example from 0 to 6 where 0 means you were not happy and 6 means you were very happy how happy did you feel at this time and the respondent was asked to provide a 0 to 6 response the same format was used for adjectives stress tired and sad for pain the item was altered slightly from 0 to 6 where 0 means you did not feel any pain and 6 means you were in severe pain how much pain did you feel during this time if any items about the meaningfulness of the episode and whether or not there was a social interaction during episode were also collected but are not analyzed here analysis plan because each episode has an equal chance of being selected specific minutes of the day do not minutes that belong to longer episodes have a smaller chance of being selected because they share their chances with more other minutes put differently if we count each episode as a unit irrespective of length our measures will neglect the duration of the episode a fourhour episode spent in misery is not the same as a fiveminute episode spent in misery for many wellbeing measures such as the number of hours spent being happy or a uindex which is the fraction of the day spent in misery we need to count each minute equally not each episode equally in this context weighting is not an option but a necessity and the bls statisticians have supplied the appropriate weights to deal with this given that minutes in longer episodes have a smaller chance of being chosen duration weighting is equivalent in this case to weighting by the inverse probability of selection a familiar technique from survey sampling in general we begin with a brief description of the wbm participant sample it is slightly different from the overall atus sample in 2010 whose characteristics are available on the bls website we next provide a description of the episodes reported in the module including the number of episodes per person and average length of episodes this is followed by a tabulation of the activities for episodes we then turn to wbm questions about each activity and present basic descriptive statistics finally we provide analyses of the relationships between respondent age and income and experiential wellbeing regression routines from stata 13 were used and when dealing with episodes as the units of analysis clusterrobust standard errors were employed to adjust significance levels based on the nonindependence induced by the fact that the 3 episodes are from the same respondent for the analyses of wellbeing differences by age and income four sets of regression models were used the first set of models tested linear and quadratic effects of an independent variable on wellbeing next selected demographic variables were added as covariates to the models and the covariateadjusted patterns of results for age and income were compared with the first models in these models when age was the predictor income was included in the model and when income was the predictor age was included third given that age or income differences in wellbeing might be explained by daily activities for example if older people engaged in more pleasurable activities than middleaged people then controlling for activities could impact the age gradient for happiness therefore a third model added the atus activity codes as a set of dummy variables and the resulting wellbeing patterns for age and income were again compared to the first model sampling weights as previously described the data from the wbm of atus requires weighting in order to estimate national means furthermore the three episodes selected by the wbm are a sample of those from the day described in the atus as such bls has created two sets of weights the first set is applied when respondent is the unit of analyses and the weights correct estimates for the us civilian noninstitutionalized population age 15 and over bls recommends that the second set of weights be used for episodelevel wellbeing data they are designed to estimate average levels of affect for the population during activities eligible for the module they can also be used to estimate population averages for functions such as uindexes these are the weights that were described above that are designed to account for the differences in the duration of activities and for the probability of having a specific episode selected given the varying numbers of episodes available for a respondent and they were used in the present analyses atus also offers the option of using replicate weights in combination with the sampling weights for computing the standard errors replicate weights contain all information about a complex sampling design and provide standard error estimates that mimic the theoretical basis of standard errors while retaining all information about the complex sample design for the present analyses we have compared results using replicate weights with those using cluster robust standard errors in combination with the sampling weights the two sets of results provided almost identical point estimates and standard errors thus the described results are based on the simpler method using sampling weights and cluster robust standard errors results respondents participants in the atus 2010 wbm were 12829 adults in the us a total of 38160 episodes were collected or an average of 297 episodes per person slightly less than the protocol specification of 3 episodes per person the breakdown of number of episodes per person is that 12518 respondents had 3 episodes 295 had 2 and 16 had 1 the sample was 44 female 12 had less than a high school education and 61 had at least some college average age was 481 79 of the sample was white and 52 of the sample was married for the subsequent analyses we included participants who were 18 years of age and older and who had at least 2 episodes reported in the wbm description of episodes the average episode length was just over an hour it is also useful to consider how many hours in total were covered by the three episodes per person the average was 322 hours with a low of 5 minutes to a high of just under 24 hours activities bls categorizes episode activities with a threelevel nested coding system where the first level is the broadest description and the third level is the most detailed for example the activity code for vacuuming is nested in housework which is nested in the code for household activities table 1 shows the frequencies and duration of first level activities in the wbm that is activities for just under 3 episodes per day the first column presents the raw unweighted frequencies and percentage of total whereas the second column applies weights to the frequencies differences in the percentages between columns 1 and 2 are due to the sampling protocol in the wbm which oversampled weekends and undersampled episodes of long duration for example 24 of the episodes in the raw data were coded as traveling but because they are relatively brief the weighted frequency data shows that traveling is only 9 of all episodes the last column of the table presents the average duration of each activity again weighted the weighted frequency data presented here are very similar to the frequencies based on the full atus as presented on the atus website wellbeing module table 2 presents the question content and descriptive statistics at an episode level for the experiential wellbeing questions considered here experiences were rated using 0 to 6 response scales happy was on average rated towards the upper end of the scale whereas sad received the lowest rating and pain and stress were rated somewhat higher than sadness followed by tired being rated a little higher the table also presents a characteristic of the distributions skewness where negative values indicate a long tail to the left of the distribution and positive values indicate a long tail to the right pain sadness and stress were positively skewed whereas happy was negatively skewed tired showed a generally symmetrical distribution correlations between the different wellbeing questions were small to moderate in magnitude suggesting that they captured relatively distinctive aspects of experiential wellbeing this is consistent with the notion that wellbeing is best characterized as a profile of indicators across multiple domains rather than as a single global concept thus each wellbeing variable was considered separately in subsequent analyses age and experienced wellbeing to determine if there were linear or quadratic effects of age in the atus data the five atus hedonic variables were regressed on age and age squared the results are labeled model 1 and are shown in the upper panel of table 3 for all of the models the first row presents the fvalue for the entire model and subsequent rows show the regression coefficients for the linear and quadratic terms and for other variables in the model ftests for all of the outcomes showed significant linear and quadratic associations with age with the strongest associations for pain and stress specifically happiness showed a slight decrease by 12 points from ages 18 to 40 with a subsequent increase by 47 scale points from ages 40 to 80 stress increased by 38 points from ages 1840 with a decrease by 103 points from ages 4080 tiredness and pain showed near linear associations with age but in opposite directions whereas pain increased by 77 scale points from ages 1880 tiredness decreased by 57 points over the same age range finally sadness showed a slight increase over the 1880 year age range sociodemographic differences over age could account for the patterns shown above the controls used here are similar to the ones used by kahneman and deaton in their analyses of wellbeing and income and we use the selected control variables for consistency and to achieve comparability with this prior research they were income education sex presence of disability weekend and marital status as expected many of these variables were strongly associated with the outcomes for example weekends had greater levels of happiness and lower levels of stress and tiredness and disability was strongly associated with much lower levels of wellbeing on all of the experiential variables although there were many variables associated with experiential variables the associations between age and each of the wellbeing variables remained very similar and in some cases the main linear effect of age was increased after controlling for these demographics observed age patterns might also be explained by the content of daily activities activity content is known to impact experiential variables but it must also be acknowledged that choice of activity is likely to be influenced by hedonic state so we are not claiming a causal association between activities and wellbeing thus in model 3 we added activity categories as covariates represented by dummy variables for the first tier of coding of the atus to the previous model as with the demographic variables many of the activities had reasonable associations with the experiential variables for example religious activities were associated with more happiness and with less stress and tiredness although activities were related to the outcomes the overall patterns of age differences were again only slightly affected by the addition of activities to the model income and experienced wellbeing we now turn to the association between experienced wellbeing and family income reported in the paper by kahneman and deaton using the same gallup survey as stone et al of the 12259 individuals who participated in the atus wbm household income was available for depending on the experiential outcome between 11703 and 11721 respondents they comprise the sample for the following analyses we transformed the categorical income information to a continuous variable by assigning values to the atus categories of 4000 6250 8750 11250 13750 17500 22500 27500 32500 37500 45000 55000 67500 87500 125000 and 180000 these values correspond to the midpoints of the income category ranges they were logtransformed for the subsequent regressions the five experiential outcome variables were each regressed on the log income variable without sociodemographic control variables no associations were evident for happy stress or tired significant linear effects were evident for sad and pain as illustrated in fig 2a doubling in income was associated with a 010 scale point reduction in sadness and with a 020 scale point reduction in pain on the 06 scale similarly stress showed no association with income in the atus data while falling and then rising with income in the gallup data however sadness in both gallup and atus data showed a downward trend as income increased as was the case for the age analyses the addition of demographic and activity variables had little impact on the results though the effects of income were slightly diminished in the presence of these controls discussion the first of the two goals articulated at the outset was achieved by presenting a detailed description of how the atus wellbeing module compares with other techniques for measuring experiential wellbeing relatedly we presented a detailed description of our approach to the data analysis and described several issues associated with using these data for addressing questions of relevance for social and behavioral scientists the second goal was to illustrate the usefulness of the atus data by examining associations of age and income with experiential wellbeing we did this in a sequential fashion by adding demographic control variables and in the last step activity controls in the analysis of each of the wellbeing adjectives we now discuss how the atus data compared with data collected by similar techniques and then turn to the substantive findings we close with some thoughts about how these data may serve the social and behavioral sciences and discuss limitations of the methodology episode and wellbeing data collected with the atus wbm module were generally consistent with expectations based on our experience with drm studies conducted by us and by others the number of episodes reported by atus respondents was in accord with prior drm research with more selective populations that is on average between 15 and 20 episodes were reported per respondent and new data from the wbm on subjective experience are similar to those from previous investigations of comparable concepts for example happiness was rated well into the upper half of the scale range whereas negative emotions were reported at much lower levels a common finding in daily measurement of these constructs thus there are several indications that the wbm module has produced reasonable data we examined how age and income were associated with the five atus ratings of episodic wellbeing experience based on prior research we expected that several aspects of experiential wellbeing would show improvements in older age but we also expected pronounced variation in the age patterns across different wellbeing dimensions our results largely confirmed previous findings for age differences in wellbeing that were based on overall experiential ratings of yesterday used in gallup although specific patterns over age were slightly different as in gallup atus happiness yesterday showed a ushaped distribution with a higher righthand tail suggesting improvements in happiness in older age this finding differs somewhat from previous studies using ecological momentary assessments to measure experiential wellbeing and that provided mixed results on associations between age and positive affect with some finding significantly positive relationships and others finding no age effects the relatively modest sample sizes afforded by ecological momentary assessment studies may have contributed to these discrepant previous findings which highlights the need for experiential wellbeing data assessed in relatively large and nationally representative samples as provided by atus consistent with prior studies sadness showed a significant inverse ushaped relationship with age although the association was the weakest of all five outcomes and the graphic shows a very modest curvilinear increase over age together though the findings on affective dimensions of experiential wellbeing support the theoretical argument that emotional wellbeing in daily life improves in older age experiences of pain stress and tiredness showed remarkably divergent age patterns the level of daily pain was positively associate with age which may be expected given deteriorating health as people age interestingly the rate of increase in pain became less pronounced in older age which replicates previous findings on lifespan developmental trends in daily pain intensity ratings using an assessment method paralleling the atus daily stress measured by atus showed high levels prior to age 50 and a steep linear decline thereafter which was very similar to the pattern found in the gallup data a slight difference is the increase in stress from age 20 to 50 shown in atus which was not evident in gallup experiences of tiredness showed a similarly pronounced decline with age even though perceived stress and tiredness both have important links to health outcomes including immunological processes and morbidity relatively scant attention has been paid to patterns of stress and tiredness over the life span and to explore what might cause it our findings suggest that fully documenting the nature of developmental trajectories in emotional somatic and physical symptom experiences could advance a more comprehensive understanding of wellbeing over the course of life our analysis of household income and experiential wellbeing was less consistent with the prior gallup study unlike prior work with yesterday global diaries which showed that income was positively associated with wellbeing at least from low to moderate income levels the atus wbm data indicated no relationship with happiness however negative emotions from the wbm were more consistent with prior work providing an overall mixed picture of the concordance between findings based on the gallup data versus those from the atus as would be expected the results for happy and sad confirm the findings of kushlev dunn lucas higher income had a pronounced negative relationship with daily pain which may be in part reflecting differences in occupation medical care or health behaviors across income groups on the other hand experiences of stress and tiredness did not systematically differ by income which seems surprising in view of the fact that lower income is associated with numerous environmental and social conditions that constitute enduring stressors in daily life as for age these results patterns suggest that multiple dimensions of peoples life experience should be considered in concert to gain a comprehensive understanding of the association between income and wellbeing our findings could be viewed as evidence that the amount of money people earn may have only little bearing on several dimensions of wellbeing experienced during the episodes of a given day whereas stronger positive relationships between income and subjective wellbeing occur when people make global evaluative judgments and to some extent when they make global assessments of yesterdays experiential wellbeing the differences between the present findings from the atus and previous gallup study could be regarded as a challenge to the idea that data collected with yesterday global diaries are equivalent to those collected with drmtype data where the day is reconstructed and affect is subsequently obtained about the entire day apart from the higher resolution provided by drmdata the rationale for the wbm reinstantiation methodology was to possibly provide more accurate data the drm method encourages people to relive each episode of the day in order to avoid the recall and summary biases that may be inherent in recalling and summarizing the emotions for an entire day that is the procedure was specifically developed to evoke the contextual experience as opposed to the semantic and decontextualized information involved in ones beliefs about emotions admittedly the generation of timeuse data used in the atus was not as specific as the drm protocol nevertheless the technique of recalling and reporting the activities of yesterday should engender at least some reinstatiation and likely much more than with overall day recall methods nevertheless we do not claim that drm data are more accurate than data from yesterday recall methods because this study did not directly address that question there are other possibilities for the differences observed between income and wellbeing here compared to prior findings one is that the variability or random error introduced by having experiential wellbeing data for only 3 episodes per day brought a high level of variability within each respondent and so obscured the true association we expect smaller standard errors from a full drm where emotions for all daily episodes are assessed and are subsequently used in analyses while it is possible that high variability obscured associations we are not sure how likely this is given the relatively large sample size and the fact that the atus data replicated the prior age effects derived from diary recall we also note here that it is essential that the proper weights be applied to the wbm data given the undersampling of lengthy episodes finally the population sampling strategies of the studies varied with gallups survey being based on randomdigit dial interviews whereas the atus based on the individuals sampled from the current population survey which was conducted 25 months earlier but again we have no evidence that this is causing the discrepant results more generally we speculate on how the atus wbm data could be used to address issues in the social sciences economics medicine and policy research as mentioned earlier the time use data are already serving those disciplines but time use combined with subjective experiences in episodes has even greater potential to more deeply tackle important issues a few examples when an individual is out of work and looking for a job what happens to their daily experience a question addressed in recent work by krueger andmueller or what is the daily experience of individuals with chronic diseases in terms of activities emotions and pain what is the impact of climate in different parts of the country on daily experience how are activities and emotion related to presence of children in the household what is the wellbeing of those who are married versus those who are divorced and do daily activities moderate that difference another facet of the wbm that should be appreciated is that the specific aspects of experience that are included in the module are not inherently limited to those concepts mentioned here the method of reconstructing a day and questioning individuals about what happened and how they felt during the identified episodes is generic in the sense that future uses could include other content for instance if the focus was on health one could imagine a set of episodelevel questions that asked about symptoms and healthrelated behaviors that were preidentified from other surveys or if the focus was on consumption then questions about consumption within episodes could be developed although this paper has highlighted many of the positive attributes of the atus wbm data we hasten to add that it and the drm on which it is based have limitations perhaps the main one is that the data is based on up to 24hour retrospection though this is much shorter than many other wellbeing assessments it is likely that some aspect of yesterdays experiences are forgotten or distorted by cognitive processes research comparing the drm to momentary data capture for the same days has yielded promising results but additional research is needed to confirm these findings second the method is still relatively new and it is likely that modifications to the procedure could enhance its validity for example in the process of recreating the events of yesterday and in the selection of adjectives that best characterize daily experience in closing we turn to the policy implications that the measurement of experiential swb could inform and we reference a chapter from the national academy of sciences report and a report from the oecd touching on this issue because experiential swb is associated with biological states and is predictive of later morbidity and mortality policies to improve wellbeing could impact the nations health monitoring of wellbeing has the possibility of informing policy decisions pertaining to economic progress health behaviors loss of employment the impact of civic projects retirement childcare and employment benefits to name just a few areas in fact a prominent economist has advocated for a national time accounts that include experiential wellbeing in sum the value of the atus has been enhanced by the addition of the wbm and we have attempted to demonstrate this with concrete examples how the atus wellbeing questions and more generally the drm methodology can deepen our understanding of daily experience and address topics of interest to the scientific community 47 notes from 0 to 6 where a 0 means you were not at all and a 6 means you were how did you feel during this time a the order of the first five adjectives was randomized by participant by the interview program b correlations were determined using episodelevel sampling weights all correlations are significant at p 001 table 3 regression models predicting happy stress tired sad and pain from age and log income

there has been a recent upsurge of interest in selfreported measures of wellbeing by official statisticians and by researchers in the social sciences this paper considers data from a wellbeing supplement to the american time use survey atus which parsed the previous day into episodes respondents provided ratings of five experiential wellbeing adjectives happiness stress tiredness sadness and pain for each of three randomly selected episodes because the atus wellbeing module has not received very much attention in this paper we provide the reader with details about the features of these data and our approach to analyzing the data eg weighting considerations and then illustrate the applicability of these data to current issues specifically we examine the association of age and income with all of the experiential wellbeing adjective in the atus results from the atus wellbeing module were broadly consistent with earlier findings on age but did not confirm all earlier findings between income and wellbeing we conclude that the atus with its measurement of time use specific activities and hedonic experience in a nationally representative survey offers a unique opportunity to incorporate time use into the burgeoning field of wellbeing research

introduction people are influenced by the neighborhood in which they live the neighborhood may be particularly important for childrens wellbeing because of the constraints it imposes on their patterns of daily activities 1 furthermore the neighborhood is a central context for social development being a place where children form networks and learn social skills and values 2 health promotion experts have become increasingly aware of the social environment within neighborhoods the ways in which individuals relate to wider social networks and communities and the important effects these factors have on health and wellbeing 3 when attempting to capture childrens experiences of their social environment from the viewpoint of wellbeing the concept of social capital may serve as a useful framework 4 social capital in the context of social life is characterized by the extent of membership in formal and informal social networks norms of reciprocity and trust and facilitating mutual cooperation in resources or benefits interpersonal trust is an indicative consequence of social capital 5 it can be divided into thick trust which is established in close personal relations and thin trust which is embedded in people in general who are not personally known 56 individual and community investment in social networks and associational relationships generate social capital in the form of resources that individuals can utilize to promote selfgrowth and opportunity social capital is of the people and for the people and is fundamental to community networks based on reciprocal relations where individual responsibility shifts toward that of collective responsibility 5 for the purposes of this study it is relevant to distinguish between the bonding and bridging dimensions of social capital this distinction has shown to be significant in the study of health and wellbeing 78 and is also relevant in studies which take a rural perspective 4 bonding social capital is generated out of relationships and social networks between similar persons 9 the networks are inwardlooking and characterized by dense loyal ties and strong but localized trust the networks can be an important source of social support but may be exclusionary towards nonmembers of the network 57 bridging social capital on the other hand operates between dissimilar persons at the same level of social hierarchy the bonds between the members are rather weak but the networks are characterized by solidarity and a mutual respect for different social positions within society the introduction of social capital as a determinant of health has not been uncomplicated and the research has been criticized on various conceptual and methodological grounds the first and most prominent critique is directed towards the multidimensional and inconsistent definition of the concept which has created confusion over how to operationalize and measure it empirically this confusion leads to contradictory and nonconsistent results which in turn creates questions about both the meaning of the concept and its relevance to different health outcomes 10 however the concept of social capital is useful in the study of social processes and experiences because it has the potential to incorporate the influence of neighborhood social factors on an individuals wellbeing second there has been criticism concerning the concepts relevance for children putnam did not incorporate children in his notion of social capital and so studies exploring social capital in child research have neglected childrens agency and overstated the influence of parents on childrens lives 11 family background and the home environment are obviously important to childrens wellbeing but it is also important to take into account the broader social environment including relationships and contexts beyond the family and household such as the school and the neighborhood several quantitative studies have established a relationship between neighborhood social capital and child wellbeing 12 13 14 15 16 17 18 19 as mentioned social capital has been defined and operationalized in a number of different ways which has led to rather disparate results thus no clear conclusions can be drawn from this empirical work against this background it seems reasonable to believe that qualitative methods could be useful in more thoroughly exploring the elements of social capital from the perspective of childrens wellbeing to date qualitative contributions to this area have been few 282021 however morrow has pointed out that from an urban perspective it is not only social networks in the neighborhood that can affect childrens wellbeing specific places such as the school and green areasplaygrounds are important too 2 most research on neighborhood social capital and health has been carried out in urban contexts 22 however among an adult population empirical evidence shows that some factors relating to social capital are more prominent in urban areas for example tolerance of diversity while others such as trust and safety participation in the local community and neighborhood connections are more salient in rural contexts in general rural people perceive higher levels of social capital than their urban counterparts 4 studies exploring young peoples experience of living in a rural neighborhood report that long distances along with lack of transportation and leisure facilities lead to limited social opportunities and further to truancy alcoholdrinking and other health problems 202324 in summary the major part of the literature on social capital and child health has a quantitative approach focusing on the urban perspective moreover there are a number of different theoretical approaches and operationalizations of the framework of social capital the aim of the present study was to address the less well explored aspects of this field by describing how social capital in the neighborhood is perceived by children living in rural areas and revealing what this adds to their sense of wellbeing methods design and sample a descriptive research design with a qualitative approach was used in order to provide a deeper understanding of different social processes in the community 25 participants were recruited using purposeful sampling the inclusion criteria were boys and girls aged 1112 years and those with experience of growing up in a rural area thus participants were recruited from two schools in two different rural municipalities in the interior parts of northern sweden with a population density of approximately one person per km 2 the municipalities were selected using the criteria for the swedish definition of rural municipalities a population density of less than 7 people per km 2 and a total population of no more than 20 000 individuals the total population in the selected municipalities were approximately 7400 and 10 300 respectively the average total income among the inhabitants in the municipalities was lower than the average for the whole country of the inhabitants aged 2564 years 1821 had a threeyear senior high school education and 1216 had a threeyear university education 26 the inhabitants of the municipalities were mostly swedishborn the participants lived in villages and hamlets that consisted of between one and approximately 100 households the distances from the villages where the schools were located to the nearest town were 40 and 60 km respectively the services available in the villages included schools health and child care centers grocery stores libraries and sports grounds most participants had lived their entire lives in the area and at the time of the study were living in traditional nuclear families in villas or on farms some lived on family estates with three generations living on the same farm some participants lived in the villages where the schools were located but several traveled up to 20 km to school from the surrounding areas the principals of the schools were contacted by the first author and given information about the study after approval by the principals the 6th grade homeroom teachers were contacted and a meeting with the pupils was arranged all children received verbal and written information about the study this purposeful sampling process yielded a sample of 28 children the homeroom teachers created 7 singlesex groups each consisting of three to five children interviews focus group interviews are a suitable method for data collection because they provide a natural environment where experiences and opinions are constructed modified and redefined in the groups dynamics focus group interviews with children also provide a safe and more natural peer environment than individual interviews thus redressing the power imbalance between adult and child 2728 focus group interviews were conducted following an interview guide that included openended questions about the childrens perceptions of the social environment with reference to the neighborhood and to the school the discussions also focused on how these social features could be seen and understood from a wellbeing perspective the first focus group interview of four girls served as a pilot interview aimed at testing and refining the questions in the interview guide the pilot interview was included in the final sample because only minor changes were made to the wording of the questions the interviews were taperecorded and conducted in a separate room in the school by a moderator and an assistant moderator the latter made notes managed technical equipment and gave an oral summary at the end of each session the interviews allowed participants to interact comment on and share information and included the opportunity for probing and clarifying the answers given 29 each interview lasted between 50 and 120 min data analysis a deductive content analysis was applied to the interview text 3031 after transcription the first author read the excerpts several times in order to become familiar with the text a categorization scheme was developed identifying key concepts derived from theories of social capital the next step consisted of highlighting of meaning units focusing on perceptions of social capital in relation to wellbeing the meaning units were labeled with codes the codes were compared for similarities and differences and then sorted into the scheme of categories and subcategories based on their similarities all authors were involved in the various stages of the analysis ethical considerations the participants were assured that participation was voluntary and that they could withdraw from the study at any time they gave their assent and were guaranteed confidential treatment of the narratives parents of the children interested in participating received written information about the nature of the research and were asked for written permission for their child to take part the research ethics committee of mid sweden university reviewed the study and raised no ethical objections results the findings are presented in four categories each category is described by subcategories and illustrated with quotations from the interviews an overview of categories and subcategories is presented community attachment sense of community the children described their community in both positive and negative terms in environmental terms the rural community was described as a good place to grow up in living close to nature generated feelings of freedom and tranquility which seemed to be important to the childrens wellbeing nature played a significant role in these childrens lives its accessibility was clear in the childrens choice of leisure activities which were mainly performed outdoors such as bicycling skiing horse riding or fishing the outdoor environment was described as safe and secure because road traffic was neither disruptive nor heavy negative aspects of living in rural areas were also mentioned the neighborhood was described as deserted boring and far away from everything it was tedious to live in an area with few people and long distances to social activities and friends the children mentioned a lack of and wish for natural meeting places where they could socialize and play such as soccer fields one focus group discussed how social control in the local community could lead to children not having the opportunity to choose their own friends the children felt that they were urged to make friends with all the children in the village even if they did not have anything in common hannah it sense of school the school formed an important community in itself while the most obvious function of the school is education it is also a setting for social interaction as children meet friends and classmates and get to know new people and this function is crucial for the wellbeing of children the participants in the focus groups made it clear that going to a small school with only a few pupils resulted in tight bonding networks however the discussions also revealed the downsides of these bonding networks as the children described experiences of exclusion and being left out the small size of the schools led to limited possibilities to choose friends and in some cases the children described having to be friends with people they did not actually like hannah but you know since there were so few kids i think that they should close down these small schools and make bigger schools cause i think its kind of weird there being only a few kids if you dont have a real friend you kind of have to be with everyone like children three years younger than you who you dont even like i dont think thats so good moderator why not hannah if you dont have a friend no one that you can really trust and that and well even if its a small school then someone will be left out and it was really weird last year cause it was like all the girls stuck together moderator in the whole school hannah yes there werent many and then some of them started shutting people out there were varying perceptions of how new pupils were welcomed into the class in most cases there were no problems with new pupils arriving in the class however some of the focus groups revealed stories about cultural clashes and problems such as disorder and changes in network structures it seemed that it was sometimes hard for a newcomer to be included and accepted in the new class moderator if a new student joins the school how do you usually treat them hannah its like weve only had one new kid in our class ummm… and that was like a cultural clash she was from the big city and like everyone else has always lived here social control was another topic discussed in relation to school situations in school were often handled on the basis of hierarchy and power for example one girl mentioned how older pupils kind of rule over everyone further graffiti and property damage were common problems and intervening in such situations could be frightening depending on ones age and degree of respect for the troublemakers reporting these problems to a teacher could be perceived as sneaking and there was always the risk that the perpetrator might take revenge sense of belonging besides a strong sense of belonging to their individual homes the children also described a sense of belonging to the local community the village or hamlet the school or the natural environment this sense of belonging was derived not only from places but also from relationships and people the children also described a sense of belonging when they spent time with their pets such as horses or dogs a sense of belonging could also arise from hanging out with someone who was similar to you and who shared the same values it was seen as important to belong somewhere and to know that you always had somewhere to go moderator participation in local activities the children attended various local activities at places such as the youth recreation centre the public swimming pool the library and the church these places constituted a major part of their leisure time and were important for social interaction in order to promote the spirit of community and communion village festivals and regional fairs were organized locally and often included special activities for children moderator do you have village festivals and events like that where you live anna yes julia not really village festivals but you can kind of celebrate new year and things like that in the village hall so everyone who lives nearby can go there social networks friends friends were fundamental in the childrens social networks however opportunities to hang out with and choose ones friends were limited developing social networks could be tricky and some children mentioned a lack of friends of the same age in the local community distance was another reason for the children not being able to spend time with friends seeing friends out of school time required planning and the involvement of parents for transportation jessica its kind of tough to live here cause you have a friend over in another village and then you have 20 kilometers to go there …so your parents have to be home and drive you the children wished their friends lived closer however they found alternative ways of keeping in touch with friends text messaging email chat programs and webcams were considered useful tools although personal meetings were preferred family and wider kin family and relatives were vital resources for childrens wellbeing not least because they supplied both social and practical support siblings were also described as significant because growing up in a rural area meant that opportunities to see friends could be limited the practical support of the family was reciprocal the children described how parents and relatives helped them in different ways for example by driving them to see their friends and to their activities but also how they assisted their parents by babysitting younger siblings shoveling snow or cooking the importance of emotional support from family and relatives was also highlighted in the discussions feelings of security were engendered by having someone in the family to talk to and rely on and who would always understand moderator however neighbors could also exercise social control which was not described in positive terms they might nag or moan or tell the childrens parents when they had been up to some mischief or done something undesirable trust thick trust the notion of trust also came up during the discussions being trustworthy meant being able to keep a secret telling the truth and being able to be close to and confide in someone there was a clear consensus that you could trust people you knew well such as family members friends and neighbors but also that you could also trust some people even if you did not see them very often lisa the children described the familiarity of the local communities as creating a trustworthy and secure atmosphere however they also discussed unpleasant incidents that created feelings of mistrust toward strangers i one example was that of drunk and obnoxious strangers behaving in a disruptive way at village festivals discussion this study describes rural childrens perceptions of social capital from perspectives of wellbeing the results reveal that the spatial isolation that characterizes rural areas creates a special context of social network structures cohesion and trust but is also a breeding ground for exclusion and social control the stories revealed paradoxical feelings of living in a good and safe area that also felt isolated and restricted the however these tight and closeknit bonding networks in the community and in school may also have negative effects on childrens wellbeing exclusion and problems with integration for newcomers can be seen as particularly problematic in areas with limited options when choosing friends the sense of inconvenience stemming from social restrictions is consistent with previous research on childrens perceptions of rural community life revealing that youths perceive the closeknit community as controlling and intrusive 2024 furthermore the limited opportunities for social interaction with friends reported in this study and the childrens perceptions of their surroundings as being isolated and boring seemed to create a sense of loneliness similarly previous research has pointed out that rural youth saw their area as a fine place to grow up in but also experienced a lack of leisure time resources and social spaces 24 especially if they were not interested in organized sports 202123 thus our results highlight both the negative and the positive influence of bonding social capital on the wellbeing of rural children this complex picture shows that it is important to neither romanticize the social life of rural children nor to describe it in terms that are only pessimistic 2332 bridging social capital constitutes another noteworthy aspect of rural childrens social life and seemed in the present study to have a significant importance for wellbeing participating in an organized activity may be beneficial in providing opportunities to socialize with friends with whom special interests are shared and may promote bridging social capital this finding may apply particularly in rural settings because participation in associations and sporting activities can compensate for the sometimes limited freetime access to friends and social networks 33 the school constitutes a setting where bonding and bridging social capital simultaneously act and are produced our focus groups members interaction with friends took place primarily in the school while the small rural schools sustained the existing bonding networks the school was also viewed as a place to meet new people and therefore constituted a crucial setting for rural children to be a part of bridging social networks obviously children view the school as a community on its own and one fundamental to social interaction and therefore of importance for wellbeing and sense of belonging 2 the authors who conducted the interviews had experience in working with children they were also familiar with the rural context because they had spent reasonable amount of time living in similar areas this preunderstanding of the context may have been useful when gathering data in terms of facilitating an ability to deepen and develop the group discussions however it could also have been a weakness if statements had been taken for granted and important statements not thoroughly probed there are ethical problems specifically related to focus group research the discussions during the interviews are shared with all the participants in the group thus making it more difficult to protect the participants right to confidentiality however before the interviews the children were reminded to keep the discussions within the group and not to reveal any more than they wanted to each focus group was singlesex providing four groups of girls and three groups of boys homogeneity with respect to sex is frequently recommended when conducting focus groups with children because mixedsex groups can hinder group productivity 282934 further in order to promote discussion advantage was taken of preexisting aquaintances by choosing group members already well known to each other 272935 this strategy also reduced the otherwise unequal power relations between researcher and participants to decrease power imbalance and to reduce the risk of eliciting only socially desirable answers the children were reminded that there were no wrong or right answers and that they could choose not to answer questions to improve the comfort level the interviews opened with snacks and small talk 2936 conclusions in conclusion the concept of social capital constitutes a useful framework for studying childrens perceptions of their social environment from a rural perspective this study reveals the complexity of the childrens experience of their social environment and the ways in which their preceptions have both positive and negative connotations for wellbeing in particular the results highlight how important it is for health professionals in rural areas to consider the complex influence of bonding social capital on childrens wellbeing and to be aware that it can promote exclusion as well as trust and cohesion however there is a need to more thoroughly investigate rural childrens notions of bonding and bridging social capital in perspectives of health and wellbeing

introduction people are influenced by the neighborhood in which they live the neighborhood may be particularly important for childrens wellbeing because of the constraints it imposes on their patterns of daily activities furthermore the neighborhood is a central context for social development being a place where children form networks and learn social skills and values the aim of this study was to describe how social capital in the neighborhood is perceived by children living in rural areas and to reveal what this adds to their sense of wellbeingthe study had a descriptive research design with a qualitative approach seven singlesex focus group interviews were conducted with children the in 6th grade aged 1112 years data were analyzed using deductive content analysisthe children perceived a lack of social capital due to environmental and social constraints in their everyday lives however their wellbeing was enhanced by strong cohesion in the neighborhood in addition settings such as the school the natural environment and sporting associations were highly valued and emerged as crucial factors for enhancing the childrens wellbeing the spatial isolation that characterizes rural areas created a special context of social network structures cohesion and trust but was also a breeding ground for exclusion and social control the stories revealed paradoxical feelings of living in a good and safe area that simultaneously felt isolated and restricted conclusions from a rural perspective this study reveals the complexity of the childrens perceptions of their social environment and the ways in which these perceptions have both positive and negative effects on wellbeing the results highlight how important © u eriksson k asplund e sellström 2010 a licence to publish this material has been given to arhen 2 it is for health professionals in rural areas to consider the complex influence of bonding social capital on childrens wellbeing and to be aware that it can promote exclusion as well as cohesion

introduction for social movements aiming to mobilize broader public interest in political issues the prominence of new media in the dynamics of protest movements has led observers to suggest that these technologies have become vital tools for the healthy functioning of civil society and a democratic public sphere which holds power to account photograph attribution insideout today at and distributed under a c reative c ommons license reinvigorating the public sphere or encouraging political slactivism in australia in early 2014 thousands took to the streets to march in march registering their disaffection with the liberal party of australialed government on a range of issues what was interesting about this protest was its grassroots social media driven mobilization with an absence of organization or even involvement by formal political groups massive audiences are available for flows of political content across social networking environments facebook alone had 139 billion monthly active users at 31 december 2014 in their study of political activist networks across the us c olombia and guatemala harlow and harp 2 found social media environments to be important for organizing mobilizing informing and promoting debate in other words serving as a mode of alternative media and a counter public sphere where collective identities can form social media can be used to organize and highlight campaigning around social issues but can they help affect real political change for some the ease with which social media users can engage with political campaigns is derided as clicktivism or slacktivism white and morozov suggest that the click of a mouse to like a political cause on social media is a form of political engagement of such limited effort as to barely warrant significance in terms of producing real political change pdfcrowdcom open in browser pro version are you a developer try out the html to pdf api yet new media consistently act as a significant mechanism for the organization mobilization and amplification of public protest findings from a number of international studies suggest that online forms of political participation are increasingly important in the expression of political identity australia the united kingdom and the united states demonstrate that for young people the expression of political views and perspectives via social media forms a significant element of their political identity for bennett andsegerberg this is an emerging mode of political engagement in networked democracies they suggest that collective forms of political engagement are framed by the twin logics of personalization and networked collectivity furthermore merceas study of environmental protest in romania and the uk found that political engagement across social media does translate into offline political involvement for gladwell it is the sustainability of involvement that is in question studies undertaken in is there a middle ground to be found between shirkys strengthened public sphere and morozovs low engagement political slactivism arguments how can we explore the dynamic impact of new media on social movement action how does the appropriation of new media by social movements actually influence political change in this paper we report on an approach that we have used to explore these how questions in a study that focuses on a specific environmental conflict around the protection of native forest in tasmania australia research context tasmania is an island separated from the australian mainland by the bass strait the island is itself a state of the c ommonwealth of australia with its own regional government and parliament environmental issues are a frequent political battleground on an island where spectacular native forest ecosystems support both the local tourism and forestry industries forestry agriculture and fishing together make a combined contribution of around 10 percent to tasmanias economic output the forestry industry operates in constant tension with regional and national environmental movements figure 3 the tasmanian forestry industry and protected native forest coexist in close proximity photograph attribution ta ann truths at and distributed under a c reative c ommons license for example a long running protest has focused around the plan to build a pulp mill in tasmanias tamar valley the australian governments planning approval for the pulp mill has a lengthy history of political opposition from a range of political environmental and community groups the project was originally planned by the tasmanian forestry company gunns limited and has on a number of occasions been refused approval by the government as a result of environmental concerns gunns limited has now gone into receivership but the pulp mill proposal still has political capital given tasmanias limited economic growth the creation of a pulp mill operation has been projected as having the potential to bring more than aus 67 billion into the tasmanian economy 3 yet significant concerns relating to the impact of the mill on the natural environment in the region have been loudly voiced by range of stakeholders such as the australian greens and the wilderness society despite the involvement of stakeholders from the environmental movement and the forestry industry in the negotiation of the tasmanian forests agreement in 2011 the pulp mill proposal reemerged as a significant political issue in the march 2014 tasmanian state elections the tasmanian wilderness has been listed since 1982 by the united nations educational scientific and c ultural organization as a site of world heritage significance signaling a prioritization of economic development over environmental protection the australian federal government issued an unprecedented proposal to unesc o in january 2014 requesting that 74000 hectares of world heritage list forest be delisted and thus available for logging this environmental conflict offered a microcosm within which to explore how increasingly pervasive networked technologies may impact on the nature and dynamics of political protest methodology the internet is changing how we do research for anderson the ready availability of big data and the advances in computing power for storing and sifting through them negate the need for interpretation anderson 4 suggests the new availability of huge amounts of data along with the statistical tools to crunch these numbers offers a whole new way of understanding the world c orrelation supersedes causation and science can advance even without coherent models unified theories or really any mechanistic explanation at all for boyd and c rawford however data lose their meaning without context they 5 note data are not generic there is value to analyzing data abstractions yet retaining context remains critical in relation to research around social media data highfield and leaver advocate a mix of quantitative and qualitative approaches as a way of generating interpretive contextual depth others agree that mixed methods approaches to internet research are essential for making meaningful interpretation of how we engage in social interactions online in this study we employ a mix of research methods and incorporate digital data into our analysis drawing on the specificity of the local environmental conflict described above we acknowledge the significance of context in shaping our interpretation of data to provide an overarching interpretive framework for the study we have drawn on the contructivist grounded theory research of kathy c harmaz c harmaz 6 advocates an attitude of creativity around research design as a way of providing scope for methods to emerge during the study as researchers become familiar with the data essential elements of grounded theory methodology are the minimizing of preconceived ideas around both research problem and data a simultaneous process of data collection and analysis with each informing the other the importance of openness to different understandings of the data and a focus in data analysis on the construction of theory 7 an iterative process of data collection and analysis enables the researchers to develop conceptual categories and analytic themes research design in this study we have combined multiple research methods in order to generate a rich layered research narrative around how the environmental groups campaigning on forest protection use new media to influence public opinion on the issue and mobilize political engagement we make use of phases of network analysis and data visualization quantitative and qualitative content analysis and the analysis of public policy formulation network analysis has evolved from the study of social networks that establish and maintain communities sociologist barry wellman has pioneered the extension of this approach into the sphere of online relational patterns and structures we use network analysis as a means of mapping the relational structures between groups actively engaged online in campaigning around the protection of native forest in tasmania visualization the graphical representation of the network analysis data set can be helpful to assist in analysis as an aid in the identification of patterns within the data and as a basis for further exploration our approach to network analysis draws on the hyperlink as a relational metaphor for shumate and dewitt analysis of interconnected patterns of hyperlinking helps us to understand the social structures underlying the web they 8 suggest hyperlink networks have meaning and are pdfcrowdcom open in browser pro version are you a developer try out the html to pdf api fundamental elements of community creation foundational to the understanding that hyperlinks represent communities is their intentionality these links do not happen automatically or at random the decision to link one organization with another is a strategic communicative choice the hyperlink in this relational sense can convey symbolic meaning affiliation deference even hostility in their exploration of climate change debate online rogers and marres 9 note the significance of meaningful reciprocation greenpeace does not link to shell but shell links to greenpeace in political communication hyperlinks may signify a poor view or negative relationship ackland and gibson 10 note that whilst the environmental movement uses hyperlinked interconnection to collectively reinforce identity for political parties hyperlinks can act as rejection devices representative of a negative symbolic relationship c ontext as we have already acknowledged is everything for this study we used issue c rawler software to locate and visualize an online network of organizations interconnecting around tasmanian forest protection and the tamar valley pulp mill protest this web crawling software runs on servers at the university of amsterdam and its use is shared by an international community of new media researchers the crawl is initiated by supplying the software with a set of web site addresses from these starting points the software maps web sites to which they have hyperlinks in common and completes iterations of this task incorporating the newly discovered web sites the software navigates and records these common linkages until there are no further commonalities to be discovered we provided the issue c rawler with three urls as starting points those of the web sites of the tasmanian greens the wilderness society and gunns limited each of these sites featured prominently in a series of google searches that were undertaken to explore the online landscape around the issue on which the study is focused ie the proposal to build a forestry pulp mill in tasmanias tamar valley whilst gunns limited was the forestry company behind the plans for the pulp mill both the tasmanian greens and the wilderness society were active in the campaign against the proposal each represented stakeholders across civil society the tasmanian greens as an elected political party directly involved in the formulation of public policy and legislation the wilderness society as a national environmental lobby group striving to influence policy on the issue with gunns limited as a significant company in tasmanias forestry industry and a major employer on the island each is reflective of the stakeholder interests involved in attempting to influence the development of public policy around tasmanias forestry industry c ontent analysis provides a way of exploring the content and meaning in online political communication in this study given that each node on our network constituted an organizational web site we used the network analysis data as a sample for a phase of quantitative and qualitative content analysis building on previous content analyses of the democratic affordances of civil society web sites we coded the organizational web sites on the studys network sample for their use of web design and social media to facilitate democratic engagement the lobbying and protest campaigns around the protection of tasmanian native forest in general and the proposed tamar valley pulp mill in particular ongoing since 2006 coincide with a significant increase in the use of the internet for political communication in australia referring back to the questions we discuss in our introduction can online political activism affect change we have used the analysis of policy formulation on forestry and forest protection as a way of engaging with questions of influence and impact our efforts in this regards were due to a fortunate coincidence in 2011 after years of dispute stakeholders from the environmental movement the forestry industry the tasmanian government and australian government negotiated the tasmanian forests agreement findings and discussion the issue c rawler located a network of 50 web sites we categorized the organizations represented on the network in order to identify the nature of stakeholder engagement more than half of the nodes on the network comprised a range of environmental activist and lobby groups the reciprocal hyperlink patterns between the web sites of australian greens federal and state parties and those of their elected representatives constituted a cluster of 13 nodes c entral positioning within the network is dominated by two prominent environmental lobby groups australian c onservation foundation and the wilderness society this central positioning relates to the significance of hyperlinks to them from others on the network with both receiving more links to their web sites than to any other network node political party 13 a significant factor in the context of digital activism is that relational linkages within these environments are often based on homophily the cluster of web sites of the australian greens provides an example from this studys network data the capacity to create links of political affiliation across web sites and social media is a significant strategy in emerging forms of political organization due to the potential to mobilize the public through engagement via their trusted individual personal networks by means of content analysis of the network nodes we explored how web design and social media were being used to facilitate political engagement we used both quantitative and qualitative content analysis combining and extending the coding schemes of burt and taylor and gerodimos these networks of linked relationships become powerful channels to these massive international audiences enabling civil society actors such as the environmental groups represented in this study to extend their limited access to mainstream broadcast media with the communicative possibilities afforded by social media twentyeight organizations on the studys network use new media content within their sites facebook twitter and youtube are the primary social media channels that these groups employ to engage with networked publics and disseminate sharable new media campaign content the wilderness society at the centre of the network has graphical links to its social media channels displayed as a consistent design feature across its web site the use of social networking sites such as facebook and twitter enables environmental groups like the wilderness society to engage with networked publics and potential audiences in order to do so the digital campaign content that these groups create must be easily sharable across social media the addthis social content sharing plugin is embedded within the design of the wilderness society web site enabling sharing of the organizations content across more than 300 social media platforms within a couple of mouse clicks the visual nature of digital media allows organizations like the wilderness society to use emotive imagery of tasmanias native forest to help shape public perception of issues relating to forest protection in this way sharable new media content frames the narrative of forest protection in terms sympathetic to the campaign objectives of the wilderness society the site incorporates embedded functionality that offers visitors the opportunity to enact a relational connection with the organization via social media platforms such as facebook and twitter this creates latent loose organizational structures that can be activated during more intense and focused periods of campaigning another notable feature of sociotechnical functionality within the data was the use of new media to facilitate copresent embodied forms of political engagement the c airns and far north environment c entre an environmental organization from north queensland is pulled into the studys network of affiliation by hyperlinks from the wilderness society and the australian greens c afnec embeds a google c alender widget within its web site in order to encourage those engaging with the organization online to extend that participation through various offline events here we draw attention to calls for those undertaking research involving the internet to avoid a digital dualism a distinction between what happens online and what happens in real lifein their analysis the data from this study supports a position that acknowledges the intertwining of the digital and the material c ontent analysis of the c afnec web site indicates that forms of online and offline engagement can be seen as a spectrum of participation each reciprocating the other the combined analysis of both campaign network and development of policy produced significant findings around the relationship between central network positioning and the capacity to influence policy formulation two nodes dominate central network positioning those representing the web sites of australian c onservation foundation and the wilderness society these two organizational web sites have the highest number of hyperlinks from other network nodes resulting in their central positioning pilny and shumate 11 suggest that for online social movement actors the hyperlink is a public acknowledgement of another and symbol of representational communication by assigning hyperlinks the network as a collective takes shape these patterns position particular organizations within the network enabling their identification with the broader network hyperlinking to symbolize alignment is a practice in selfidentification with and the formation of collectivity ackland and oneil go beyond this to suggest that the giving and receiving of hyperlinks are resources in a hyperlink economy an organizing system within selfidentifying networks as sites with more inlinks are generally higher ranked in the indexing processes of search engines ackland and oneil 12 describe as index authority the status that is created through the inlinks that a site receives pilny and shumate 13 discuss the same concept as hyperlink capital if we think of the web as a network of social relations then who we link to and who links to us becomes significant the numbers of links to a site from others form a significant component of the ranking algorithm of the dominant search engine google the visibility of numeric analytics across social media environments assists in creating an aura of authority significance and standing within online communities the analysis of policy developments helped us to explore the kind of capital that australian c onservation foundation and the wilderness society had to influence legislation around forestry and the protection of native forest in tasmania in 2011 representatives from government the forestry industry and the environmental movement negotiated the tasmanian forests agreement bringing some resolution to the longrunning conflict around the balance between forestry and the protection of native forest on the island these data suggest that online positioning within networks of political action is indicative of the capacity to influence policy the study demonstrates that network data are helpful in understanding organizational features of online social movement collectives such data can also provide indications as to the capacity of specific actors to drive forward agendas of political action within the spheres of institutionalized political power we avoid a simplistic analysis of this relationship however noting that central positioning in online networks and the capacity to influence policy may themselves both be related to economic resources yet the relational structures afforded by the web and social media are of particular importance for civil society diani and ackland and oneil suggest that patterns of hyperlinking reflect the exchange of both symbolic and practical resources in the context of networked social movements actors within social movement collectives are conscious of the resources upon which different organizations within the movement can draw analysis of online social movement networks suggests that those organizations most central within the network receive the most publicity and are the most visible to the media conclusion the data from our study suggest that central network positioning in online social movement structures has a relationship with the capacity to influence the formulation of public policy this positioning is dependent pdfcrowdcom open in browser pro version are you a developer try out the html to pdf api upon the symbolic capital associated with the intentional designation of hyperlinks furthermore this finding suggests that for civil society organizations an awareness of social media analytics and search engine algorithms is necessary for an effective and influential communications strategy furthermore our study highlights several prominent aspects of how civil society groups use the affordances of new media in political campaigning for collectivity and connectivity to campaign and create a narrative and to catalyze mobilization and influence policy the studys findings suggest that hyperlink practices amongst the environmental groups campaigning on tasmanian forest protection are strategic and political reinforcing collectivity and channeling symbolic capital environmental groups use the relational properties of social media to create latent social movement structures enhancing the potential for public engagement through connectivity this is significant given that the personal networks of supporters can be deployed as campaign channels across social media new media can be used to create a powerful narrative that shapes how issues are presented to and perceived by the public the online to offline transfer of participation offers novel opportunities for digital activism and political mobilization about the authors

le cture r school of positioning within social movement online network structures arises from strategic linking practices these strategic communications practices enhance not only movement cohesion but also the visibility of those actors best placed to influence public debate and the formulation of policy

introduction whether they are endeavoring to improve public health or reduce healthrelated social inequities public health officials suggest and initiate increasingly complex interventions 1 indeed the problems they face are most often multidisciplinary because of the diverse social determinants of health 2 these problems therefore require responses that are adapted to local contexts and involve the participation of a number of people they differ from clinical interventions for which the objective is to prevent and treat illness in individuals and which can be handled in a standardized manner 1 these complex social interventions are based on the presumption that they will produce better results than standard individual interventions involve the action of several players in the field consist of a chain process involving several professionals and adapt to the social context in which they occur the implementation of these interventions is not linear it uses the bottomup or topdown model and offers the ability to return to earlier stages of the implementation to adjust and adequately meet the needs of the supporting environment 3 4 5 to illuminate the complexity of these interventions their characteristics are illustrated in table 1 6 by a concrete example based on recent policies in africa intended to eliminate direct payment for health care given the nature of these interventions knowledge transfer in such situations is challenging the popularity of kt has been growing since the 1880s especially in the health sector for example the canadian institute of health research now funds projects that promote the use of researchbased knowledge by potential users there have also been many systematic and critical reviews of the literature they generally deal with transfer of knowledge from clinical research such as the efficiency of strategies that promote knowledge use 7 8 including practice guidelines 9 10 none of these critical reviews deal with kt from research involving complex social interventions in public health despite the major challenge in encouraging interventions based on convincing evidence the rapid development of the research field on the use of scientific knowledge has manifested itself in the emergence in recent decades of numerous terms to refer to the concept of knowledge to action in a study of 33 funding organizations in 9 countries graham and his colleagues 11 identified 29 different terms used including knowledge transfer knowledge translation and knowledge mobilization among others most of these terms have been promoted by research funding agencies for example the canadian institutes for health research are using the term knowledge translation while the social sciences and humanities research council used instead knowledge mobilization although the definition of these terms may sometimes vary different words are mostly used to designate more or less the same thing to avoid this confusion some organisations are now using the term k in this study we use the term knowledge transfer which is still the most frequently used term the knowledge transfer strategies are ultimately aimed at the use of knowledge this study considers three types of knowledge use instrumental utilization conceptual utilization and persuasive utilization 12 with a view to guiding kt research in the field of complex social interventions in public health we examined existing literature on this topic to obtain an overview of the knowledge available more precisely we looked at two distinct aspects kt strategies and the way they are assessed and the manner in which knowledge utilization is measured the objectives of this scoping study are to describe the status of research on knowledge transfer strategies in complex social interventions in the public health field and to identify priorities for future research methods our critical review of scientific literature was conducted as a scoping study 13 this type of review differs from systematic reviews in that the intention is to obtain an overall picture of an issue or field of research in order to assess the feasibility of a systematic review and guide future research it does not assess the effectiveness of an intervention in this study the choice to include or exclude a study was based not on the research specifications but rather on relevance to the topic in question 13 we also included gray literature our study was divided into four steps 1 study identification 2 choice and application of selection criteria 3 data classification and 4 data analysis the review was carried out in accordance with a protocol developed in advance the prisma checklist for this paper is presented as table s1 study identification first the following public health databases were consulted medline eric psycinfo cinahl and the french public health database banque de donne ´es sante ´publique the search in each of these databases was limited to the period from 1960 to october 2010 key words included the term knowledge transfer and its alternative expression as listed in graham et al 11 in english and french the search strategy adopted for the various databases is described in table s2 the tables of contents of two periodicals evidence policy and implementation science were also thoroughly explored next a snowball strategy was applied to the bibliographies of articles identified in the databases and selected for analysis this combination of research strategies was used to find the maximum number of documents on the topic selection criteria the studies selected 1 focused on kt in public health 2 dealt with the use of researchbased knowledge 3 covered complex social interventions in public health 4 provided empirical data 5 were written in english or french and 6 were published in or after 1960 the decade in which the concept of kt appeared in scientific documentation 14 moreover since the objective was to obtain a complete picture of this field of research the type of study specification was not considered as a criterion for inclusion or exclusion with these criteria in mind a first sort was done by consulting titles then document abstracts two reviewers worked independently on this sort on the references obtained from the databases the reviewers agreed 957 of the time differences were resolved by consensus a second sort was then done in which the texts selected during the first sort were read in their entirety data classification the articles selected were distributed to three members of the research team who classified the data and then checked all their table 1 the seven characteristics of complex interventions applied to policies on eliminating healthcare payments in africa complex social interventions … policies on eliminating direct payment … … are theories or consist of several theories … seek to reduce the financial burden on households improve access to health service and provide early recourse to care and so on … involve the participation of numerous stakeholders … involve governments the international community ngos people health agents and so on … consist of a chain of decision processes … assume identification of the problem formulation of the policy implementation of the policy by various players acceptance of the policy by the people and so on … are not linear and are subject to feedback loops … are transformed and adapted by the action and influence of health agents patients decisionmakers and so on work for the specific requirements of this study an assessment framework was developed 15 for this framework the team members looked at the following information authors publication year and location sample type types of knowledge users fields of practice research goals methods measuring instruments and important results the mixed method appraisal tool developed by pluye and his collaborators 16 was used to evaluate the quality of the articles selected on the basis of the method used this tool links five types of research specifications with qualitycriteria questions all of the conclusions from the use of this framework were checked by at least one member of the team and differences were resolved by consensus because it is the only assessment framework that combines evaluation of five types of research specifications quantitative qualitative or mixed this instrument appeared to us to be the most suitable for the study context … data analysis from the grouped data an overall description of all the material was compiled we compared the different studies and found gaps in research on kt strategies and knowledge utilization in complex social interventions in public health results our research identified 1374 potentially relevant references based on the titles and abstracts 341 articles were read for a more indepth examination of these 26 empirical studies were included kt strategies recipients and users table 2 provides the characteristics of the studies on kt strategies the field and type of study strategies and type of utilization were examined 1732 for the target publics we differentiated the recipientsindividuals or groups directly targeted by the kt strategyand the publics concerned by the knowledge in question table 3 gives the characteristics of the studies that measure knowledge utilization 3342 we examined the field of public health the type of study specifications the type of utilization measured and the knowledge users in the articles assessing kt strategies most of the strategies focus only on diffusiondissemination distribution of documentation emailing or development of web sites for example these activities are sometimes accompanied by telephone assistance or training workshops the strategies often involve several dissemination activities distribution of policy briefs and workshops for example only two articles deal with research made in partnership withwith stakeholders one study discusses the knowledge transfer activities made by a liaison centre and one evaluates a kt strategy involving a knowledge broker this strategy is designed to support evidencebased decisionmaking in the organization management and execution of health services the studies generally contain few details about the strategies so relatively little is known about the knowledge concerned the underlying conceptual or theoretical bases or their objectives as for the knowledge users targetedtargeted the two categories most often concerned are administrators or managers of organizations and practitioners few strategies specifically address policy makers or researchers on the other hand many have an organizational component and are intended to bring about a more systemic change as for the target publics they are usually the general public in the united states or canada some of the strategies assessed deal with knowledge relating to preschoolers or school children but few target women or actual patients in the articles that measure research utilization we identified three main categories of users administrators or managers practitioners and policy makers most of the studies deal with research utilization what type of use for which field of public health we classified the studies according to the public health field and the type of utilization in general most of the articles dealt with instrumental utilization particularly in public health and health promotion it is interesting to note that some studies specifically in these two areas discuss conceptual utilization persuasive utilization is very rarely considered in the studies research specifications and study quality tables 6 and7 show the results produced by the mixed method appraisal tool developed by pluye et al 16 table 6 shows the relationship between the research specifications and the three types of research utilization regardless of the research specifications the studies deal mainly with instrumental utilization of knowledge except for the qualitative studies that also take conceptual utilization into account table 7 shows the research specifications regarding study quality in decreasing order of frequency the studies are based on qualitative quantitative nonrandomized quantitative randomized mixed methods and descriptive specifications overall the quantitative studies are based on data sources and analysis techniques that answer the research question and take the context into account however in half of the qualitative studies the researchers did not specify their a priori considerations or the impacts of these assumptions on interpretation of the results most of the quantitative nonrandomized studies include participant recruitment mechanisms that reduce selection bias have a response rate of at least 60 and explain the comparison between the groups sampled over half of the studies use measuring instruments whose psychometric properties are not welldocumented as for the quantitative randomized studies half do not provide a clear description of the selection method or attrition information while threequarters of them have less than 20 missing data in the studies using mixed methods application of the pluye et al 16 criteria shows that the specifications chosen are relevant for meeting the research objectives in addition half of the studies explain the integration of the qualitative and quantitative results and only one article does not provide the limits of this integration two studies use a quantitative descriptive specification the sampling strategies appear relevant for answering the research questions the samples seem representative of the population and the response rates are greater than 60 the measuring instruments are rarely described well enough to judge their quality more specifically reliability and validity are rarely reported discussion and conclusion limits of the study one limitation is related to the study topic the definition of complex social interventions was particularly difficult to pin down from the literature on the one hand this term incorporates two concepts that are still not welldeveloped complexity and the social nature of an intervention which makes it difficult to obtain a precise definition articles often comment superficially on the knowledge behind the kt strategy that is being assessed and we sometimes needed to do additional research to determine what this knowledge was this was not always possible so we decided to include false positives ie studies for which the knowledge behind the kt strategy does not necessarily involve a complex social intervention on the other hand a more restrictive or broader definition of this expression might have made the composition of the pool of articles somewhat different with regard to mixed method appraisal tool analysis of study quality it would be necessary to contact the authors of the articles when the response to one of the screening questions was incomplete after reading the articles owing to lack of resources we were unable to do this our description of quality is therefore based exclusively on the information available in the article and the way in which the authors presented their study status of research on kt and areas for future research we found relatively few studies dealing with our research topic kt strategies for complex social interventions in public health the definition we chose may have reduced the pool of existing studies these concepts are recent and the definition is still fuzzy furthermore as we have seen the vast majority of identified studies have been published over the past ten years thus this field of research is recent not yet welldeveloped and involves major methodological challenges for researchers since not much knowledge is available on the effectiveness of this type of intervention it is not surprising that research on knowledge transfer to user groups remains limited neither was it surprising that no studies were found on kt strategies for complex social interventions in environmental health or health administration it is also possible that the search strategy was unable to track down specialized literature in these areas kt in public health is therefore a field of study that remains to be explored in addition to these contextual comments we observed that most of the included studies deal with instrumental utilization of knowledge whether relating to assessment of kt strategies or measurement of knowledge use despite the methodological challenges involved in this type of study we can suppose that they are not as great as for studies of conceptual or persuasive utilization what method should be preferred what measurements are appropriate what measuring instrument should be used what construct should be studied as weiss noted in 1977 future research should pay attention to these questions as a number of authors 1143 mention the significance of these types of utilization in complex decision making moreover the effects of a kt strategy on instrumental utilization can be measured in the short term and is evident in observable behavior even though knowledge use is a process that can continue in the medium and long terms researchers may therefore tend to prefer to study this type of use when other types of utilization are considered such as conceptual utilization the effects are not evident in observable behavior and this makes their study more complex since the effects of kt strategies on knowledge use can appear in the short medium and long terms the choice of the appropriate time to assess a kt strategy also poses a challenge the question of what methods to use to assess kt strategies or measure knowledge use is closely tied to these challenges few studies use mixedmethod design or descriptive quantitative design although descriptive quantitative design may impose limitations on evaluation of this type of relatively complex intervention the use of mixedmethod design appears to us to be worth exploring given the complexity of kt strategies and the extent of the potential effects and considering the added value of these methods in enhancing understanding of a phenomenon 45 it seems obvious to us that mixedmethod studies should be used more the issue of study quality is also pivotal aside from the aforementioned limitations of using the mixed method appraisal tool our results clearly show that it is premature to conduct a systematic review cochranestyle for example on this specific study topic firstly few studies could be included in such a systematic review because of their methodological attributes secondly the methodological weakness of most of the studies would limit the scope of the systematic review results as for measurement of knowledge use we noted that the studies devote little explanation to the measuring instruments used which makes it difficult to evaluate the quality of these instruments and by extension the quality of the results produced finally this study has shown the preponderance of evaluations of strategies limited to diffusiondissemination yet thanks to studies of factors that promote knowledge use we now know that diffusion and dissemination alone have a very limited impact it is therefore surprising to see the limited number of more complex strategies implemented 43 44 45 46 we now know that oneway pushpulltype strategies are often insufficient to promote knowledge application 1047 compared to twoway strategies 48 there seems to be a gap between existing knowledge about effective strategies and the strategies that are actually implemented this being said the task here was to identify studies that evaluate kt strategies and not to identify the strategies themselves we can imagine that more elaborate strategies are now being implemented but have not yet been researched we also wonder whether the methodological challenges and lack of funding are responsible for limiting researchers interest in this type of intervention finally with regard to the second objective of this study we think that future research on kt strategies involving complex social interventions in public health should consider that n some reflection is required regarding the methodological issues raised by kt studies in general and more specifically on measurement of conceptual and persuasive utilization of knowledge n we encourage the organizations involved in kt to describe the conceptual and theoretical bases of their kt strategies this would help researchers understand the logic behind the kt strategies and assess their plausibility relevance and validity which is rarely done n future research should focus on two aspects assessment of kt strategies used in complex social interventions with explicit descriptions in the articles of what knowledge is involved and assessment of more complex elaborate kt strategies not just diffusiondissemination strategies n lastly a brief look at the web shows a lot of activity surrounding knowledge transfer and a multitude of strategies of all kinds that are being used in the world however although much has been written on the theory of the potential effects of these strategies and the factors that promote their use convincing evidence remains limited 43 49 50 51 52 consequently we think researchers should endeavor to develop assessment projects for various kt strategies and publish their results so that this knowledge can be utilized supporting information

objectives scientific knowledge can help develop interventions that improve public health the objectives of this review are 1 to describe the status of research on knowledge transfer strategies in the field of complex social interventions in public health and 2 to identify priorities for future research in this field method a scoping study is an exploratory study after searching databases of bibliographic references and specialized periodicals we summarized the relevant studies using a predetermined assessment framework indepth analysis focused on the following items types of knowledge transfer strategies fields of public health types of publics types of utilization and types of research specificationsfrom the 1374 references identified we selected 26 studies the strategies targeted mostly administrators of organizations and practitioners the articles generally dealt with instrumental utilization and most often used qualitative methods in general the bias risk for the studies is highresearchers need to consider the methodological challenges in this field of research in order to improve assessment of more complex knowledge transfer strategies when they exist not just diffusiondissemination strategies and conceptual and persuasive utilization

theoretical frameworks suggest that individuals typically drink for a variety of reasons but most often due to social influences andor coping motivations individuals who drink to cope consistently demonstrate more problematic drinking outcomes compared to those who drink for social reasons warranting special attention to coping motivations as an explanation for heavy drinking alcohol use has long been described as a coping strategy whereby drinking reduces unwanted internal experiences related to stress in addition heavy drinking has been robustly linked to a variety of stressors including relational problems such as marital disruption intimate partner violence and childhood abuse as well as indicators of social disadvantage such as neighborhood disorder poverty and involuntary unemployment south africa presents a uniquely challenging environment with numerous stressors especially for women levels of poverty and unemployment in many areas of south africa are among the highest in the world with particularly scarce employment opportunities for women in the densely populated urban townships originating from the apartheid system the social fabric is highly disrupted characterized by communitylevel crime and disorder as well as fragmented families moreover prevailing patriarchal beliefs and practices have fostered a context in which women face disproportionately high rates of abuse violence sexual coercion and rape up to 40 of south african women have experienced some form of sexual violence during childhood and nearly 50 women will experience physical andor sexual intimate partner violence during their lifetime given this setting fraught with cumulative stressors it is possible that south african women engage in heavy drinking in large part to cope with these stressors to examine this theory the current study employed a qualitative approach to explore womens narratives of drinking not only to understand whether their drinking might be related to life stressors but also to elicit in their own words the meanings and motives of drinking in the context of these stressors and how drinking behavior unfolds in this particular cultural setting given that womens experiences of alcohol use are typically overlooked this study has the potential to illuminate underlying factors that lead women to engage in risky drinking behavior and thereby inform interventions for hazardous drinking and its sequelae in this population methods setting the study was situated in delft a rapidly growing township 15 miles outside of cape towns city center delft was established in 1990 for residents of both black african and coloured ethnicities in delft community resources and local infrastructure are limited and socioeconomic indicators point to high rates of poverty and hardship according to the most recent available census data only 10 of residents had completed a high school education over half were unemployed and 60 reported an annual household income below 19200 south african rand this study was embedded as the qualitative component of a mixedmethods study conducted in alcoholserving venues in the township study venues were selected from 124 local shebeens and taverns identified in the community through key informant interviews of these 124 venues 38 met the studys eligibility criteria because they had seating area for patrons served over 50 unique patrons per week with more than 10 female patrons and were willing to participate for the length of the study of these 12 venues were purposively selected for geography patronage size and predominant ethnicity to achieve a diversely representative set indepth interviews interviews were conducted by south african field workers trained in qualitative methods and matched to the venues based on the dominant race and language of the patrons prior to the interviews the field workers conducted systematic observations in their assigned venues to develop rapport with the owners and patrons women whom the fieldworkers observed to be regular patrons at each venue were recruited into a cohort that completed quantitative assessments over the course of a year from this cohort individuals who appeared to offer insight on the venue andor community were invited to participate in indepth interviews after written consent interviews took place in a private room at the study office located in the delft public library the interviews were conducted in the language most comfortable for the participant and audiorecorded with the participants permission interview questions followed a semistructured guide that included openended probes on life history alcohol use and various potential stressors such as employment family romantic relationships and experiences of violence to probe further into themes regarding drinking in response to stressors followup interviews were conducted with 12 women identified by the local fieldwork team as having potential to provide deeper insight on this topic participants were compensated with a grocery card in the value of 100 rand all study procedures were approved by the institutional review boards at duke university university of connecticut and stellenbosch university analysis audiorecordings of the interviews were transcribed and simultaneously translated into english following a grounded theory approach an analytic memo was written from each transcript to summarize and organize themes incorporating quotes to maintain fidelity to the participants words and narrative the first three authors wrote the memos and each memo was discussed by at least two authors to ensure it captured the primary issues from the transcript the complete set of memos was then uploaded to a qualitative analysis software and coded for text related to reasons for drinking and drinking in the context of stressors memos were further examined for reports of past or current stressors the three authors independently reviewed the coded output to identify emerging concepts and themes the authors then discussed and reached consensus on key thematic categories and representative quotes for representative quotes the corresponding memo and transcript were revisited in order to contextualize participants words within their overall narrative the local fieldwork team reviewed the findings and confirmed the data interpretation to characterize the study sample demographic characteristics and levels of alcohol use were extracted from the cohort assessment data alcohol use was measured using the 10item audit which assesses frequency and quantity of drinking hazardous drinking was defined by a score of 8 or higher the fouritem cage questionnaire was used to screen for problem drinking endorsing any two of the items was indicative of a high likelihood of engaging in problem drinking results description of the sample the sample consisted of 54 women who were regular patrons at the 12 study venues the average age was 35 years ranging from 18 to 55 about half of the women identified as black and the other half identified as coloured most women were unmarried although the majority reported having children only 5 women in the sample had completed a high school education analysis of the qualitative transcripts revealed that 1 women drank in the context of stressors 2 they were motivated to use drinking as a coping strategy in order to facilitate emotion management social engagement and a sense of empowerment and 3 although the women drank to cope they also recognized the limitations of this strategy description of life stressors the women in our sample described a constellation of stressors in their lives physical sexual and emotional abuses were common women shared painful experiences from childhood in which they had been regularly abused by a male relative or generally mistreated or abandoned by their families reflecting on their adult lives women talked about romantic partners being abusive or even cruel for example exhibiting jealous and controlling behavior beating them up threatening to hurt or kill them and demanding or forcing sex also common among women were accounts of relational infidelity many described their husbands or boyfriends cheating on them having affairs sleeping around with various girlfriends and leaving home to live with other women women expressed not only being distressed about their partners infidelities but also anxious about contracting sexually transmitted diseases as a result a portion of women reported they had since separated from their unfaithful or abusive partners but divorce was often characterized as a major emotional and financial stressor itself experiences of chronic poverty and unemployment were also apparent in this sample food insecurity was common 74 of the women reported that in the past month they or someone in their household went for a whole day without eating because there was not enough money for food in addition the majority of the women were unemployed and in some households the entire family was unemployed and lived primarily on social grants from the government the home environment was often an additional stressor houses were described as crowded consisting of one or two rooms with many residents 378 of the women lived in households with six or more people and four of the women lived with 10 or more people against this backdrop women talked about chaotic lives marked by interpersonal conflicts including harsh treatment and criticism from family members problems with rebellious children and strained relationships with unsupportive mothers other stressors consisted of more discrete onetime experiences which included instances of violence and loss for example about one fifth of the sample disclosed being victims of assault such as being stabbed attacked or raped and even more women mentioned the fear or threat of such violence other women shared accounts of material loss through robberies or fires more than half of the women talked about the early andor recent loss of loved ones including children women reported a range of reactions to stressors which sometimes persisted beyond the stressors themselves several women with traumatic or abusive histories talked about having intrusive memories andor vivid nightmares that were suggestive of posttraumatic stress responses as described by one woman who experienced emotional abuse in her first marriage sometimes it feels like a movie that is being played back at you losses of loved ones even if they had occurred several years ago were commonly linked to unresolved feelings of grief which would emerge through displays of distress and crying during the interview women in more generally stressful situations tended to describe feelings of anger helplessness and frustration as well as somatic symptoms such as headaches and high blood pressure others spoke of being depressed miserable some even to the point of not wanting to be alive anymore drinking in the context of stressors heavy drinking was common in our sample with over 75 meeting established criteria for problematic alcohol use andor hazardous drinking when asked why they drink alcohol many women spontaneously cited past or current stressors as an explanation i drink i think because i have marital problems one woman explained according to another woman who had over the years lost her husband and children the reason why i am drinking is all of the hurt i had to endure in my life women related the initial onset of their hazardous drinking to life stressors when i started drinking i had stress said one woman referring to her separation from her exhusband indeed a number of women described how their drinking began at the same time a stressful situation was occurring in their lives things started at home which made me drink several reported that their drinking started the day they discovered their partners infidelity according to one woman when he cohabitated with this woman thats when i started drinking heavily other women linked the onset of their drinking to distinct traumatic experiences for example one woman acknowledged after the rape incident i had many boyfriends and i started drinking a lot women also linked their life stressors to the severity of their drinking behavior in one womans words the reason why my drinking increased is because i had a disappointment in my life relational stressors were frequently cited as an explanation for elevated levels of drinking my marriage isnt right… thats why i drink so much said a woman who had recently separated from a husband who was abusive and unfaithful this experience was echoed by another i am drinking a lot because of the problems my husband has brought in my life he beats me up daily generally women talked about drinking more heavily during periods in their life when they were experiencing problems conversely some explained that when stressors were resolved their drinking levels decreased now that i work im not drinking as much because things are better now stressors were also sometimes described as triggers for discrete episodes of drinking for example one woman shared how she felt an urge to drink when upset by her delinquent sons actions that made me stress so last night i decided to buy more beer in such cases drinking was characterized as a behavioral response that would directly follow a stressful experience for some women stressors appeared to catalyze drinking episodes beyond their control sometimes i want to stop drinking but then something stressful happens how women use drinking to cope with stressors our analysis revealed that women were motivated to use drinking to cope in three major ways first women reported drinking in order to manage their emotions by increasing positive feelings and decreasing negative feelings second women pointed to drinking in the venue as an avenue for social engagement which enabled them to escape stressful situations and find social interaction and support third women felt that drinking provided a sense of empowerment that allowed them to be more assertive act in selfprotection and challenge unequal interpersonal dynamics emotion management increasing positive feelings many women mentioned that they drank alcohol for its hedonic properties that is drinking makes them feel good references to pleasure and enjoyment of alcohol were many i drink for enjoyment i just enjoy it i just only drink to gain that enjoyment one woman even described drinking as her only source of enjoyment in addition drinking was described as a way to facilitate fun and excitement women conjectured that it could be that i drink to have fun or to heighten my sense of fun they explained that alcohol had positive effects on their mood and demeanor often they said consuming alcohol made them feel happy or free several mentioned that they felt more talkative and friendly after drinking it allowed them to laugh and be happy again in general women talked about the happiness energy and wellbeing they felt they lacked in their daily lives and being able to access these states solely through drinking as one woman described it i can say i feel right… what can i say i become human then decrease negative feelings many women endorsed the notion that drinking would help ease the pain in their lives and reduce the impact of unwanted internal experiences such as tension sadness and anxiety sometimes i drink for the fun but mostly it is for the depression i am going through women talked about using alcohol to numb themselves to distressing stimuli for one unemployed woman who was experiencing conflict with family members drinking to the point of intoxication would physically dampen her senses to criticisms at home when i go home after drinking i wont hear what they scold me about according to many women drinking alcohol also served as a way to release physical and emotional tension related to stressors i need to drink to calm me down said one woman another explained it relaxes my mind in moments of stress drinking was also described as a way to feel sorted out when restless and was often cited as a sleep aide in addition women frequently suggested that their drinking was motivated by a desire to mentally disengage from stressors rather than confront them as one woman explained you dont want to deal with your problems you just go on and drink again women shared that drinking allowed them to avoid unwanted thoughts when you drink you stop thinking about a lot of things they described drinking as a way to cloud their thoughts to forget for a little bit about their life and problems and in many cases to completely clear their minds there is nothing i think about when im drinking on the other hand when i am sober i think about everything said one woman who was dealing with divorce and conflict at home when the weekend comes and i drink my alcohol i dont think about my problems anymore when the alcohol is finished i stress a lot social engagementin addition to noting the effects of alcohol itself the women also reported finding relief in the drinking environment women pointed to social engagement in the venue as a way to escape from stressful contexts find interaction with others and garner support to deal with their problems escape women reported finding mental escape in the shebeen or tavern that was not possible at home drinking in the venue was often characterized as a way to avoid solitary contexts in which distress could arise one woman expressed a common sentiment if im at home then i will just think about my problems thats why i go and drink over the weekends in particular several women noted that the presence of others in the drinking environment provided a distraction from ones own thoughts according to one woman i dont think about a lot of things when im around people this was echoed by a woman who linked her drinking to the loss of her husband and children when i am alone with my thoughts i get sad… if i am around people i am ok in addition to the mental escape they found by drinking in the venue women also reported a sense of physical respite from difficult or stressful environments unemployed women talked about how going out to drink was a relief from the mundane life of staying at home and many women explicitly contrasted the shebeen or tavern to their homes at home it is another environment things at the venue are different for example nobody is abusing me or treating me badly specifically women found the drinking venues to be relaxing safe and pleasurable in comparison to their unhappy home lives fraught with stressors such as isolation physical crowding food insecurity and interpersonal conflict going out to drink was a way to physically escape these circumstances as one woman who fought constantly with her mother described she drank at the venue to get out of the house i feel trapped and claustrophobic and need to get out interaction another reason that women expressed for drinking was the opportunity to interact with others in the drinking environment women shared that they enjoyed being able to meet new people and to chat with them as one woman explained if i am stressed it is nice being there at the venue … you see and hear a lot of things from others that sit there women mentioned the stimulation of simply being able to mingle with and watch other patrons i enjoy things there that i wont see at home such as people dancing or performing drinking and being happy they also referred to participation in social activities at the venue as relaxing and enjoyable support the community within the venue also provided women with the support they otherwise lacked at home women who spoke of feeling isolated and neglected in their homes said they were attracted to the venue for the chance to connect in positive ways with other people i just disappear from home and then i go to the venue to have conversations with my friends laugh with them one woman said many women characterized the drinking venue as their second home we all know each other at the venue we make jokes… we are like family they often spoke of the drinking environment as providing a tangible sense of connection community and social support drinking in the venue also seemed to facilitate conversations that could lead to shared advice or problem solving one woman explained that when she was experiencing a problem or stressor having a beer in the venue would give her the chance to talk to someone another woman talked about how drinking allowed her to connect more candidly and genuinely with people regarding her stressors in this context i become very open and even talk about personal things that were bothering me she expressed that drinking helped her to share her burdens with other people something that was not often done outside the venue sense of empowermentin a context where women often feel disempowered due to imbalanced relationships and prevalent maltreatment women talked about how drinking seemed to enable them to challenge the status quo that produced or maintained their stressors assertiveness many explained that drinking would allow them to lose their shyness and finally express their thoughts and feelings regarding their life stressors according to a woman who linked her drinking habits to her husbands marital affairs there was a stark contrast in her courage and ability to verbally assert herself in the relationship before and after drinking if im sober i dont have anything to say but when i have a couple of beers in me i have the power to speak my mind the verbal expression that emerged after women drank alcohol also seemed to help them to get emotional burdens off their chest one woman shared that whenever she was drunk she was able to address past hurts with her mother to tell her how she treated me all these years as if i am someone she picked up on the street action and selfprotection women shared that drinking made them bold not only in what they dared to say but also what they dared to do as one woman said alcohol gives me confidence you can do anything you have no fear after drinking alcohol no matter what happens you are ready for it unafraid a number of women talked about becoming more able to fend for themselves when challenged i am strong… i can fight and defeat anyone who stands in my way even to the point of physical aggression and retaliation against abusive partners in addition one woman seemed to believe that her fearless behavior after drinking helped deter a potential assault you can defend yourself… one evening i walked from the pub and three guys were approaching me… i walked through all of them… alcohol can make you strong challenge unequal interpersonal dynamics women recounted how drinking allowed them to challenge the existing power dynamics between themselves and others for one woman drinking established her authority over her delinquent sons so they could no longer take advantage of her i keep telling my children that they can take me for a ride when im sober but they should not try that when i have a drink in me if they see me drinking beer they know that their mother is on the war path similarly another woman said her boyfriend would normally beat her up but would become afraid of her whenever she was drunk because she would fight back one woman whose boyfriend would often get drunk and speak badly to her said that her motivation to drink was so she could be like him many other women shared this view of drinking as enabling them to contest the typical roles in their romantic relationships for instance one woman described herself as usually tolerant of her husbands abuses however she noted when i am drunk and then he messes with me then he has a problem limitations of drinking as a coping strategy while women explained their drinking in terms of how it helped them deal with their stressors they also acknowledged its limitations as a coping strategy in particular they pointed out their awareness that relief is temporary and that drinking can in fact exacerbate existing stressors relief is temporarywomen explicitly recognized that drinking does not truly resolve their problems or remove their stressors because the mental and emotional relief it provides is shortlived drinking does not always work because if you are drunk you feel okay but tomorrow that problem is still there moreover most women seemed aware that drinking is just something for now a temporary distraction from their stressors when the effects of the alcohol dissipate and they become sober not only do the stressors remain but the unwanted thoughts and feelings return nevertheless despite recognizing these ephemeral effects many women continued to drink in order to gain temporary relief according to one woman its just to feel good for a little bit and forget for a moment drinking can exacerbate stressorswomen noted that drinking sometimes has the unintended effect of increasing levels of emotional distress rather than easing them alcohol may actually bring to surface anger and anxiety according to one woman when drinking it feels everything becomes too much… i am getting mad indeed several women noted that alcohol seems to amplify the impact of their stressors such that they think more about problems when… drunk women also reported that drinking heightens uncontrollable emotions that could be harmful to their mental health and wellbeing one woman described when i drink i feel like i want to commit suicide i only feel like that when im drunk women also recognized that drinking can increase the likelihood of exposure to stressors for example they revealed that when drunk they are actually more likely to experience and even elicit the interpersonal conflicts such as fights arguments and abuse that they were trying to avoid by drinking one woman identified her drinking as problematic for relationships at home when i am drunk and go into the house my mother makes sounds or swears at me then disagreements start other women noted that drinking could increase their exposure to traumatic events such as sexual assault moreover in this sample it seemed that a habit of heavy drinking increased the burden of poverty and unemployment women talked about how they must drink on the weekends despite having to borrow money or sacrifice basic expenditures to do so discussion this qualitative study explored narratives of drinking as a coping strategy among female drinkers in south africa consistent with known patterns of alcohol use in this setting most women in our sample reported drinking at heavy levels the array of chronic and acute stressors they described including poverty unemployment marital disruption relational abuse and violence also reflected previously reported conditions in socioeconomically disadvantaged areas of south africa given that such stressors have been associated with increased alcohol consumption in other settings it was therefore not surprising that women framed both the onset and continuation of their drinking in the context of their stressors despite being aware of the limitations women were motivated to use drinking as a coping strategy in particular to manage their emotions engage socially and achieve a sense of empowerment these findings highlight how womens motives for drinking in the context of stressors are multidimensional and complex underscoring the need for multifaceted modes of intervention in this setting existing theories of alcohol use posit that individuals use drinking in part to regulate internal experiences perhaps reinforced by the intoxicating or anxiolytic effects of alcohol notably a number of women disclosed symptoms of distress depression and anxiety citing them as triggers for heavy drinking episodes in response to stressors drinking heavily to manage affective states is a process referred to as selfmedication the selfmedication model has been studied extensively in western settings but deserves further investigation in south africa our data gives preliminary support to this theoretical framework in south africa by illustrating how management of emotions through drinking was achieved through two psychologically distinct avenues the enhancement of positive feelings and the reduction of negative feelings in addition though our qualitative study did not assess posttraumatic symptoms in detail it is possible that women drank heavily to manage these symptoms as well corroborating this idea a recent quantitative study in this township setting has found that womens ptsd symptomatology mediates the relationship between trauma history and levels of hazardous drinking the motivation to selfmedicate ptsd symptoms may thus help to explain the link between traumatic life experiences and substance use a pathway which has been well documented in both south african and western contexts while literature on drinking as a coping strategy has often focused on the effects of alcohol as a substance our study suggests that the act of drinking is also intertwined with the characteristics of the drinking environment womens narratives revealed that they saw drinking as a way to situate themselves in an alternative setting where they could escape stressful contexts and access social interaction and support although belonging and affiliation are an established component of drinking behavior these motivations may be especially salient in lowresource settings where alcoholserving venues serve as one of the only social and entertainment outlets consistent with literature that characterizes drinking as an avoidant coping strategy women in our study reported that drinking facilitated mental disengagement from stressors and provided literal escape from stressful contexts however we found that drinking could also be classified as an approachbased strategy women would sometimes drink in order to share their problems more openly as well as to solicit support and advice from others conceiving of drinking as purely avoidant or escapist may diminish the fact that it can also represent womens efforts to attend to difficult and often entrenched stressors as further evidence of an approachfocused strategy women endorsed the idea that drinking not only enabled them to find relief from stressors but also to confront and challenge those stressors women spoke of how drinking seemed to empower them to assert themselves in relationships and to defend themselves from violence and abuse in essence to challenge gender hierarchies and become like men through their drinking these findings can be examined within the framework of gender theories historically and across different cultures alcohol consumption has been a way to demarcate gender roles and differences with drinking as a symbol of male privilege and drinking venues as a predominantly male domain drinking has also been associated with power typically demonstrated by men showing aggression against women while these constructions have not been fully explored in south africa there is anecdotal evidence that similar conflations of drinking masculinity and power are still being reinforced in this setting thus by drinking south african women may be in part seeking to challenge these norms not only by adopting a traditionally maleprivileged behavior but also by using drinking to enact the aggression and power typically associated with drinking of course it could be argued that heavy drinking may inadvertently reinforce those same gender inequalities by increasing womens risks for sexual violence and victimization however our findings suggest that despite awareness of such risks women still conceptualized drinking as a compelling avenue for achieving a perception of strength empowerment and equality our qualitative study collected rich narratives from women attending alcoholserving venues and provided insight into their varied motivations for drinking which would not have been possible through quantitative methods however as with all qualitative inquiry our analysis is influenced by subjective interpretation though every effort was made to remain true to the data and to confirm interpretations with the study team while drinking as a coping strategy came through as a dominant and consistent theme across our sample it is possible that framing of drinking in this way was partially influenced by social desirability prior research in south africa has found that unlike men women who drink in alcoholserving establishments are often seen as not virtuous or respectable and some may even feel the need to drink secretly in a setting where womens drinking behavior is generally frowned upon it may seem more acceptable for our respondents to attribute drinking to life circumstances rather than to addiction or simple enjoyment it is also possible that some women justified their drinking as a response to stressors when in fact their drinking may lead to or at least increase their vulnerability to such stressors based on our data we can only speculate on the direction of the pathway between stressors and drinking a cyclical relationship may exist in which drinking leads to stressors stressors motivate drinking drinking exacerbates stressors and so on finally this study has limitations to generalizability participants in the study were purposively selected because they were regular patrons at alcoholserving venues women who preferred to drink in their homes and did not attend the venues may have other motivations for drinking or use alcohol to cope in other ways our findings reveal several significant avenues for intervention to reduce heavy drinking in this setting to decrease womens tendencies to rely primarily on alcohol during stressful circumstances therapeutic services and psychoeducation could be provided to help women manage their stress and emotions perhaps by drawing on other strategies to enhance positive emotions and cope with negative ones to identify promising coping alternatives future research could also examine nondrinkers in this setting in order to uncover factors of resiliency in the context of stressors our findings also point to a need for communitylevel interventions through fieldwork experience in this setting we know there is currently a dearth of sites for women to relieve stress or simply get away from their homes and that alcoholserving venues currently fill this gap exploring local opportunities for diversion and social interaction as well as education and employment could help to reduce heavy levels of drinking in addition the abundance of interpersonal and homebased stressors described by the women suggests that interventions focusing on the family unit and addressing the quality of romantic relationships could be helpful in reducing key stressors and therefore curbing excessive drinking finally our findings on womens efforts to achieve a sense of empowerment through drinking raise implications for broaderscale change in a context where women are extremely vulnerable to abuse and violence interventions that address gender inequalities and foster conditions of empowerment for women are needed such interventions may provide opportunities in the venue environment to discuss norms and stereotypes related to womens roles as well as cultural concepts and expressions of masculinity in conclusion our study found that women have complex motivations for drinking in the context of stressors motivated attempts to use drinking as a coping strategy may maintain a cycle in which women experience stressors and then drink only to experience further stressors and drink again this study thus provides a framework for understanding the prevalence of heavy drinking behavior both in our sample and among female drinkers in south africa which in turn can guide efforts to reduce hazardous drinking in this setting biographies

this study explored narratives of drinking as a coping strategy among female drinkers in a south african township in 201011 we conducted qualitative indepth interviews with 54 women recruited from 12 alcoholserving venues most women drank heavily and linked their drinking to stressors they were motivated to use drinking to manage their emotions facilitate social engagement and achieve a sense of empowerment even while recognizing the limitations of this strategy this study helps to contextualize heavy drinking behavior among women in this setting multifaceted interventions that help female drinkers to more effectively manage stressors may aid in reducing hazardous drinking

i introduction i mproving road network efficiency is often the main objective of traffic authorities to that end authorities aim to direct the network state from a user equilibriumentailing an equal distribution of travel time among travelers resulting from the personal optimization of their own route choicestowards a social system optimum in which the total travel time within the road network is minimized in this some travelers need to choose route alternatives with higher travel times to the benefit of the system as a whole resulting in a less equitablethough socialnetwork state in other words travelers need to act socially and choose social route alternatives conventional steering approaches to direct travelers towards these social routes are road pricing and the use of personalized incentives however with advances in information communication technology the application of realtime traffic management using personalized information strategies becomes more promising as a result the application of informationbased travel demand using social routing advice is receiving increasingly attention in real world it is more likely to observe a user equilibrium than a system optimum although the system optimum is the desired state from a collective perspective it is generally difficult not only to achieve it but also to maintain it over time in this paper we argue that this instability and unattainability of the systemoptimal traffic state is related to market penetration and compliance of the corresponding control or routing strategies and that resulting intrastate and interstate travel time differences should be considered when looking at the acceptance of a socialrouting service several studies explicitly consider the possible impacts of social routing with respect to one of the abovementioned factors in isolation many of them assume full market penetration or full compliance to a social routing service others adapt the travel time function so that travelers value the social outcome besides their own travel times and thereby partially ignore intraand interstate travel time differences the assumption of full market penetration and full compliance might hold in the case of autonomous vehicles in other cases it is unlikely that all travelers will use an information service for their trip let alone a social routing service or follow the recommended social routes moreover most studies on the potential impacts of social routing only evaluate network efficiency while network efficiency is important to traffic authorities travelers are more concerned with personal travel time as such some recent studies propose social routing algorithms that take into account interand intrastate travel time differences 2 4 6 in assessing impacts most studies present findings on a relatively aggregated level however it is in fact the individual impact and the corresponding acceptance that determines the success of a social routing service the efficiency of the systemoptimal traffic state and the associated instability and unattainability is often assessed with respect to simplistic road networks consisting of a single origin and destination and only two or three route alternatives eg 5 6 or similar smallscale networks eg 7 a study by çolak et al 1 shows differences in the percentage of potential savings achieved between a single commodity network compared to five realworld city networks this suggests that studies using small road networks do not capture all dynamics that play a role in realworld networks in this study we propose and apply a novel framework that assesses the impact and related acceptance of social routing services on realworld networks we overcome abovementioned shortcomings by a combination of aspects first of all our study evaluates the potential impacts of social routing on both network efficiency and equity thereby we explicitly investigate the interaction between efficiency equity and market penetration of a routing service on a disaggregated level second we use a largescale realworld road network to enhance external validity and apply several compliance rates in addition we pay special attention to the spatial distribution of social travelers among origins and destinations and the corresponding interaction with network equitability that might influence network performance we discuss our findings in light of observed individual compliance behavior and market penetration obtained from a field experiment this experiment assessed whether travelers are willing to take a detour to the benefit of the road network when they are being asked or advised to do so in dailylife 8 by these efforts we complement abovementioned studies and are able to identify the potential of informationbased demand measures in improving road network efficiency using social routing advice in real world the remainder of this paper is structured as follows section ii provides the research background subsequently section iii describes the used methodologies for traffic assignment we present the results with respect to network performance and equity in section iv and we interpret these results in light of the observed compliance behavior in section v finally this paper presents key conclusions in section vi ii background when all travelers choose their routes socially and a pure system optimum is achieved up to 25 of total travel time could theoretically be saved compared to a user equilibrium 9 in realworld networks however savings up to only 10 of total travel time would typically be attained see eg 2 10 and potential savings depend on prevailing congestion levels eg 11 actual traveltime savings highly depend on travelers willingness to take the detour due to low compliance rates in response to social routing advice aforementioned potential savings might never actually be achieved in reality however part of the potential savings could be attained by introducing an acceptable social routing service route assignment strategies aiming at system optimal network conditions face equity issues from the perspective of route guidance and traffic assignment interpersonal equity refers to the distribution of travel time among travelers in a certain road network to be more specific comparable groups or individuals are treated similarly 12 eg individuals travelling between the same origin and destination should have similar travel times moreover individuals have internal standards based on both previous experience and common knowledge to which they compare their own outcomes as well ie intrapersonal equity 13 as a result a route advice that burdens a certain individual with a longer travel time than he is used to will not be easily accepted these equity issues might be important in the acceptance of and compliance with systemoptimal route guidance pigous example shows that in a system optimum travel times on the detour route are twice as high as travel times on the shortest route in more realistic road networks jahn et al 2 found detours with travel times of 12 to 21 times as high on the other hand levy et al 6 demonstrated that although a static system optimum is unfair alternating single travelers between sacrificing and gaining travel time on the longterm results in an equitable outcome that leads to overall travel time savings for all travelers although efficiency equity and market penetration of a socialrouting service clearly interact in reality most studies solely focus on one or two of these aspects jahn et al 2 propose a routing assignment strategy that involves user constraints which impose restrictions on the extra travel cost for each traveler in order to determine acceptable route alternatives they use a fixed tolerance factor that is applied on a socalled static normal length similarly angelelli et al 3 propose a proactive route guidance system to minimize congestion in which the total inconvenience of drivers is bounded ie only those routes are considered for which the relative difference with respect to the shortest travel distance route is below a given threshold however although aforementioned studies limit the inconvenience of drivers in reality many travelers may still not comply with the route advice and optimize their situation at the expense of the travel times of compliers moreover knowledge about how inequitable the pure system optimum would be whether this would lead to unacceptable travel times specifically in relation with market penetration is limited we introduce an explorative approach to address these shortcomings and to assess the impacts of social routing at several compliance rates when no constraints are applied iii methodology we perform a traffic assignment in which we simulate the impacts of a social routing navigation service and conduct a crosssectional analysis providing a scope that is manageable for a given day a multiclass traffic assignment we consider a static multiclass traffic assignment which is formally as follows consider a graph g with v the set of nodes and e the set of roads e with i j ∈ v the network has a set of origindestination pairs pairs k ⊆ v × v with demand d k ≥ 0 k ∈ k each odpair k ∈ k is connected by a set p k of paths a feasible flow for a given demand d is a pathflow vector f ≥ 0 so that the demand is satisfied traffic interacts on roads e ∈ e and we apply a travel time function l e l e following the commonly used bureau of public roads function 15 the traffic on a road x e e ∈ e is the sum of all path flows that cross this edge the cost of a route c p p ∈ p k k ∈ k is the sum of the travel costs of all edges in that path c p e l e we assume the setting in which there are two types of trips the first type entailing a fraction of the demand d n ≥ 0 consists of selfish trips the second type are socalled social trips with demand vector d s so that d d s d n we denote the corresponding path flows for the selfish and social trips as f s and f n respectively the resulting traffic state denoted by so that the demand is satisfied satisfies the following conditions f s p 0 ⇒ cp mi n q∈ p k cq for all p ∈ p k k ∈ k f n p 0 ⇒ c p mi n q∈ p k c q for all p ∈ p k k ∈ k with cp e∈ p l e x e being the marginal path costs indeed the traffic state that satisfies and is such that all social trips follow the shortest marginal cost path while the selfish flow is on the shortest travel cost path note that the travel time depends on both f s and f n in our setting the corresponding final traffic state has unique link flows 16 also note that not each social trip results in a detour we apply several shares of social trips 0 10 30 50 70 90 and 100 of total demand for each odpair ie d s αd d n d with α 0 01 03 05 07 09 1 as such we assume that social travelers are equally distributed among odpairs after all it is unknown between which origins and destinations social travelers exactly travel we identify three scenarios selfish behavior social behavior and mixed behavior • selfish behavior all trips are made selfishly and take the shortest route results in a user equilibrium this network state roughly represents current traffic conditions • social behavior all trips are made socially and take the route with the lowest marginal travel time results in a system optimum this network state represents desired traffic conditions by the traffic authority • mixed behaviorpart of the trips are made socially while the remaining trips are made selfishly results in a mixed equilibrium this network state represents traffic conditions when a social routing service is applied we adapt a static traffic assignment introduced by larsson and patriksson 17 this algorithm is more efficient than commonly used optimization algorithms especially for largescale applications like ours the algorithm explicitly provides an overview of used route alternatives as follows given an trafficflow distribution we use dijkstras algorithm to find the short path with respect to the marginal and travel costs not yet included we assign the selfish trips to the network until condition is satisfied then we assign the social trips until condition is satisfied we iteratively repeat this process until both condition and are satisfied and the shortest cost paths are in the path set calculations were done using the matlab software package extending matlab codes provided by josefsson 19 we evaluate convergence of an assignment by the normalized surplus called tolerance that is with respect to condition k p∈ p k f n p c p mi n q∈p k c q k p f n p c p we converged to the desired equilibria in all experiments the tolerance is less than 1e3 and absolute route cost difference is less than 01 minutes we refer to josefsson 19 for background with respect to the settings b traffic assignment the road network used for traffic assignment entails part of the region of twente the netherlands as illustrated in fig 1 the road network is obtained from the multimodal transport model twente region 2010 20 we considered a very busy morning peak in line with the realworld experiment where calibrated demand from 2010 is increased by 50 to save computational time we removed all trips from those odpairs with a demand below 001 this resulted in a decrease of the total demand by only 09 whereas the number of odpairs halved this network topology and demand are quite common for the european context one should note that the demand in the transport model represents trips rather than travelers at a given day ieee transactions on intelligent transportation systems c outline of analyses our analysis consists of three parts ie impacts on network performance impacts on equity and an elaboration on those impacts taking the distribution of detour trips among odpairs into consideration 1 impacts on network performance first we compare the total travel time within each network state to identify whether an informationbased demand measure reduces the total travel time with respect to the current traffic conditions and to what extent potential travel time savings could be achieved subsequently we look into the roads taken for different network states thereby we identify towards which specific roads traffic needs to be directed to enable an efficient road network in this we make a distinction between lower hierarchy and higher hierarchy roads identifying cutthrough traffic finally we look into the volumetocapacity ratio on each link in the road network for each network state the vcratio measures how well a certain road section can deal with the assigned traffic flow high vcratios indicate higher congestion levels as such we identify which roads benefit under which situation and to what extent expressed in vehicle kilometers 2 impacts on equity many general measures of equity exist eg the mean of outcome differences the range of outcome differences the variance of outcome differences or the gini coefficient we consider multiple measures as ramjerdi 21 argued that different measures might lead to different conclusions moreover we distinguish two important situations for comparison 1 comparison of travel times that would be experienced within a specific network state to travel times experienced in the current situation and 2 comparison of travel times of detours to travel times of shortest routes within the specific network state the first is relevant as travelers do not like to be worse off than their current situation whereas the second is relevant as travelers do not like to be worse off than their neighbor travelling to the same destination first we calculate gini coefficients a commonly used measure for outcome inequalityfor each abovementioned comparison this results in two ginicoefficients for each network state the first coefficient indicates the inequality of the distribution of travel time gains and losses among travelers in the specific network state compared to the user equilibrium whereas the second coefficient indicates the inequality of the distribution of travel time sacrifices among travelers within the specific network state we apply a normalization method that is able to deal with negative values as introduced by raffinetti 22 in line with their definition a coefficient of 0 represents perfect equality whereas a coefficient of 1 represents perfect inequality subsequently we look more detailed at the distribution of travel time gains and losses for each network state compared to the travel time in the current situation 3 elaboration considering the share of detour trips among odpairs we elaborate on the impacts on network performance and equity taking the distribution of detour trips among odpairs into consideration as such we illustrate the importance of this distribution in improving road network efficiency first we provide an example showing the origins at which travelers need to take a detour at the system optimum for one specific destination subsequently we assess the cumulative distribution of odpairs on which a certain fraction of trips entails a detour 4 some definitions we refer to travel time losses and gains when comparing individual travel times between a specific network state and the user equilibrium whereas we refer to travel time sacrifices when we compare individual travel times with the shortest travel time within a specific network state we refer to travel time savings when comparing total network travel times between a specific network state and the user equilibrium ie savings at the network level finally we calculated vehicle kilometers by multiplying the number of vehicles on a road section by the length of that road section i shows the total travel time within our road network for each scenario we observe that up to 36 of the total travel time at user equilibrium could be potentially saved compared to the findings by bosch et al 7 on a small networkthey found that a social trip share of 20 resulted in a travel time reduction of 7 of potential travel time savings our results indicate higher travel time savings moreover compared to the dynamic findings of levy et al 6 on a binary route networkthey found that a social trip share of 30 resulted in a travel time reduction of approximately 20 of potential travel time savings whereas social trip shares between 60 and 90 resulted in about 2 roads taken fig 2 shows the flow differences on all road network links for the mixed equilibria and system optimum compared to the user equilibrium we observe that in order to increase road network efficiency travelers need to divert from the main roads such as the highway and a considerable number of provincial roads towards the more local roads this observation is supported by table ii which distinguishes between road hierarchy levels based on speed limit while presenting differences in vehicle kilometers travelled between the specific network state and the user equilibrium note that the total vehicle kilometers travelled increases at higher network efficiency these findings are in line with findings by boyce and xiong 10 who compared soroutes with ueroutes for several odpairs the observed trend is present for all equilibria although it appears to be stronger at higher social trip shares as expected iv traffic assignment results a impacts on road network performance 1 potential travel time savings table 3 volumetocapacity ratio fig 3 shows the volumetocapacity ratio on each link in the road network for several network states in this we use a vc ratio classification that is loosely based on hartgen and fields 23 among others • 07 reasonably constant traffic conditions with some influence by others only incidental congestion • 0709 unstable traffic flow which could easily result in structural congestion comfort and convenience levels of drivers decline noticeably and maneuverability is restricted • 09 bad traffic conditions with structural congestion on a daily basis highly sensitive to small disturbances in traffic flow we observe a decrease in number of links on which structural congestion occurs when moving from a user equilibrium towards a system optimum this entails a reduction of 87×10 6 vehicle kilometers on daily congested roads and another 35×10 6 vehicle kilometers on roads with unstable traffic flows from fig 4 it seems that this decrease mainly occurs on links within the main city areas such as those on inner city ring roads and on inor outbound routes in other words it seems that the throughput on major city roads increases whereas throughput on provincial roads and highways remains the same hence city centers seem to benefit the most b impacts on equity table iii shows the gini coefficients obtained for each network state based on the travel time gains and losses travelers experience compared to the ue and the travel time sacrifice social travelers have to make compared to the shortest travel time route within the specific network state as expected each network state suffers from inequality gini coefficients decrease at larger shares of social trips moreover equity within network states seems to be worse than equity with note that out of all network states the so is the most equal regarding gains and losses compared to ue while it is the least equal regarding travel time sacrifices within the network state as we can observe when we look more detailed at the distribution of travel time gains losses and sacrifices this might be explained by the fact that almost 40000 travelers experience a travel time loss at the so compared to the ue whereas only about half of them actually take a detour compared to their neighbors traveling on the same odpair 1 travel time gains and losses compared to user equilibrium fig 5 shows the cumulative distribution of travelers net travel time benefit in each network state compared to their travel time in ue we find that most travelers do not experience any meaningful change in travel time in each network state more than 80 of travelers experience a travel time difference within a range of only 1 minute whereas even more than 95 of travelers experience a travel time difference within a range of 2 minutes moreover we clearly observe that travelers who benefit outnumber those who sacrifice in each network state it seems that me is closest to ue as its distribution of gains and losses is most steep its overall benefit is close to zero and the standard deviation is lowest however compared to the system optimum it has higher losses whereas gains are much lower a similar although less extreme trend is visible for the other equilibria in the system optimum losses are smallest whereas gains are highest note that çolak et al 1 found an average benefit of 1 to 3 minutes for the system optimum depending on the realworld city considered we found an average benefit of only 035 minutes similarly they found larger travel time gains and losses this difference might be because they focus on metropolitan cities while our study considers a smallsized region 2 travel time sacrifices within the specific network state fig 6 shows the cumulative distribution of these losses among travelers for each of the network states we observe that the majority of travelers do not need to sacrifice any travel time as they can use the shortest route moreover only about 2 to 8 of travelers need to sacrifice more than 1 minute of travel time by taking the detour while only 1 to 4 of travelers need to sacrifice more than 2 minutes it seems that the number of losers is similar for the so and me whereas the number of losers in other mixed equilibria is considerably higher on average losses in so are smallest note that only about 12 of travelers need to take a detour in order to achieve the so c spatial distribution of detour trips if only about 12 of travelers need to take a detour in order to achieve the so then why do mixed equilibria with more than 12 of social trips not result in system optimal conditions the main reason for this might be found in the spatial distribution of detour trips within the so fig 7 shows for each origin the share of total trips to the university and business science park that entail a detour at so it illustrates that most origins of social trips are centered at the city of enschede and to the north of the city of hengelo it is highly unlikely that travelers who are willing to act social and take the detour are starting their trip at exactly these origins now take a look at fig 8 showing the share of detour trips considering all odpairs we find that at so less than 20 of the odpairs contain detour trips note that the share of detour trips on these odpairs is considerably high when the share of detour trips is restricted as in the mixed equilibria we see that a larger fraction of odpairs is affected hence it seems that these additional odpairs need to compensate for the fact that not enough travelers are willing to take this detour on those odpairs at which a specific share of detour trips is necessary to achieve the system optimum this also explains why a network state with a social trip share of 30 does not result in the so while only 12 of trips have to take a detour in order to achieve the so from the aforementioned the distribution of social travelers among odpairs is crucial in achieving the so as such the prevailing distribution of social travelers within a realworld road network affects both network performance and equity when the informationbased demand measure is applied v traffic assignment results in light of observed compliance behavior now we assess the traffic assignment results in light of the observed compliance behavior from the field experiment we introduce the field experiment and its setup and discuss realistic shares of social trips based on observed compliance behavior as well as their implications a overview field experiment we conducted a realworld experiment on individual compliance with social routing advice for details on this experiment and its findings see essen et al 8 the experiment took place in twente the netherlands during 5 consecutive weeks participants installed the smartphone application smart mobility 24 on their personal smartphone which automatically collected tripdata ie origin destination departure time arrival time route and mode for each trip on working days this application sent tailored information messages containing social routing advice for the morning commute to its users for two days every working week the social route alternative was advised to each participant whereas on the remaining days of the working week their usual route was advised moreover a stated choice experiment was conducted among 211 respondents prior to the field experiment note that we were not able to determine the maximum sacrifice participants were willing to make from the field experiment as travel time sacrifices resulted from the participants dailylife context the traffic assignments in this paper are unconstrained by travel time sacrifice in other words traffic assignment assumes that social travelers will comply with the social routing advice at any magnitude of travel time sacrifice b observed compliance behavior and assumed share of social trips it is difficult to directly link the observed compliance behavior from the field experiment to a social trip share for traffic assignment after all the field experiment ran for several weeks whereas our traffic assignment represents a given day moreover participants did not commute or did not read the information message every day however using several assumptions we can derive social trip shares that would be realistic to expect at a given day let us start with setting the upper boundary the stated choice experiment resulted in a strong compliance rateie the compliance rate when the social detour was advisedof 57 of course it is quite easy to state that one would choose the detour and contribute to network efficiency from behind a computer however when the actual consequences of such a choice are experienced in reality one might not that easily choose the detour as a consequence the observed strong compliance rate from the field experiment is only 31 in the experiment all participants received social routing advice in reality only a minority of travelers would use a social routing service and receive such advice therefore we might want to take into account a market penetration rate this rate could be based on participants stated intention to choose the social route alternative as provided before the start of the experiment after all those participants are positive about the concept of social routing and therefore most likely willing to use such an information service outside of participation in the experiment this results in a market penetration rate of 41 if we now take into account the observed strong compliance rate from only those participants this results in a social trip share of 23 in the experiment social routing advice alternated between participants usual route and some longer route alternative observed strong compliance behavior might result from the frequency at which the detour route was advised to participants as our traffic assignment represents only one given day we could introduce some alternation rate only some part of the travelers would receive the advice to take a detour on a given day whereas another part would receive this detour advice the next given day note that this might not exactly hold as the trips in the transport model do not represent individual travelers hence trips at a certain given day and a certain other given day are not necessarily made by the same person in the experiment however 43 of the advice messages entailed a detour if we would combine this with the market penetration rate of 41 and the observed strong compliance rate of 56 this would result in a social trip share of only 11 one could argue which assumptions might hold and several combinations could be made due to the low sample size of the field experiment one should take these shares rather lightly overall observed compliance behavior seems to be represented most realistically by social trip shares between 10 to 30 this is still a broad range hence in order to provide a conservative estimate of the impacts of a social routing service we take the social trip share of 10 as such we take into account compliance behavior market penetration and alternation of detour advice in that case 16 of potential travel time savings would be achieved moreover 10 of daily congested vehicle kilometers and another 5 of vehicle kilometers in unstable traffic flows would already be avoided however the resulting network state would be far from equitable as a minority of travelers would experience high travel time losses as well as large sacrifices some travelers lose up to 55 minutes whereas the majority of travelers will experience a travel time difference of less than 2 minutes compared to the user equilibrium moreover less than 4 of travelers need to sacrifice more than 2 minutes compared to their neighbor on the shortest route on average travelers who take the detour would only sacrifice 078 minutes vi conclusion and discussion this paper shows the impacts of social routing on network efficiency and equity in a largescale road network several network states were determined the user equilibrium the system optimum and several mixed equilibria based on different social trip shares representing traffic conditions when a social routing service is implemented we expect that a social routing service as implemented in the field experiment would result in 10 to 30 of the trips being made socially in order to provide a conservative estimate on the impacts we assume a social trip share of 10 when looking at network efficiency we observe that 36 of total travel time at the current traffic conditions could potentially be saved in our research area during the morning peak to put this into perspective a total of 60700 minutes could be collectively saved each day corresponding to annual regional economic benefits of about c2600000 the informationbased demand measure is expected to achieve about 16 of these potential travel time savings whereas individual benefits are marginal the majority of travelers experience a travel time gain of less than 2 minutes most travelers would not notice these travel time differences as travel time variability caused by events weather conditions or traffic lights are often higher 1 nonetheless their driving comfort might increase due to the improved throughput observed network impacts indicate that at the desired network state structural congestion and unstable flows would be reduced especially on major city roads however trips seem to be redirected through minor local roads increasing cutthrough traffic hence livability in these areas is negatively affected one should realize that these findings might be dependent on the network used however in many networks the alternatives to arterial roads are local roads as such these findings are likely to be generalizable moreover these findings provide evidence for the need to pursue a societal optimum where not only travel time savings are considered but also livability as well as other societal relevant issues rather than the traditional so one should realize that this might be at the expense of network efficiency regarding equity impacts we observe that network states resulting from lower social trip shares are on average closer to ue than network states resulting from higher social trip shares most travelers experience a net benefit close to zero however in those network states a few travelers experience large travel time losses those extremes might be problematic when it comes to compliance after all travelers are more likely to comply with social routing advice when travel time sacrifices are small from that point of view the so would be more beneficial to all travelers ie average losses are smallest and the maximum loss is lowest whereas average travel time gains are highest moreover the detours travelers have to make compared the shortest travel time route are smallest under system optimal conditions hence it seems that the lower the share of social trips the more social travelers need to compensate for the selfish behavior of others by taking longer detours and sacrificing more travel time policymakers should be aware of this as it forms an important barrier in initiating a shift towards so in order to achieve the so only 12 of travelers need to take a detour however all those social travelers need to be concentrated on only a few specific odpairs ie on these odpairs a large share of travelers need to take a detour while on other odpairs none of the travelers needs to do so it seems highly unlikely that on these specific odpairs the share of social travelers would be large enough this emphasizes the fact that the distribution of social travelers among origins and destinations is crucial in achieving a desired network state note that route flows within static cases of traffic equilibrium are nonunique ie there could be many route flow solutions even so other assignment algorithms might be applicable as well whether or not our findings are general or are partly explained by particularities of the applied algorithm and the produced route flows is an important topic for further research moreover results may depend on traffic demand and network topology however the network topology and demand used in this study are quite representative for common european cities therefore we expect the results to be applicable for many other cities as well moreover one should realize that our findings are generalizable to the extent that the considered road network should contain congestion but is not saturated and route alternatives exist ie there should be room for efficiency improvements overall the application of a social routing service as implemented in the field experiment is expected to be positive in reducing total travel time within the network and in keeping cutthrough traffic limited compared to the so whereas individual travelers seem to be less fortunate as higher sacrifices and lower gains are experienced compared to the so our findings emphasize the importance for future research in social routing to not only pay attention to potential travel time savings but also consider impacts on equity among others moreover we provided insights into network impacts that result from the application of an informationbased demand measure providing social routing advice using findings obtained by a field experiment in a dailylife context as such we identify the potential of applying travel information as a measure in order to improve road network efficiency

informationbased demand measures using social routing advice are receiving increasing attention as they are expected to be successful in reducing the traffic congestion such measures direct travelers toward routes that benefit the road network as such some travelers need to act socially and take a detour this paper explores the impacts on network performance and equity that result from the application of a social routing service we complement the existing work by using a largescale realworld road network by assessing impacts on the individual level and by discussing our findings in the light of observed individual compliance behavior obtained from a field experiment our results show that 36 of total travel time within our road network could be reduced when all trips are made in compliance with the received advice however based on the observed compliance behavior a social routing service is expected to direct only a minority of travelers toward social routes we show how the attained travel time savings vary with the assumed compliance rate eg to achieve 50 of the potential travel time savings about 30 of travelers need to be willing to take a detour moreover we find that lower the compliance among travelers the more the social travelers need to compensate for the selfish behavior of others by taking longer detours finally we demonstrate that the impacts on network performance and equity highly depend on the spatial distribution of social travelers among origins and destinations

introduction human civilization stands at a crossroads avoiding a decline of the human species and ensuring its longterm survival requires scaling up human cooperation at all levels from individual to global sustainability issues such as climatic change biodiversity loss and resource depletion can result in a conflict of interests between individuals groups organizations and nations these challenges inevitably require collaborative decisionmaking processes to coordinate different interests and reach conflict solutions negotiation is a pervasive communication process that is mostwidely used to plan for the future allocate resources resolve conflicts of interests and solve complex problems via mutually satisfying agreements negotiations can dramatically reshape the social and physical environments we occupy the transformative potential of collaborative decisionmaking processes to lead to new practices has long been recognized by scholars of social conflict indeed pruitt and carnevale concluded that … negotiation presides over much of the change that occurs in human society conflict often results from dissatisfaction with the status quo and it often leads to negotiation about how to do things differently … s ociety usually prospers if negotiation goes well and the agreements reached are mutually satisfying to the parties conversely society is often harmed when negotiation goes poorly and fails to produce a mutually satisfying outcome negotiation processes can trigger change at different societal levels at the microlevel at which individual actors operate negotiation processes can promote sustainability transitions at the mesolevel diverse stakeholders and representatives of social groups incrementally transform the current state of society via negotiations across both levels negotiation processes constitute an essential element of collective sensemaking processes and can foster societal change it is important to note that the structure and processes of negotiation are fundamentally the same at the personal level as they are at the diplomatic and corporate level indeed negotiations are interactive human decisionmaking processes in line with this reasoning our conceptual article stands in the tradition of psychological and behavioral decisionmaking research in assuming that negotiators depart from rationality in systematic ways in the transformation toward sustainability negotiators are confronted with socalled wicked problems which are characterized by systemic complexities including the involvement of multiple interdependent actors beyond these social interdependencies negotiators are also confronted with the critical element of time and temporal interdependencies as has been emphasized in the extended conceptualization of super wicked problems previous research has revealed that negotiations on sustainability issues are often ineffective and end in suboptimal solutions and that the involved parties external stakeholders and most often societies would benefit from moremutually beneficial solutions we argue that negotiation aimed at the transformation toward sustainability faces fundamental psychological barriers grounded in the conglomeration of social and temporal interdependencies given these conflicting interests both between people and over time exactly how such transformation can be promoted remains unclear in the psychological literature two major lines of research have contributed significantly to our understanding of complex decisionmaking processes first the negotiationresearch perspective and second the individual decisionmaking perspective these two research perspectives have been the focus of a longstanding dialog that has spurred innovation across and beyond lines of research in the present contribution we seek to reinvigorate this traditional dialog between the two psychological research areas and address key barriers and drivers in the transformation toward sustainability given that the transformation toward sustainability faces super wicked problems including conflicts between people and over time these conflicts should be considered jointly rather than in isolation we posit the existence of an interplay between interand intrapersonal conflicts politicians for instance must navigate political conflict over climate policy in congress … and within themselves importantly we believe that the web of interplay between conflicts is difficult to disentangle because negotiators must simultaneously integrate their own interests with those of their counterparts and reconcile their presentand future interests the interplay between conflicts therefore acts as a significant barrier to the transformation toward sustainability to explicitly delineate the concrete challenges that arise from this interplay between interand intrapersonal conflicts we introduce the concept of interdependent conflicts we propose that a solution to one conflict impacts the solution to concurrent conflicts consequently interdependent conflicts can only be resolved efficiently by considering them simultaneously by developing a framework of interdependent conflicts we contribute to existing research on decisionmaking and negotiation in the transformation toward sustainability in various ways first we provide a unifying structure for complex and interdependent decisionmaking processes second taking the negotiation perspective we seek to expand existing research by introducing a temporal dimension third from a multilevel perspective we offer a systematic link between psychological negotiation research and transition management and highlight negotiation processes at different societal levels fourth from an applied perspective we aim to provide a morecomprehensive understanding of psychological conflicts in the transformation toward sustainability and to offer potential leverage points with handson tools for interventions that foster sustainable solutions in essence we seek to encourage future research to further examine human decisionmaking processes in the context of interdependent conflicts with the goal of fostering the transformation toward sustainability the framework of interdependent conflicts based on the assumption that conflict resolutions depend on one another in the social and temporal dimensions we derive a basic structure for the framework by distinguishing between three psychological conflicts the involved parties may experience present interpersonal conflict between their own and their counterparts present interests this type of conflict has traditionally been investigated by socialconflictand negotiation research simultaneously each party may experience intrapersonal conflict between their presentand future interests this type of conflict has predominantly been studied by individual decisionmaking research finally the two parties may also experience future interpersonal conflict between their own and their counterparts future interests very few studies have investigated outcome delays and the efficiency of negotiated agreements found in this type of conflict the parsimonious framework focuses explicitly on dyadic twoparty conflicts of interests and on two instances over time 1 figure 1 illustrates the proposed framework of interdependent conflicts for individual decisionmakers our paper is structured as follows to establish our framework we first introduce interdependent conflicts at the individual level in so doing we review the existing literature outline characteristic psychological processes derive propositions and conclude with an intervention approach to addressing the proposed problems at the individual level second we scale up our framework from the individualgroup to the socialgroup level to establish interdependent conflicts as an interplay between interand intragenerational conflicts we then follow the same structure as at the individual level introducing interdependent conflicts at the individual level interpersonal conflicts interpersonal conflicts emerge whenever two or more parties perceive their views or interests as being incompatible and negotiation is the decisionmaking process 1 besides the specified psychological conflicts in the framework two other psychological conflicts might emerge for each party these interpersonal conflicts over time directly reflect the unique characteristic of interdependent conflicts since conflicts are interdependent the specified three different types of psychological conflicts in our framework can determine the parties interpersonal conflicts over time therefore the framework of interdependent conflicts implicitly integrates these interpersonal conflicts over time for conciseness reasons the presented version of the framework of interdependent conflicts offers the most parsimonious version that may be extended in future research on interdependent conflicts in the transformation toward sustainability our reasoning also applies to interdependent conflicts at the level of social groups that we address in the latter part of the article figure 1 the framework of interdependent conflicts at the individual level figure shows the integration of traditional research fields into our unifying framework of interdependent conflicts the framework distinguishes between present interpersonal conflict intrapersonal conflict emerging for each party and future interpersonal conflict these conflicts naturally cooccur and interdependently affect one another that parties with divergent interests use to reconcile their differences traditionally the interest structure of interpersonal conflicts has been a central element of theorization and research in general the literature distinguishes between convergentand divergentinterest structures when parties have convergent interests these interests are compatible and no interpersonal conflict emerges by contrast when parties have divergent interests these interests can be diametrically opposed resulting in a distributiveinterest structure in zerosum negotiations the best solution for both parties is a compromise when parties have divergent interests these interests can also be opposed but since the parties have different priorities they form an integrativeinterest structure which includes mutually beneficial tradeoff opportunities and allows the parties to explore integrative agreements in contrast to compromise agreements integrative agreements create value for both parties and therefore leave them better off than would a compromise importantly in order to exploit integrative potential and reach mutually beneficial transformative solutions parties must consider their own and their counterparts underlying interests and coordinate them via negotiations in interpersonal conflicts negotiators typically display the detrimental psychological tendency to devalue their counterparts interests parties therefore have a biased idea of how to resolve a social conflict in favor of their own interests pinkley et al demonstrated that negotiators devalue their counterparts interests and thus create suboptimal agreements even though the parties have complete information on their counterparts interests as parties have a basic propensity toward interpersonal devaluation resolving interpersonal conflicts is difficult and often leads to suboptimal agreements intrapersonal conflicts over time the individual decisionmaking perspective decisionmakers who experience intrapersonal conflict must make a choice between different alternatives that entail consequences that occur at different times people must weigh immediate against future utility and thus make tradeoffs among costs and benefits occurring at different times in the transformation toward sustainability intrapersonal conflicts are ubiquitous and challenging to decisionmakers for instance when choosing between maintaining the status quo or developing an alternative with substantial longterm benefits research has demonstrated that people tend to temporally devalue their own future interests relative to their immediate ones as individuals put a premium on immediate benefits they often prefer smaller immediate benefits over larger later ones hardisty and weber describe this human tendency as a strong desire all things being equal to get things now decisionmakers therefore have a biased idea in favor of their present interests in terms of how to resolve the temporal conflict the negotiation perspective socialconflict research metaphorically describes intrapersonal conflicts as two psychological states with opposing interests in which one party seeks to protect present interests and the other to protect future interests schelling describes this situation with the following metaphor everybody behaves like two people one who wants clear lungs and long life and the other who adores tobacco or one who wants a lean body and the other who wants dessert… the straight one often in command… but the wayward one needing only to get occasional control to spoil the others bestlaid plans read et al indicate that such intrapersonal conflict can have similar interest structures to interpersonal conflict when a decisionmaker has convergent interests presentand future interests are compatible and no intrapersonal conflict emerges when one decisionmaker has divergent interests presentand future interests can be diametrically opposed resulting in a distributiveinterest structure over time in this case the decisionmaker prefers the diametrically opposed option now as opposed to later alternatively the decisionmakers presentand future interests can also be opposed but have different priorities resulting in an integrativeinterest structure over time preferenceconsistent tradeoffs can therefore also reconcile a partys interests over time in individual decisionmaking read et al suggest that analogously to interpersonal conflicts individual decisionmakers can reach integrative agreements with themselves if they consider the possibility of tradeoffs across the many choices that they face to reach efficient solutions in an intrapersonal conflict decisionmakers must consider their own presentand future interests and reconcile them by negotiating with themselves over time therefore researchers argue that intrapersonal conflicts are as difficult to resolve as interpersonal conflicts characteristic psychological processes in interand intrapersonal conflicts in the following sections we highlight the central psychological processes involved in the interplay between interdependent conflicts based on the reviewed literature we remain fully aware that other cognitive motivational and affective processes may also contribute to inefficient conflict resolution interpersonal and intertemporal devaluation as parties are prone to devalue others present interests and their own future interests we conclude that devaluing interests is likely the dominant psychological tendency in interdependent conflicts decisionmakers face three distinct interests in addition to their own present interests their counterparts present interests their own future interests and their counterparts future interests solutions to interdependent conflicts are hence impaired by either interpersonal devaluation intertemporal devaluation or both in a present interpersonal conflict a party socially devalues their counterparts present interests in an intrapersonal conflict a party temporally devalues their own future interests in a future interpersonal conflict a party interpersonally and intertemporally devalues their counterparts future interests in line with previous research devaluation should be strongest in future interpersonal conflicts due to the duality of interpersonal and intertemporal devaluation outcome interdependence and decisional control in addition to the processes of interpersonal and intertemporal devaluation outcome interdependence and decisional control play an important role in interdependent conflicts following interdependence theory the structure of any given interdependence situation can be described in terms of specific features that aid in the understanding of psychological processes outcome interdependence and decisional control differ systematically across types of psychological conflicts specifically the degree of outcome interdependence varies across interand intrapersonal conflicts whereas party as outcomes are interdependent on party bs outcomes party as future outcomes are purely dependent on its present outcomes consequently parties decisional control also ranges across conflicts from joint control in interpersonal conflicts to actor control in intrapersonal conflicts 2in intrapersonal conflict decisionmakers face a situation with outcome dependence and full actor control and can decide how to resolve a conflict between their own presentand future interests independently of their counterparts herrnstein and prelec describe actor control with a metaphor from the courtroom the moment that a temporal decision is made the actor functions as both judge and jury in intrapersonal conflicts parties have full actor control to simply overrule their own future interests and only serve their present interests or viceversa by contrast in interpersonal conflicts parties face a situation with outcome interdependence and joint control that is both parties outcomes are mutually dependent on the decisions and actions of their counterparts parties thus have joint control and must therefore coordinate their decisions with those of their counterparts joint control has been metaphorically described by conflict scholars as the negotiation dance to highlight the coordination of decisions and actions in interpersonal conflicts based on the distinction between full actor and joint control parties could perceive of having different degrees of freedom in resolving their conflicts of interests over time and between people specifically conflicts over time may be resolvable via actor control by contrast conflicts between people may only be resolvable via joint control due to these differences across conflicts parties may experience more constraints in resolving conflicts of interests with their counterparts compared with resolving conflicts of interests with themselves we therefore conclude that negotiators tend to prioritize the resolution of interover intrapersonal conflicts because solutions between people require interpersonal coordination whereas solutions over time are less constrained by coordination with other parties parties consideration of interdependent conflicts building on the abovementioned research our framework of interdependent conflicts postulates how parties cognitively process the interplay between different psychological conflicts in contrast to a rational approach in which parties cognitively process interdependent conflicts in a comprehensive unbiased way we hypothesize that parties systematically prioritize the consideration of certain conflicts in a biased way prioritizing the consideration of interdependent conflicts proposition 1 in interdependent conflicts parties prioritize the consideration of present interpersonal conflicts over intrapersonal conflicts and future interpersonal conflicts these priorities are derived both from parties tendency to discount their future interests and to devaluate their counterparts interests as well as from the parties differences in decisional control when considering present interpersonal conflicts parties devalue their counterparts present interests only on the interpersonal dimension when considering intrapersonal conflicts parties devalue their future interests only on the temporal dimension however when considering future interpersonal conflicts they devalue not only their own future interests on the temporal dimension but also their counterparts future interest on the interpersonal and intertemporal dimension this devaluation should lead to a morepronounced consideration of the present interand intrapersonal conflict compared with future interpersonal conflicts however as detailed above in addition to devaluation parties also experience less decisional control and more constraints when resolving interover intrapersonal conflicts together this observation should lead to a prioritized consideration of present interpersonal conflicts over intrapersonal conflicts and future interpersonal conflicts consequently parties prioritization of interdependent conflicts should impair a balanced and comprehensive consideration of conflicts noteworthy such a prioritization of conflicts should result in an unbalanced and biased way of processing interdependent conflicts in line with this reasoning prioritizing the consideration of conflicts should also determine which conflict is resolved at the cost of another 3 we postulate that conflicts with a higherorder priority are likely to be resolved at the cost of resolving conflicts with a lowerorder priority this biased prioritization may have important implications for resolving interdependent conflicts and threaten the transformation toward sustainability initial support for our assumptions can be found in a survey study that investigated conflictmanagement strategies when parties experienced only an interpersonal conflict vs both an interpersonal conflict and an intrapersonal conflict parties preferred morecooperative strategies for resolving the present interpersonal conflict when they experienced the intrapersonal conflict simultaneously as compared with when they did not similarly parties that experienced interdependent conflicts were more inclined to collaborate with their counterparts when the intrapersonal conflict between present interests and longterm adverse consequences was made explicit this finding is in line with recent 3 psychological conflicts may be either independent positively interdependent or negatively interdependent when conflicts are independent of one another one conflict can be resolved without any consequences for resolving the other in current individualand societal challenges conflicts are rarely independent of one another by contrast in most current social issues interdependence between conflicts occurs parties consideration of their present interests in an interpersonal conflict usually impacts their consideration of interests in the future and vice versa when conflicts are positively interdependent resolving one psychological conflict also facilitates finding a solution to the other interdependent conflict however positive interdependence does occur in realworld settings albeit rarely most importantly though when psychological conflicts are negatively interdependent parties efforts to resolve one conflict impede efficiently resolving the other interdependent conflict we therefore only focus on negative interdependence between conflicts in our framework research revealing that parties value agreements over impasses when dealing with present interpersonal conflicts even if the impasse would lead to moreprofitable outcomes than would the achieved agreement effects of priorities in the consideration of conflicts on the quality of agreements proposition 2 prioritizing the consideration of conflicts determines the extent to which parties can exploit integrative potential and reach integrative agreements to resolve interdependent conflicts in an integrative way decisionmakers must consider their interests in a comprehensive rather than in an isolated prioritized way from a rational perspective parties can maximize the utility of a solution by making integrative tradeoffs between their own and their counterparts interests and between their presentand future interests such tradeoff opportunities can only be exploited when parties consider the conflicts in a comprehensive unbiased way however the predicted tendency to prioritize conflicts should lead to a biased prioritized consideration and therefore hinder parties in exploiting integrative potential specifically if integrative potential is found in the intrapersonal conflict or even in the future interpersonal conflict parties should neglect these tradeoff opportunities and instead seek to resolve the present interpersonal conflict consequently prioritizing conflict consideration can be particularly detrimental because parties do not consider all tradeoff opportunities in a comprehensive unbiased way and may thus overlook mutually beneficial and transformative solutions o connor et al showed that responders in a simulatedultimatum game rejected more bids when instructed to focus on the present interpersonal conflict compared with the figure 2 prioritized consideration of interdependent conflicts we propose that parties prioritize present interpersonal conflicts over intrapersonal conflicts and future interpersonal conflicts intrapersonal conflict this finding provides initial support for our assumptions on the detrimental effects of prioritizing interdependent conflicts an intervention approach to addressing a prioritized consideration of conflicts we assume that prioritizing the present interpersonal conflict is caused in part by constraints in decisional control resolving interpersonal conflicts requires negotiating between parties to overcome divergent interests whereas resolving intrapersonal conflict does not require negotiating to overcome divergent interests in the present or future to balance the consideration of interdependent conflicts we propose also applying a negotiation strategy to intrapersonal conflicts over time negotiating with oneself should help parties reach integrative solutions over time and raise the priority of intrapersonal conflicts socialconflict research has revealed that integrative solutions are particularly likely when each negotiator has a strong concern for his or her own outcomes and takes both parties common interests into consideration accordingly parties should be concerned about their presentand future interests and their common interests over time considering dual and common concerns over time should trigger negotiating with oneself and this strategy should raise the intrapersonal conflict to the same level of priority as the interpersonal conflict simultaneously raising the priority of intrapersonal conflicts by negotiating with oneself should also lead to an increase in the priority of future interpersonal conflicts overall we posit that combining interpersonal and intrapersonal negotiation should lead to a balanced unbiased comprehensive consideration of interdependent conflicts applying the intervention approach to the transformation toward sustainability negotiations play a vital role in communityled grassroots innovations that are niche spaces supporting localscale transitions toward sustainability grassroots initiatives have been shown to foster change in diverse areas such as mobility or energy however a crucial success factor for exploiting the transformative potential of grassroots innovations is the successful negotiation and mutuallybeneficial conflict resolution conflicts emerge because local partners and stakeholders of such an initiative may have at least some common interests but may also have opposing interests in reaching their shared objectives for instance individual owners of cooperative housing apartments may share their interest in investing in energyefficient buildings but may have diverging interests in the potential pathways to reach this energy transition some of the owners may prefer to install solar panels on the rooftop whereas others may prefer to maintain the rooftop accessible for the residents and to use other energy sources for powering the building energyefficiently as they can only reach their objectives jointly the cooperative owners must negotiate strategies that lead to the intended transformation of existing structures however all involved actors may enter negotiations by positioning their interests in their immediate and local context that may hinder figure 3 the negotiationwithoneself strategy for balancing the consideration of interdependent conflicts at the individual level the horizontal ellipses show how common concern can lead to integrative negotiation processes between parties the vertical ellipses show how common concern can lead to integrative negotiation processes over time the implementation of the pathway toward innovation both our framework of interdependent conflicts and the suggested intervention approach of intrapersonal negotiations for reconciling ones presentand future interests may help to facilitate successful negotiations in grassroots innovations therefore implementing the proposed intervention approach in the context of communityled grassroots initiatives requires that individual actors are concerned with their dual interests in the present and future at a subordinate level as well as with their common interests at a superordinate level at a subordinate level future interests come into play when the involved actors formulate longterm goals develop a vision and specify their expectations for the transition toward sustainability present interests may guide decisionmaking when searching for pathways to implement the innovation additionally at the superordinate level actors should share the common concern that radical innovation will lead to the intended transformation toward sustainability when actors consider their dual and common concerns intrapersonal negotiation may be initiated and a prioritized consideration of conflicts may be debiased as a consequence negotiation processes between local actors may be improved and lead to moremutually beneficial and transformative solutions for the societal transformation sparked by grassroots initiatives tools for implementing the intervention approach tools for implementing the negotiationwithoneself strategy can be derived from both decisionmakingand socialconflict research decisionmaking research suggests that an increasing similarity between ones presentand future self may trigger a partys readiness to negotiate with themself alternatively changing the primary default consideration from presentto future interests may also stimulate intrapersonal negotiations socialconflict research suggests that perspectivetaking of ones own future interests may also help induce negotiations with oneself over time and balance the consideration of interdependent conflicts furthermore learning approaches that support analogous reasoning in transferring integrative insights from one type of psychological conflict to another could facilitate interdependentconflict resolution although interventions may support negotiators in reaching mutually beneficial transformative solutions reaching integrative solutions at the level of social groups has been shown to be even more challenging however the transformation toward sustainability mostoften requires negotiations between social groups such as between larger institutions or organizations that represent certain interests compared with interpersonal conflict intergroup conflict stands out in terms of the distinct psychological processes involved to further elucidate the psychological barriers to and drivers of interdependent conflicts at the group level we next scale our framework up and focus on intergenerational conflict such situations include central psychological barriers that hinder us from taking dramatic action in the transformation toward sustainability introducing interdependent conflicts at the level of social groups the interplay between intraand intergenerational conflicts at the zenith of the covid19 pandemic in july 2020 the european union agreed on the largest budget and financial package in its history to address the aftermath of the onceinacenturypandemic crisis this negotiation had implications not only for member states within the present generation but also for their successor generations to come the talks lasted almost 100 h because the member states contributions were heavily disputed after an agreement had been reached chancellor merkel was relieved that europe had shown that it can come together after all however other european politicians criticized the fact that the funds for important future eu projects had been cut back to reach a deal between the member states this example can be systematically structured using the framework of interdependent conflicts conflicts in the transformation toward sustainability include a social dimension between groups and a temporal dimension between generations over time in line with our framework scholars have proposed that many realworld intergenerational dilemmas ie over time are confounded by intragenerational social dilemmas ie between groups following this reasoning we systematically differentiate between three types of psychological conflicts present intragenerational conflict intergenerational conflict and finally future intragenerational conflict 4 intergroup conflicts a group consists of two or more individuals connected by social relationships these relationships can be established objectively via outcome interdependence between 4 we are aware that different constellations between presentand future generations can be conceived however we follow the standard definition and focus explicitly on the basic situation in which the present generation has no contact with the future generation individuals which induces the formation of groups alternatively relationships can also be established subjectively by assigning memberships to ingroups or outgroups to oneself and others based on similarity the conflicts between groups can be described as incompatibilities in the different groups values andor goals which may be caused by outcome interdependence andor perceived similarity this idea implies that intergroup conflict may involve not only economic interests but also categorization as an inor outgroup in the transformation toward sustainability the two foundations of intergroup conflict often arise in combination early theorizations on the causes of intergroup conflict focused on economic interests in resources as the root of competition in intergroup conflict when comparing interpersonal and intergroup interactions research found that intergroup relations are more competitive than are interpersonal relations and suggested that fear and greed explain this discontinuity effect in intergroup interactions specifically fear is based on the expectation that the other group will maximize its outcome which poses a threat to the given group and increases competition by contrast greed is based on the expectation that the other group will tend to cooperate which makes the other group vulnerable to the given groups greed and increases competition 5however another line of research suggests that merely categorizing oneself and others as members of an inand outgroup respectively is sufficient to induce intergroup conflict specifically selfcategorization theory posits that individuals are motivated to make themselves positively distinct from others by comparing themselves to others on relevant dimensions if comparisons are favorable for the ingroup relative to the outgroup people can make themselves positively distinct with beneficial and direct consequences for their selfconcept and selfesteem evidence shows that people strive for positive distinctiveness which can be obtained via different strategies including social competition for instance by discriminating the outgroup overall greed and fear as well as the need for positive distinctiveness all contribute to intergroup devaluation greed and fear are particularly pronounced when outcome interdependence exists however the need for positive distinctiveness can be explained by the psychological process of selfcategorization as an inor outgroup member intragroup conflicts over time in contrast to intergroup conflicts within a generation muchless work has focused on intergenerational conflicts over time from a psychological perspective intergenerational conflicts are characterized as decisions in which the interests of present decisionmakers stand in conflict with those of future others such intergenerational conflicts have distinctive features as compared with intergroup conflicts specifically outcomes are not reciprocally interdependent in intergenerational conflicts instead the outcomes of the future generation are fully determined by the present generation present generations therefore have complete actor control without the need to coordinate their interests with future others consequently future generations have no voice in intergenerational conflicts in addition present generations do not have to bear the longterm consequences of their decisions and actions because they are not part of the generation that experiences the consequences furthermore no direct or indirect reciprocity between the presentand future generation is possible the future generation cannot give anything back or punish the present generation this lack of direct or indirect reciprocity also implies a lack of figure 4 the framework of interdependent conflicts in the intergenerational context figure 4 displays the interplay between the arising present intragenerational conflict the intergenerational conflict and the future intragenerational conflict communication between the presentand future generations importantly in intergroup conflicts between different groups within a current generation reciprocity and communication have been shown to increase cooperation and lead to moremutually beneficial solutions however as the direct experience of consequences reciprocity and communication are ruled out in intergenerational conflict cooperation and integrative solutions between the presentand future generation are further exacerbated in intergenerational conflicts the future generations outcomes depend on the present generations beneficence which is often lacking to increase intergenerational beneficence it is therefore necessary for a perceived similarity between the presentand future generation to exist and for the present generation to identify with the future generation characteristic psychological processes in intraand intergenerational conflicts intergroup devaluation intergroup devaluation can be explained by the processes of greed and fear in intergroup relations as well as by the need for positive distinctiveness in comparison with the outgroup intergroup devaluation has been found to be particularly prominent in presentand future intragenerational conflicts which renders these conflicts difficult to resolve intergenerational devaluation intergenerational conflicts are difficult to resolve because intergroupand intertemporal devaluation jointly impede integrative conflict resolution the future generations interests are devalued temporally in addition intergroup devaluation arises because the presentand future generations are typically not part of the same collective both intergroupand intertemporal devaluation are additive components of intergenerational devaluation which is the major barrier to integrative solutions in intergenerational conflicts although the degree of intergenerational devaluation should depend on perceived similarities between the presentand future generation in general the need for positive distinctiveness should be morepronounced in intragenerational conflicts between distinct groups within the present generation however in the case of intergenerational conflicts intergroupand intergenerational devaluation can accumulate and lead to severe devaluation against the opposing groups successor generation in the future outcome interdependence and decisional control outcome interdependence in intragenerational conflict only exists between the two different groups within the present generation in intergenerational conflict over time however future generations outcomes fully depend on the present generation concerning decisional control intragenerational conflict can only be resolved via joint control because one group within the present generation must coordinate its interests with another group of the same generation by contrast the present generation has full actor control in intergenerational conflicts because this generation fully determines the consequences for the succeeding future generations parties consideration of interdependent conflicts across generations in line with the general assumption of our framework of interdependent conflicts we postulate that social groups cognitively process different psychological conflicts in a biased way this idea stands in contrast to a rational approach in which groups cognitively process interdependent conflicts in a comprehensive unbiased way prioritizing interdependent conflicts within and between generations proposition 3 in interdependent conflicts at the socialgroup level parties prioritize the consideration of present intragenerational conflicts over intergenerational conflicts and future intragenerational conflicts social groups have a tendency to prioritize present intragenerational conflicts because joint control with the other group within the present generation places constraints on the decisionmaking process and requires coordination between groups this joint control stands in contrast to intergenerational conflicts over time which should be given second priority because the present generation has full actor control when it comes to resolving these conflicts in line with this reasoning future intragenerational conflicts should be given third priority because in addition to intergenerational devaluation the need for positive distinctiveness from the other group also contributes to the prioritization of these conflicts these priorities also determine which conflict will be resolved at the cost of another conflicts of higher priority may be resolved at the cost of lowerpriority conflicts because present intragenerational conflicts should receive more consideration than intergenerational conflicts or future intragenerational conflicts prioritizing the consideration of interdependent conflicts thus has important implications for the transformation toward sustainability recent research has found initial support for proposition 3 by showing that adding the dimension of intergenerational conflict over time to the dimension of intragenerational conflict renders conflict resolution between parties more shortsighted effects of priorities in the consideration of conflicts on the quality of agreements proposition 4 a prioritized consideration of conflicts determines the extent to which social groups can exploit the integrative potential and reach integrative agreements to achieve mutually beneficial transformative solutions at the group level a balanced and unbiased consideration of all conflicts is necessary however we assume that the involved groups prioritize conflicts with detrimental consequences specifically parties consider the coordination of diverging interests in higherpriority conflicts to a greater extent than in lowerpriority conflicts integrative potential and the tradeoff opportunities embedded within lowerpriority conflicts are therefore lesslikely to be discovered a prioritized biased consideration of conflicts should thus result in suboptimal solutions for involved groups in other words resolving interdependent conflicts should be transformative and mutually beneficial if future generations interests are considered in an unbiased and balanced way jacquet et al provided initial evidence for proposition 4 by experimentally demonstrating that when a temporal dimension is introduced in intergroup conflicts conflict resolution is less optimal than when the intergroup conflict has no longterm consequences an intervention approach to addressing a prioritized consideration of interdependent conflicts across generations based on research on social conflict and negotiation and on intergroup conflict we develop an intervention approach tailored to balance the consideration of interdependent conflicts between social groups research has shown that the perception of belonging to distinct opposed groups can be changed via interventions specifically by recategorizing ones own group and the other group into subgroups of one superordinate common ingroup identity intergroup conflict can be reduced importantly managing intragenerational conflict via negotiations requires that the two subgroups consider their common concerns by creating a new superordinate common ingroup identity and that each subgroup maintain its distinct group membership and consider its dual concerns if the groups consider their superordinate common ingroup identity and common concerns while simultaneously considering their dual identities and dual concerns intragenerational conflicts can be resolved in an integrative unbiased way to balance the consideration of interdependent conflicts across social groups and time we transfer the intervention approach from intrato intergenerational conflict we find the classic common ingroupidentity approach particularly suitable for stimulating negotiations with future others in an integrative way as a prerequisite the present generation should create a common ingroup identity with their succeeding future generation that includes common concerns shared by the presentand future generations and acknowledge their distinct dual identities over time including dual concerns of the presentand future generations in order to stimulate negotiations with future others however in intergenerational conflict future generations have no voice to stand up for their concerns as communication between presentand future generations is ruled out a shift toward future generations interests is necessary to elicit negotiations with future others we propose that present generations be held responsible for resolving intergenerational conflicts via negotiations contemporary representatives of the future generation may take responsibility for speaking up for their generations interests this negotiatingwithfutureothers strategy combines a common ingroupidentity approach with a representation of future generations in order to foster integrative solutions negotiating with future others also raises the priority of the intergenerational conflict compared with that of the present intragenerational conflict thereby leading to a morebalanced consideration of interdependent conflicts if each present generation uses the negotiatingwithfutureothers strategy a morebalanced consideration of the future intragenerational conflict should also be reached overall negotiating with future others should be a particularly suitable approach to balancing the consideration of interdependent conflicts and fostering mutually beneficial and transformative solutions applying the intervention approach to the transformation toward sustainability negotiations are also an integral part of the transition management approach which typically seeks to regulate and govern fundamental processes of societal change that may take generations to realize during this transition the sustainability value of intergenerational justice must be protected however the involved societal groups of the present generation may enter negotiations by positioning their interests in their direct and immediate context thereby leading to suboptimal solutions in particular the different interest groups within the present generation may experience shortterm need for compromises whereas succeeding future generations need longterm ambitions for radical change traditionally transition management distinguishes between four types of circulargovernance activities to facilitate sustainability transitions strategic tactical operational and reflexive activities the strategic and tactical activities in the transitionmanagement cycle are largely interestdriven and require negotiation between representatives and delegates of larger societal interest groups organizations or institutions that have the capacity to contribute to the vision of the transition particularly during the tacticalactivity phase of the transitionmanagement cycle the development of a concrete transition agenda requires the negotiation and coordination of interests between groups within the present generation and the alignment of these interests with those of future generations in an exemplary innovation program on future urban mobility stakeholder groups of the present generation such as local residents public transportation services private mobility providers and city authorities develop transition scenarios which are descriptions of desirable future states that include alternative pathways for reaching them however the interests of future generations should be aligned with these transition scenarios created by the delegates of the stakeholder groups within the present generation according to our intervention approach present delegates should create a common ingroup identity with the succeeding future generation and also consider the dual identities of the presentand the future generations when developing the scenario for the urban mobility transition in addition a representative of the future generation could be assigned to safeguard the future generations interests during the development of scenarios for the urban mobility transition our proposed intervention approach may be particularly suitable for generating more mutually beneficial and transformative solutions in the management of transitions when interests within and between generations must be negotiated as a result the negotiationwithfutureothers strategy may help to overcome a biased and unbalanced consideration of interdependent conflicts between societal interest groups and their successor generations tools for implementing the intervention approach potential tools for creating common ingroup identities include placing focus on superordinategroup memberships increasing affinity with future generations and emphasizing factors that are shared by the groups alternative tools exist that may further trigger intergenerational negotiations over time by forecasting future generations beneficence priming present generations with the inevitability of their own mortality or providing advice to future generations however these tools often neglect common ingroup identities and the representation of future generations both of which are required to elicit negotiations with future others general discussion we developed and introduced a framework of interdependent conflicts for stimulating novel research that examines individualand joint decisionmaking processes in the transformation toward sustainability the critical relevance that negotiations entail in this transformation is undisputed however it is also unanimously accepted that negotiation will fail to achieve fundamental change unless there is a commitment to longterm change … despite this conclusion the existing literature on negotiations and decisionmaking treats sustainability challenges rather unidimensionally while negotiationand socialconflict research primarily focus on conflict resolution in the present individual decisionmaking often neglects the social interdependencies against which deep structural change must be negotiated and coordinated typically decisionmakers must simultaneously consider their own interests and those of other decisionmakers in addition to longterm future consequences for themselves and future others we aimed to provide a novel perspective on why agreements reached via negotiations are often not in favor of our own or others longterm interests one of the key contributions of our novel framework is that it enables an analysis of decisionmaking settings in the transformation toward sustainability in a morecomprehensive unifying and systematic way moreover our framework provides a parsimonious structure for disentangling these complex conflict situations analyzing the arising psychological phenomena and designing interventions that tap into the psychological barriers that impede transformative solutions at best agreements create integrative solutions for all parties involved not only in the present but also over longer timespans our framework offers a systematic integration of the social and temporal dimensions and thereby helps in reaching these transformative and mutually beneficial solutions sustainability challenges represent the largest collectiveaction problem ever faced by humanity joint decisionmaking and negotiation cooperation and conflict resolution are therefore inevitable in making collective progress toward sustainable living in our societies taking the proposed psychological barriers into account these negotiation processes may be biased toward solutions in the present to overcome this crucial barrier a better understanding of the underlying psychological processes may help in guiding negotiation processes that promote forwardlooking conflict resolution the european unions financial and budget deal closed by the different member states is exemplary in demonstrating interdependent conflicts on the one hand various member states of the european union have repeatedly shown that they can come together to jointly resolve issues of the present generation that they could not deal with individually on the other hand resolving conflicts between member states within the present generation may lead to costs for member states very own longterm interests and for those of their succeeding future generations the described tensions may lead to a rather skeptical view of the transformative potential of negotiations indeed the challenges for parties in creating transformative solutions are difficult however we hope that our framework and the proposed intervention approaches might help negotiators navigate toward moretransformative solutions across different societal levels and contexts in grassroots initiatives small groups of societal frontrunners may initiate negotiations over innovations and in the management of the transition representatives of larger societalinterest groups institutions or organizations may negotiate their interests in contributing to the transition pathway thereby negotiations may also help to bridge structural changes across societal levels we believe that existing and potential future tools for implementing intervention approaches should be tested adapted and refined depending on the interdependentconflict situation nevertheless we wish to emphasize the idea that interdependent conflicts are negotiable not only between individual actors and societal groups but also within ourselves and across generations making use of the transformative potential of these negotiation processes may open new transition pathways toward sustainability we therefore remain optimistic that negotiations as collaborative decisionmaking approaches are most promising for reaching transformative solutions and are our only true alternative to collaboratively achieving longterm societal prosperity in acknowledging this belief the framework of interdependent conflicts may provide innovative impulses for integrating and reconciling interests within planetary boundaries 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 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 copyright © 2021 majer barth zhang van treek and trötschel this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

transformative and mutually beneficial solutions require decisionmakers to reconcile presentand future interests ie intrapersonal conflicts over time and to align them with those of other decisionmakers ie interpersonal conflicts between people despite the natural cooccurrence of intrapersonal and interpersonal conflicts in the transformation toward sustainability both types of conflicts have been studied predominantly in isolation in this conceptual article we breathe new life into the traditional dialog between individual decisionmaking and negotiation research and address critical psychological barriers to the transformation toward sustainability in particular we argue that research on intrapersonal and interpersonal conflicts should be tightly integrated to provide a richer understanding of the interplay between these conflicts we propose a novel unifying framework of interdependent conflicts that systematically structures this interplay and we analyze how complex interdependencies between the social ie conflict between decisionmakers and temporal ie conflict within a decisionmaker dimensions pose fundamental psychological barriers to mutually beneficial solutions since challenges to conflict resolution in the transformation toward sustainability emerge not only between individual decisionmakers but also frequently between groups of decisionmakers we scale the framework up to the level of social groups and thereby provide an interdependentconflicts perspective on the interplay between intraand intergenerational conflicts overall we propose simple testable propositions identify intervention approaches and apply them to transition management by analyzing the challenges faced by negotiating parties during interdependent conflicts and highlighting potential intervention approaches we contribute to the transformation toward sustainability finally we discuss implications of the framework and point to avenues for future research

background one in three women are the target of violence by their partner or expartner throughout their lifetime suffering serious physical mental sexual or reproductive health consequences 1 although intimate partner violence against women is globally a condemned problem prevalence differs by world regions 1 2 rates vary from 377 in southeast asia to 232 in western educated industrialised rich and democratic countries 3 traditionally multicountry research has focused on possible risk factors that can explain prevalence of psychological sexual and physical forms of ipvaw 4 5 6 however a growing body of international studies have paid attention to one factor directly related to ipvaw prevalence public attitudes justifying ipvaw 7 8 9 a recent review highlighted that societies with public attitudes justifying ipvaw tend to show a higher rate of ipvaw and lower formal and informal responses towards such violence by the public professionals and victims 8 in this vein we set out to contribute to a better understanding of strengths and limitations of this study ► the probabilistic sampling strategy of the world values survey provided representative populationbased samples from 54 countries ► multilevel approach allowed accounting for attitudes justifying intimate partner violence against women by means of individual and country differences ► the crosssectional nature of the data does not allow for causal inferences ► gender inequality index is the unique composite sensitive association measure of gender gap that includes femalespecific health indicators ► measures and individual predictors of attitudes justifying ipvaw were taken from responses to an international survey research project open access attitudes justifying ipvaw that can help work towards transnational gender equality womens good health and wellbeing in line with the global sustainable development goals for 2030 10 according to the integral ecological model attitudes towards ipvaw are a multifactorially determined phenomenon 11 12 overall within this framework and using data from national and international survey projects there has been an increase of research the individual 13 and neighbourhood or community 7 14 15 risk factors on acceptability and justification of ipvaw few studies however have analysed the role of societal context and particularly the interplay between individual and societal determinants to explain crosscountry differences on public attitudes justifying ipvaw 9 1619 however some valuable empirical data are available to investigate this relation most of multicountry studies have focused on studying sociodemographic variables at the individual and gender inequality at the country level 16 17 18 19 gender inequality a set of structural features which indicate gender power asymmetries in a country have been linked to attitudes justifying ipvaw in different ways two studies showed that individuals in countries with higher levels of gender inequality were more likely to justify or accept ipvaw 9 16 but others did not find such effect 16 17 18 the interplay between multiple level factors was addressed onlybyone study finding a crosslevel interaction between gender inequality and individual victimblaming attitudes on the ipvaw acceptability 17 conversely individual determinants over and above sociodemographic variables were considered to a lesser extent by crosscountry studies 9 thus sexism was highlighted as a relevant determinant of attitudes towards ipvaw 20 21 22 specially hostile sexism beliefs related to men should dominate women and limit them to certain roles 23 has been associated positively with individuals ipvaw acceptability from 51 societies 9 however basic values an important aspect of individual variation to explain the motivational bases of attitudes 20 only were studied within a specific context 21 specifically selftranscendence values which promote the welfare of ones group society or environment as well as conservation values refer to respect and acceptance of own cultural customs ideas and religion and to limit actions that offend others social norms or expectations to protect self or those with whom one identifies 24 were negative and positive predictors respectively of myths towards rape 21 notwithstanding the effects found at individual and country level it is also suggested that individuals who are socialised in similar cultural contexts may develop comparable attitudinal patterns toward ipvaw shaped by similar underlying mechanisms 16 within this field research is limited since most studies analysed regional differences on attitudes justifying ipvaw based on data from multinational surveys which included only countries belong to the same geographical or income status region 12 13 25 although there is no direct evidence linking regional characteristics with individual attitudes justifying ipvaw tran et al 12 showed through a frequency analysis prevalence of women who endorsed attitudes accepting ipvaw was higher in countries from regions with lower national expected years of schooling human development and higher gender inequality the aim of this paper is to provide new and consistent worldwide evidence of the interplay between the individual country and regional risk factors and attitudes justifying ipvaw the specific objectives of this research are to examine the role of individual and societal context and their determinants to determine whether the strength of relations between less wellstudied individual determinants and attitudes justifying ipvaw differ across societal contexts to test the moderating role of gender inequality in the relation between the above individual level determinants and attitudes justifying ipvaw at country level methods survey data secondary data analysis was performed on data from the sixth wave of the world values survey which included 85 000 participants from 60 countries 26 since there were not availability of gender inequality indices for taiwan palestine ghana hong kong nigeria and uzbekistan we only analysed responses from 54 countries between 2010 and 2014 by means of multistage sampling method with a random selection local evaluators collected representative samples establishing some of them by quota control to homogenise samples mostly facetoface interviews were conducted at the respondents home through paper questionnaire or computerassisted personal interviewing technique when it was needed an adapted version of the source questionnaire to capture linguistic and cultural nuances was developed the final sample consists of 81 516 participants from 54 countries the mean age was 4241 the overall response rate was 625 and an average of 1500 respondents per country full information about survey patient and public involvement the research has been performed by analysing survey data from the world value survey and united nations participants were not involved in the design analysis results and dissemination of the study measurements excepting the gii values items for all variables was extracted from the wvs sixth wave questionnaire 27 respondents completed a shortened and revised version of the portrait values questionnaire 28 the measure of sexism was included in the wvs has been used in previous studies 9 29 30 a full description of the item sets for each variable is in online supplemental table s3 outcome to measure individual attitudes justifying ipvaw we used a multiitem survey question intended to know the extent to which participants would justify fifteen actions we focused on justification of ipvaw which was highlighted by one item the answers ranging from 1 never justifiable to 10 always justifiable individuallevel predictors sexism the item set focused on hostile sexism 23 and includes five items the response scale ranged from 1 to 4 all items were reversescored since higher scores indicate more hostile sexism selftranscendence values this item set consists of three items responses were given on scales that ranged from 1 to 6 scores were reversed such that higher scores mean more selftranscendence values conservation values measure comprised three items ratings were the same that for selftranscendence values items sociodemographic characteristics we collected information about sex age marital status educational level and perceived social status educational level was recoded into four categories countrylevel predictors we used an objective measure of gender equality the gii from the united nations development programme in comparison to other gii gii is a improved and sensitive measure that includes three relevant aspects 10 reproductive health empowerment and economic status ranging from 0 to 1 for the gii country the index was directly obtained from the united nation development programme website for the year in which the wvs was conducted in the country to develop the gii region we clustered countries with similar gii indices in four gender inequality regions following their distribution in quartiles as proposed by united nations development programme reports 10 gii per region was the mean of country indices which form the region statistical analysis categorical variables were converted to dummy variables for analyses the reference groups were male aged 1624 married no formal education and lower class following descriptive statistics were obtained revealing a small number of missing data so no imputation of missing data was conducted to assess the relevance of the newly introduced individuallevel variables we conducted a hierarchical multiple regression using stepwise method we also analysed multicollinearity through variance inflation factor since we assumed that responses of participants from the same country or region could be correlated because of sharing the same context we estimated a set of multilevel regressions to account for that 31 these models allow the inclusion of additional error terms to reflect the intricate pattern of variation due to the hierarchical structure of the data 32 continuous variables were groupmean centred at level 1 and grandmean centred at level 2 the multilevel analyses were carried out by steps first we ran a model to find out how much variance of individual attitudes justifying ipvaw is explained at country level after that we evaluated the effects of the individual and societal variables on attitudes justifying ipvaw assuming these effects as equal across countries then we let the effects of sexism and selftranscendence values changed across countries extending model 2 we introduced interactions between sexism selftranscendence values and gii country finally model 4 replicated previous model with another second level predictor gii region we used restricted maximum likelihood estimation method with robust se 31 deviance intraclass correlation akaike information criterion bayesian information criterion and the determination coefficient were estimated to find which model has a better fit to data a likelihood ratio test was performed to compare open access fit between models 33 multilevel analyses were performed with the lme4 package implemented in r statistical software 34 results the distribution of sample characteristics by gender inequality regions 10 is shown in table 1 in general open access attitudes justifying ipvaw sexism selftranscendence and conservation values means scores were higher in gender unequal regions the stepwise hierarchical regression model revealed that the incorporation of conservation values did not explain an additional proportion of the variance beyond sociodemographic sexism and selftranscendence individuallevel predictors in attitudes justifying ipvaw so we excluded it from multilevel models all vifs were in the range 14 and no reversal of the predictorsoutcome link between models were found therefore no multicollinearity problems were detected 35 table 2 show random effects and fit indices of multilevel models performed thus model 0 supported nested data structure and indeed allows having a multilevel approach 31 random variance of attitudes justifying ipvaw within and between countries was relevant specifically 16 of the random variance in attitudes justifying ipvaw was explained by variation between countries country residuals from this model were plotted figure 1 shows the countries ranked according to attitudes justifying ipvaw compared with the overall mean of such attitudes in the full sample on average georgia australia and the netherlands presented the lowest endorsement of attitudes justifying ipvaw while south africa rwanda and haiti showed the highest endorsement azerbaijan peru libya tunisia and kyrgyzstan showed values close to the global mean when random slopes for selftranscendence and sexism were introduced a better fit of model 2 in comparison to model 1 indicated that the effect of sexism and selftranscendence values on attitudes justifying ipvaw differs depending on the country being greater in countries with stronger attitudes justifying ipvaw likewise after introducing targeted predictors and its interactions the decrease of random variance in attitudes justifying ipvaw at individual and country level and the lower values of deviance aic dic and higher of r 2 pointed toward a better fit of model 3 over model 0 no differences emerged between model 2 and model 3 and 4 the country pooled estimations for regression coefficients of individual country regional predictors as well as its interplay are presented in table 3 women older more educated married respondents those with higher level of selftranscendence values and respondents with lower sexism were less likely to justify ipvaw significant effects on attitudes justifying ipvaw were not found for the participants from excluded groups gender inequality had a direct crosslevel effect countries with higher levels of gender inequality were more likely to perceive ipvaw as justifiable in comparison to more gender equal countries in addition a significant effect was found for regional gender inequality at country level hence countries with a higher regional gender inequality tended to endorse greater attitudes justifying ipvaw however the strength of the association between sexism and selftranscendence values with attitudes justifying ipvaw did not vary neither as a result of the degree open access of country gender inequality nor regional gender inequality discussion the present study is to our knowledge the first one performing a multilevel approach in order to explain the variability of attitudes justifying ipvaw across 54 global countries taking into account individual and societal predictors and their interplay at different levels according to our objectives the results showed attitudes justifying ipvaw changed within and between countries being explained by individual and country context sociodemographic characteristics sexism selftranscendence values and country and regional gender inequality were explanatory factors of attitudes justifying ipvaw differences in attitudes justifying ipvaw between sexist and not sexist and selftranscendent and not selftranscendent respondents changed across countries and values of the regional and country gii do not explain the above differences across countries attitudes justifying ipvaw changed across the 54 studied countries in comparison to the overall average of all studied countries haiti rwanda and south africa showed the highest means on attitudes justifying ipvaw while georgia the netherlands and spain showed the lowest endorsement of attitudes justifying ipvaw in general although we cannot consider ipvaw justification to be an accurate reflection of the target behaviour since the wvs does not include specific causes of ipvaw our results provide a gradient across a variety of countries differing between geographical location education industrialisation wealth and democracy that allow us detect globally which countries may benefit from increased efforts in prevention toward ipvaw likewise our results reveal higher variation of attitudes justifying ipvaw within countries according to previous results the most variability between attitudes towards ipvaw is found within countries and depend on the belonging to certain groups for instance in nepal ipvaw derived from a wife arguing back was less likely to be justified by women in comparison to other sociodemographic groups 8 in bangladesh women who live in poorer communities tended to condemn ipvaw to a larger extent 14 future research should aim to continue analysing distribution of attitudes toward ipvaw across specific groups or settings within countries according to not only residential area or income status but also genderrelated norms age or education segregation 36 at individual level we replicated the significant role of wellstudied individual factors on attitudes justifying ipvaw in a wider sample from countries that differ in geographical location education industrialisation wealth and democracy thus men older more educated married and sexist respondents were more likely to justify ipvaw 8 17 37 in addition we found that respondents who endorse selftranscendence values tended to justify ipvaw to a lesser extent 18 conversely our data did not provide consistent results about conservation values indeed the measure from the wvs questionnaire neither showed an adequate reliability nor explained attitudes justifying ipvaw beyond sociodemographic sexism and selftranscendence values basic values allow for an understanding of what contexts and societies at large would be more or less conducive to endorse attitudes justifying ipvaw in terms of normative discourse prior research has mainly focused on the critical role of selftranscendence and conservation values indicating a comparatively nontraditional versus traditional outlook on society evidence points towards selftranscendence values relating positively to fairnessproenvironmental and careprosocial attitudes and conservation open access values relate to purityreligious and authoritypolitical attitudes 38 therefore such generalised values might affect orientations towards what is perceived as acceptable behaviour towards different life domains such as toward ipvawassociated with them in other words our findings seem to note that selftranscendence values and their focus on universalism and benevolence provide an overlooked background against which to understand how interest about collective safety could prevent to legitimise ipvaw likewise conservation values focusing on tradition conformity and security may help to understand how more traditional gender roles could legitimise such transgressions nevertheless further research should test the real effect of paying attention to psychometric limitations of available of conservation values measures our work also shows that the effect of selftranscendence basic values hold above and beyond the effect of sexism which provides evidence relevant for the ongoing debate about the general versus groupspecific nature of prejudice as a mechanism that legitimises discriminatory or violent behaviours 39 40 the generalised prejudice hypothesis stems from the idea that holding negative attitudes towards particular outgroups could be linked to a dislike of other outgroups like open access in our case women 41 thereby while a part of prejudice would be common to all target groups another part would be specific to one group specifically cultural values have been identified as a driver of generalised prejudice 42 our data speak to this notion suggesting that selftranscendence basic values explain attitudes justifying ipvaw via generalised prejudice irrespective of whether people are sexist or not however further research should provide more evidence about the mechanisms through which prejudice works on attitudes towards ipvaw the normative societal context may be one important factor as for example to live in societies with egalitarian values decrease generalised prejudice 42 43 as well as groupspecific prejudice 29 30 probably in societies where there is more gender inequality people could endorse higher attitudes justifying ipvaw through specific rather than general prejudice this represents a future avenue for research using a crosscultural perspective regarding country level our results confirmed that a low level of country or regional gender inequality is particularly important for reducing individual attitudes justifying ipvaw across countries 9 12 16 otherwise prior research indicated that people from countries with higher gender inequality endorsed higher conservation values sexist beliefs as well as lower selftranscendence values 29 44 that seems to point towards level of gender inequality could moderate relations at individual level nonetheless gender inequality of country or region did not explain country differences in the effects of sexism and selftranscendence values on such attitudes justifying ipvaw theoretical and methodological arguments should be considered in interpreting our results basing on the just world theoretical framework 45 even today people tend to believe world is a just place where people get what they deserve thus when people have to evaluate unfair situations such as ipvaw they try to seek a coherent explanation in order to maintain their psychological wellbeing basing on available keys such as circumstance of violence they decide whether ipvaw is justified or not literature indicated that ipvaw because of womens behaviour transgresses patriarchal norms is more likely to be justify in gender inequality countries 8 16 46 likewise research has found the moderator role of gender equality when respondents decided if they justify ipvaw answering to a questions with a wide range of options 17 however wvs participants respond to a general question about justification of ipvaw that does not include any circumstances consequently specification of circumstance of ipvaw violence could be necessary to clarify the role of gender inequality otherwise researchers who used composite indices of gender inequality as our study traditionally have found contradictory results 9 1619 the indices of gender inequality that have been related to attitudes towards ipvaw are gender equality index from european institute of gender equality gender empowerment index and gdi gender development index from united nation development programme and sigi social institutions and gender index from the organisation for economic cooperation and development reviewed studies that found a direct or moderator effect of gender inequality applied sigi and gem respectively taking into account domains such womens and mens economic and political participation and entitlements as well as their level of education 16 17 however indices that introduce aspects related to womens health as gei gdi or gii found mixed effects 9 18 19 most of them did not predict attitudes toward ipvaw 18 19 or not explain enough variance of such attitudes 9 future studies should disaggregate global gii in order to determine moderator effects crossnationally some limitations related to design of wvs study indicate our findings should be interpreted with caution first although data were collected via probabilistic sampling studies were conducted using a crosssectional design prevents the possibility of establishing any causal connection of the associations found 47 it would be advisable to collect data via longitudinal or experimental designs to understand the causal direction of the relations obtained here however the manipulation of gender inequality sexism or selftranscendence values is not ethically or logistically feasible intervention in representative and large samples from many countries further research should deepen the potential causal relations following analytical strategies in which outcome data are taken from a time point after to predictors 29 second social desirability could affect the report about sensitive topic because wvs data were obtained through facetoface interviews two questions assessed same sources of responses bias but there was a high number of missing values across studied countries so we did not included this assessment in our analysis furthermore prior research did not document a strong effect of social desirability measures in topics related to violence against women 48 we argue that future efforts should address data collection methods to ensure adequate privacy in subsequent waves of the wvs and consequently improving respondents honesty 49 third wvs questionnaires are developed to collect public opinions about relevant social topics in a large number of countries even though several quality controls are implemented there is a challenge to reach equivalence across all countries moreover crosscultural equivalence of measures should be tested 50 51 once equivalent survey statistics across countries are available research could cast a valid set of indicators to observe differences between open access countries focusing on how gender inequality could be an important factor for justifying ipvaw or not depending on level of countrys wealth education democracy and industrialisation finally our findings have practical implications for international organisations and national governments currently primary prevention programmes are focusing on promoting local activism against ipvaw as well as mens commitment and dissemination of nonviolent and gender equality through media 52 we highlight regional and country gender inequality as a target factor in three domains female reproductive health empowerment through education policy and labour market since laws send a clear message to society about the level of ipvaw acceptability above aspects should be considered in national and international laws policies and protocols to reduce public attitudes justifying ipvaw contributors csm and mb conceived of the study and chose the dataset and measures jlp gave some recommendations in the above step csm and lml performed the statistical analysis and were the firsts to interpret the results all authors agreed on the final interpretation of the results and discussion in several meetings csm wrote the first version of the manuscript lml mb and jlp reviewed and prepared the manuscript competing interests none declared patient consent for publication not required ethics approval the original data were collected following approval by ethics committees in each of the participating countries as organised by the wvs under the auspices of the teams collecting the data in accordance with data protection regulations in participating countries only anonymous data are available to users before contributing data to the wvs each national team was responsible for checking their data with confidentiality in mind anonymity is maintained after merging of data files see worldvaluessurvey org wvscontents jsp cmsid intconduse provenance and peer review not commissioned externally peer reviewed data availability statement data are available in a public open access repository data used in the research are available in a public open access repository these can be obtained at osf io vza98 view only 8748 b54b f6a1 44b0 896e 6a9e 5f239e89 or by emailing to first author 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

objectives attitudes justifying intimate partner violence against women ipvaw can play an essential role in explaining the prevalence of such public health problem the study aim was to explain attitudes justifying ipvaw identifying individual and societal risk factors design and setting a multilevel crosssectional study of the world values survey wvs in 54 global countries participants a representative transnational communitybased sample of 81 516 participants 478 male 521 female aged mean of 4241 measures attitudes justifying ipvaw sociodemographic sexism selftranscendence and conservation values were measured using questions from wvs country and regional gender inequality were assessed by gender inequality index results around 16 intraclass correlation016 of individual differences in attitudes justifying ipvaw are explained by countries statistically significant predictors at individual and country level were sex b024 95 ci 027 to 022 age b008 to 025 95 ci 034 to 003 marital status b009 to 023 95 ci 0002 to 033 educational level b010 to 014 95 ci 020 to 004 selftranscendence values b010 95 ci 020 to 012 sexism b021 95 ci 015 to 028 country b218 95 ci 109 to 326 and regional b223 95 ci 104 to 342 gender inequality country gender inequality b018 p012 and regional gender inequality b021 p010 did not moderate the associations between selftranscendence values and attitudes justifying ipvaw in the same way for sexism data did not provide support for a moderating role of country gender inequality b022 p026 and regional gender inequality b010 p066 conclusions individual and country predictors accounted for differences in attitudes justifying ipvaw however neither gender inequality of country nor gender inequality of region interacted with sexism and selftranscendence values theoretical and methodological implications are discussed

introduction worldwide the population is ageing as a result of decreasing mortality and fertility 1 the global share of individuals aged 60 years or over represented 117 of the world population in 2013 and is expected to reach 211 by 2050 2 up to 50 of those aged over 60 are at risk of social isolation 3 and approximately onethird of older people will experience some degree of loneliness later in life 4 5 social isolation has detrimental effects on health 6 7 having been identified as a risk factor for allcause morbidity and mortality 8 with outcomes comparable to smoking obesity lack of exercise and high blood pressure 9 it has also been associated with decreased resistance to infection 10 11 cognitive decline and mental health conditions such as depression and dementia 9 and with increased emergency admission to hospital 12 longer length of stay and delayed discharges 13 the literature identifies two main types of interventions aiming to reduce social isolation and loneliness groupbased interventions and onetoone interventions these types of interventions can be implemented in the community or in a supported living facility these interventions can focus on social skills training enhanced social support and social cognitive training furthermore these interventions can either be technology assisted or not previous reviews of health promotion interventions aimed at reducing social isolation in the elderly suggest that interventions with groupbased formats and where individuals are required to actively participate were more effective than onetoone interventions 32 33 also involving the study participants in the planning implementation and evaluation of policies 34 highquality training of facilitators 32 and interventions based on existing community resources seem to produce more successful outcomes 4 34 the individuality of the experience of loneliness is an important issue which has also been highlighted in the literature as this may cause difficulty in the delivery of standardised interventions it has been suggested that programmes which are tailored to meet individual needs may be more appropriate and successful 4 but previous reviews were restricted to studies published in english language 33 34 35 36 37 38 and up to 2013 furthermore statistical synthesis of effectiveness data has been largely lacking 33 34 36 38 39 as well as the assessment of the quality of the studies included using a validated tool 3436 39 previous systematic reviews that assessed the quality of the studies suggest that the literature investigating the effectiveness of interventions aiming to reduce social isolation or loneliness is of poor methodological quality and although conclusions have been drawn further investigation is required 32 the aim of this review is therefore to identify health promotion interventions aiming to alleviate social isolation or loneliness in older people and to assess their effectiveness methods and analysis protocol and registration we followed the reporting guidelines of the preferred reporting items for systematic reviews and metaanalysis for protocols 2015 40 the completed prismap checklist is provided in online supplementary file 2 the protocol is registered with the prospero international prospective register of systematic reviews the final review will be reported following the prisma statement 41 42 43 important amendments to this protocol will be reported and published with the results of the review study selection criteria type of participants studies will be included if the full or part of the study population is older persons the agreed united nations cutoff age of 60 years will define the older population 1 type of studies this systematic review will include studies published in a peerreviewed journal or doctoral thesis using a randomised control trial nonrandomised controlled trial controlled beforeandafter or uncontrolled beforeandafter study design type of outcome measure the outcome of interest is social isolation or loneliness measured using appropriate instruments both validated and nonvalidated outcome instruments of social isolation or loneliness will be considered to be included studies must report a quantitative measure of the effect of the health promotion intervention on social isolation or loneliness type of intervention studies will only be included if the health promotion intervention under analysis was designed specifically to alleviate or prevent social isolation or loneliness search strategy electronic databases the selection of electronic databases and the search strategy were developed in conjunction with an information specialist and were based on previous literature reviews search strategies 33 39 49 the following electronic databases were searched from 1995 until the end of 2015 medline embase psycinfo cumulative index to nursing and allied health literature applied social sciences index and abstracts lilacs opengrey and the cochrane library no language or geography restrictions were applied to the search the exact search terms used in all databases are described in online supplementary file 1 manual searches the reference list of the studies included in this review as well as those of previous literature reviews on health promotion interventions to reduce social isolation or loneliness will be searched to identify additional potentially relevant studies study selection endnote x7 thomson reuters will be used to manage the references duplicates will be removed by one reviewer two reviewers will then independently assess each abstract to determine whether fulltext review is needed any disagreement between the two reviewers will be resolved by a third reviewer full text of potentially eligible studies will be retrieved and reviewed and assessed for final inclusion by two reviewers again with a third reviewer being consulted if necessary following prisma guidelines 41 a flow diagram will be created to illustrate the selection process data extraction data extraction will be conducted independently by two authors and disagreements will be solved as open access described above nonenglish references will be reviewed by two native or fluent speakers the following information will be extracted using a data extraction form based on the cochrane group data collection form for intervention reviews 50 risk of bias assessment two reviewers will perform a quality appraisal of each study independently using the effective public health practice project quality assessment tool for quantitative studies 51 recommended by the cochrane public health group as it is applicable to both experimental and quasiexperimental study designs 52 nonenglish references will be reviewed by two native or fluent speakers for the quality assessment description of studies and measurements of effect size we expect to find a diverse range of study designs and heterogeneous interventions aimed at social isolation or loneliness hence data will be divided by type of outcome impact of interventions on social isolation and impact of interventions on loneliness social isolation and loneliness are intricately related but distinct concepts which are frequently used interchangeably 4 social isolation is defined as a scarcity of contacts or social encounters of adequate quality or quantity and is regarded as an objective measure of social interaction 6 39 53 54 whereas loneliness is described as the subjective counterpart of social isolation where an individuals perceived level of interaction with others does not fulfil their expectations often resulting in an unpleasant emotional experience 4 6 55 56 given that these two concepts have been used interchangeably and inconsistently in the literature we will consider both collectively for search purposes but separately in terms of analysis similarities and differences found in the literature will be compared and discussed we will further divide the studies by type of study design and subdivide them by type of intervention a narrative synthesis of all relevant studies will be provided by type outcome divided in terms of study design and subdivided by type of intervention describing study and participants characteristics interventions outcomes results and authors conclusions the effectiveness of the health promotion interventions on alleviation or prevention of social isolation or loneliness will be presented in terms of mean effect size and respective ci the rationale for these summary statistics is the expected variation in the instruments used to assess the same outcome the effect size will be calculated using hedges g as it provides a superior estimate of the standardised mean difference in studies with small samples 57 the primary effect size for each study will be calculated from the first available postintervention measurement time point if a study has more than one intervention the primary effect size will be calculated for the main intervention group targeting social isolation or loneliness or the group with the most robust design 35 if a study has more than one control group the primary effect size will be calculated using the group which theoretically is expected to generate the greatest difference from the intervention group 35 in cases where there are more than two groups we will first conduct pairwise comparisons and also explore more complex analysis if appropriate as suggested by cochrane 58 the authors of the studies included in this review will be contacted with the aim to retrieve any missing data necessary for our analysis we will attempt to calculate any missing smds for continuous measures from the reported statistics in the relevant paper if sufficient data are available subgroup analysis will be conducted to account for heterogeneity if there are sufficient numbers of comparisons for the same outcome and intervention across studies the betweenstudy heterogeneity will be quantified by calculating the χ 2 test for heterogeneity and the i 2 statistic we will report the sum of the studies using both a fixedeffect and randomeffects metaanalysis by type of study design and intervention discussion this systematic review will be performed to compare the effectiveness of health promotion interventions in alleviating social isolation or loneliness in older persons by grouping interventions we will be able to determine which type of intervention is more likely to be effective and we will also assess the role technology plays in promoting social contacts we will use a validated tool to assess the quality of evidence since previous reviews refer they were limited by the weak methodology of studies analysed and we will synthesise the data using appropriate statistical methods if feasible furthermore we will include studies conducted in the last 20 years without any languages or any geographic restrictions previous reviews were restricted to studies published in english language and up to 2013 open access our review aims to address an increasingly relevant problem in terms of the impact it has on older peoples health and on health and social care systems worldwide this review will therefore provide policy makers with a better insight on how to tackle social isolation and loneliness by identifying the type of interventions that alleviate or prevent social isolation or loneliness and under which circumstances contributors fl conceived the initial idea for the study and is the guarantor of the review fl and pb wrote the protocol enm amg and jl critically appraised the protocol and also contributed to its development by revising different versions all authors read and approved the final version of the manuscript competing interests none declared provenance and peer review not commissioned externally peer reviewed

introduction social isolation and loneliness affect approximately onethird to onehalf of the elderly population and have a negative impact on their physical and mental health groupbased interventions where facilitators are well trained and where the elderly are actively engaged in their development seem to be more effective but conclusions have been limited by weak study designs we aim to conduct a systematic review to assess the effectiveness of health promotion interventions on social isolation or loneliness in older people methods and analysis a systematic review was conducted in medline embase psycinfo cumulative index to nursing and allied health literature applied social sciences index and abstracts lilacs opengrey and the cochrane library on peerreviewed studies and doctoral theses published between 1995 and 2016 evaluating the impact of health promotion interventions on social isolation andor loneliness for individuals aged 60 and over two reviewers will independently assess each study for inclusion and disagreements will be resolved by a third reviewer data will be extracted using a predefined pro forma following best practice study quality will be assessed with the effective public health practice project quality assessment tool a narrative synthesis of all studies will be presented by type of outcome social isolation or loneliness and type of intervention if feasible the effectiveness data will be synthesised using appropriate statistical techniques ethics and dissemination this systematic review is exempt from ethics approval because the work is carried out on published documents the findings of the review will be disseminated in a related peerreviewed journal and presented at conferences they will also contribute to a dphil thesis trial registration number crd42016039650

introduction a critical challenge for social machines research is to design and develop systems that support and enhance human social interaction within a given social machine the social machines environment we currently dwell within has emerged from adaptation by people to more and more computerisation and automation our social connections are increasingly found on the network rather than in our geographic location one of the key outcomes of social interaction and consequent social relationships is cooperative interaction where people collaborate directly or indirectly to achieve jointly acceptable outcomes virtually everything we value in our daytoday life is a result of such collaborations including family relationships access to food energy transportation and the security of our person and possessions in short most of what we value and require in order to live is a result of successful cooperation in modern urban society these collaborations can be very indirect few of us have direct relationships with most of those we depend upon over time a complex system of interrelations between groups and locations has evolved that generally ensures we can live the lives we do these circumstances are not unique and are always changing however in change it is critical that the outcomes that we depend upon are not disrupted to the point these cannot be recovered thus any changes to social interaction are worthy of attention cooperation depends on successful communication when social interactions are on the network and distributed across multiple geographic locales the cooperation these foster may have limited benefit in a given local locale when interaction was mostly limited to a local locale people in that locale would frequently benefit indirectly from cooperation by others in the locale without necessarily being aware of that cooperation activities that depend on cooperative efforts have increasingly shifted to the communications network the various social networks that comprise the communications network interact without a strong mechanism for connecting groups to each other other than the coincidence of individuals bridging multiple social networks through joint membership the shift of cooperative efforts from local locales to social machines is only a concern if the shift fails to induce a means for people to reproduce their way of life social machines may be a part of the response that must emerge to address such change such change promises to bring about many new possibilities however within that change it is also important to maintain some level of continuity consequently social machines have the potential to improve how organised cooperation is coordinated and even semiautomated without being creepy privacy invading or rigid we explore the role of social machines to support change and enhance human cooperation in physical geographic local locales cooperation shifting to the network 21 managing messaging polysocial reality describes the dynamics of multiple multiplexed synchronous and asynchronous messages within a network of agents messages we send to each other to machines or that machines send between themselves or to people 1 outcomes of posr dynamics include missed communications due to either digital or social network topology contributing to a greatly reduced capacity to cooperateor even disruption the consequences of missed communications can be minor such as someone needing to resend a message or major if critical messages are not received or responded to within a required timeframe outcomes from posr dynamics can be merely inconvenient when people are mainly monitoring connections and messages when the messages are social pings or when the content of the messages can be anticipated due to familiarity with the task or with the other parties but when messages are critical for example acting as a token of control in an automated subsystem missed message coordination can effectively assign automated systems unintended agency that conflicts with human agency successful receipt of messages matter because these foster cooperation for cooperation to work well first and foremost critical messages must be successfully received and understood as outcomes of posr dynamics messages can be received and understood not received or received and not understood in the latter two cases the opportunity for cooperation is greatly diminished or dependent on enough familiarity between parties and skill in the tasks involved to anticipate a critical message failed cooperation can be due to a combination of human and machine errors or due to lack of opportunity real world examples of failed cooperation due to poor communications can be a simple as someone not receiving a message to meet a friend or as grave as a cargo ship not receiving a message that a traffic bridge is down and unknowingly sailing through it leaving people drowning in its wake automated messages that are not well designed can decrease the effectiveness of cooperation a parking ticket machine that can only receive commands in a certain order or the process breaks down or the program that enables retail transactions in a certain order but cannot be interrupted or changed once it is in motion can cause frustration and problems for people as cooperation between the human and the machine is disrupted humans and algorithms are coadapting smart and shadbolt state that social machines are best understood as systems in which human and machine components make complementary contributions with respect to the performance of some larger joint process 2 this could be interpreted as the foundation for a joint process of cooperation applin and fischer argue that we are entering a cycle where humans and algorithms are adapting to each other humans are filling in the gaps where algorithms cannot easily function and algorithms are calculating and processing complex information at a speed that for most humans is not possible together humans and computers are sorting out which is going to do what type of task it is a slow and tedious process that emulates a kind of sociability between entities in order to form cooperative outcomes either one or both parties must yield a bit for cooperation to work and if a program is developed in a rigid way the yielding is usually done by the human to varying degrees of frustration as agency becomes constrained by the process of automation indeed sociability and social relationships depend on the assumption of agency on the part of the other human or machine 3 humans often attribute agency to machines in their assumptions underlying how the machine will satisfy their present need or indeed inhibit them from satisfying a need people communicate and cooperate in varying degrees of success with machines on a daily basis via our mobile devices humans are cooperating with machines and through these cooperating with other humans who may not be in their same geographic location to achieve this type of cooperation people must first negotiate with the specific devices hardware then its software then a communications layer which may or may not be wireless or mobile technology which they then use to connect to others via voice text or other types of software enabled messaging such as email social media messaging or networked applications or chat programs soon this will include mediation with numerous other devices on the internet of things if the entities attempting communication are successful in this negotiation of medial layers they might make a stable connection to their intended target in synchronous time and messages can be exchanged to contribute to a cooperative effort if they are successful in sending an asynchronous message there may be no feedback that a received message is a read message and senders may want to wait to receive a confirmation or reply to their message before taking action as messages continue to be exchanged each round is a potential vulnerability for both communication and cooperation until a cooperative outcome is negotiated thus much of todays cooperation is an automation hybrid whereby people are cooperating with autonomous or semiautonomous systems in order to connect and cooperate with other people andor with machines and systems communication and thus cooperation is not necessarily with those in our local locale as much of our communication passes through one sort of network or another especially where there is substantial geographical population mobility such as in the us where people have networks that include members far outside their local locale and indeed these can be quite distant even so there is enough local cooperation to reproduce supplies power water adherence to law etc in the local locales in many ways we are unable to cooperate locally as we once could some of this is due to the urban problem of high heterogeneity in a concentrated space and the outcomes of cultural differences coexisting in a given locale typical of cities since their inception more likely with the advent of automation in many of the processes of locales problems of local communication and cooperation are instead being addressed by process script algorithmic or other lossofagency solutions that require more yielding of humans to the automation rather than the other way around 3 frustration with processes scripts and algorithms in a local locale translates into a more general frustration within a locality when people are unable to get what they want locally they have network tools to enable them though cooperating with automation to shift tasks that they may have done in their communities to online thus the infrastructure of geographic localities becomes more utilitarian and less social as people though various pressures and time constraints in their lives use their mobile devices more often than not as they move through the local locale as a result opportunities for exchanges of information between people such as pleasantries gossip about the neighbourhood and community political concerns are reduced as local people with jobs that support local needs are replaced by algorithms and packages left on doorsteps this social glue is replaced by function people can order the supplies they need to survive in their locale and can do so without socialising with others in the same locale this contributes to a breakdown of cohesion understanding and ultimately cooperation in locales and a concentration of shopping patterns and behaviour tracking privately owned on the network by companies that may or may not be in business in the future social machines as cooperative agents when people use mobile devices in the local locale more frequently than not and are connecting socially and cooperating with those on the network more than they are with members of their local community then the way to connect them to their locality will be more effective when done through their mobile devices this is what some civic and retail systems are currently doing by relating people to services based on local regions 4 5 6 7 however they are not necessarily connecting people to people but rather to regions often that stop as abstract representations within software this type of blended reality has problems in that people may no longer have privacy in spaces where they are sharing a data history now attached to their patterns in the local locale simultaneously the future of cooperation may be hinged upon peoples willingness to engage with blended reality in their communities as automation takes hold social machines might meet the hybrid need in several ways 1 social machines can bridge the blended reality issue of network and local locale presence 2 social machines provide useful data to each individual user on the network whilst simultaneously connecting to many multiple users on the networkin the users preferred asynchronous time schedule 8 and 3 social machines have a unique capacity to replicate some human behaviour in a way that takes up the slack of humans emotional andor physical limitations when engaged with the network in short social machines have the potential to provide some of the cooperative social glue that humans have forfeited in our local locales as we have become consumed by nearly constant connection to the network 2 for example waze googles communitybased traffic and navigation app 9 has been used as an example of a social machine 10 that collects data from individual nodes aggregates and processes it and returns it to individual nodes as smarter data that gives more contextually relevant information that aids in navigation with waze users forfeit some privacy and location information but what they receive is a deeper and more useful dataset which has the potential to save them time and stress during a commute in addition waze gives some identity and presence to fellow travellers on the road thus humanising and creating a virtual community that exists as a blended reality where real cars that participate in the network have node representation as well the dataset is dynamic and useful for the time the user is driving but the idea of the community on the road and fellow travellers may be persistent and could potentially provide a sense of community long after the commute has finished drivers are characterised as cartoon cars in the app and thus may seem more human than the dissociation drivers often have when isolated in their vehicles waze may be successful because it provides crowdsourced navigation information however it may also be successful because it is evidence of a cooperative community and illustrates that community to users in real timeeven if the drivers as individual nodes may not be so cooperative to other drivers thus an area of research could be to explore if the community aspect of waze produces feelings of group membership that are sustained after the commute has finished do waze users feel more camaraderie on the road is waze as a social machine providing a community cooperative glue that is not available on the roads when drivers are by themselves in their cars social machines as community proxies social machines show properties of being an emergent system as the fabric itself of its constituting parts mutates under their mutual influence as do the interactions between them 11 as such social machines interoperate with other social machines and systems merging and transforming we too move through groups in a similar fashion potentially social machines could create a cooperative experience that offers a cohesive sense of community that promotes successful cooperation without compromising to various automation and algorithms that keep digital personal experiences separate from each other and as such leave them open to posr dynamics related social vulnerabilities what is currently missing in much of mobile application design is the shared locale and shared information that operates at a community level that gives information back to that community which is useful to both individuals and the groups part of this is due to trust and privacy issues in that people are become more wary to share personal information including location to larger entities they either do not understand andor do not offer much of a reciprocal cooperative relationship programs such as foursquare yelp and other apps enable individual contribution and usage but do not necessarily have a means to connect people to each other in a local locale part of this is due to privacy and part of this is due to technology specifically the problems with interoperability and devices there are two major smartphone platforms iphone and android 12 and within them users have highly heterogeneous computing environments the waze example of a social machine supports cooperation by providing highlevel communication between different isolates to enable more collaborative activities while simultaneously not cluttering the individual networks emulating the predigital or in other terms the constraints of local geography social machines have to be adaptable because they are dependent on and service systems that change the companies that are responsible for the infrastructure that social machines utilize may reorganise stop shipping products make new products and render others obsolete or may be victims of power failures that disable internet services altogether the heterogeneity even of the five major players 12 can create potential for disruption of social machines thus social machines are required to be nimble and transcendent of the systems they use at any given time in contrast the physical communities whose cooperation and other social features social machines could and likely will take on board change more slowly and although they absorb new changes they maintain their physical structures due to the physical constraints of geography and materials this presents a challenge for transferring cooperation to a digital platform that is useable in the local locale because of the temporal nature of technology contrasting with the slower change of communities and community participation however social situations are changing particularly in urban areas where real estate is expensive and people are transient in these cases social machines and the network in general may perform a type of anchor function and promote community coherence absent in daily life it is in these environments and amongst these users that social machines could first flourish as a cooperation proxy conclusions the social machines construct encourages exploration of distributed cooperative computing as a new means for connecting people and making possible new processes and outcomes not previously achievable there is a real shift of peoples behaviour from managing cooperation through relations and sociability within geographic localities to managing cooperation through social relations over a network using tethered or mobile devices connected to the internet the results of this shift in cooperative behavior add a layer to the dynamism of social machines these can become critical custodians to support necessary cooperative human social behavior while assuming an active cooperative role themselves this is particularly challenging when the systems that social machines rely upon do not endure to the same extent as the physical locales and persistent stories that have hosted human cooperation and knowledge throughout history while persistence is an enduring issue with data behaviour is only recently something that has become datafied and social machines are now challenged to be social in ways that can provide behavioural persistence a future direction to explore is whether or not the community experience created by social machines such as that found with waze can sustain and demonstrate a residual cooperative effect after engagement with any particular social machines has ended thus creating a sense of cooperation continuity and community even when detached from both the network and others within a geographic locality there are a number of other issues that require further consideration most pressing is the role of social machines as people are not shifting to networkbased locales at the same time or with the same degree of enthusiasm social machines will be deployed into a complex social environment where some people may not have or want access to the technology that enables social machines in order for them to shift to networkbased locales from their local locales with different rates of adoption degrees of enthusiasm and personal preferences adoption of social machines will be a process in any process of broad and radical change younger people incorporate the adaptations of older people adding many peersourced adaptations these may be largely inaccessible to older people due to cultural and social restrictions on acceptable adult behaviour that will change in acceptance as the new generations age economic and social inequality can have dramatic impacts on the capacity for participation aggravating inequality further in addition people in nations with weaker infrastructure may be excluded from shifting it is important that to the extent possible social machines promote benefits for all and minimise differences in capability in a mixedrate period of change lest a truly divided society emerge the result of present processes with or without social machines will result in dramatic changes in society worldwide social machines can help by making these changes a more positive experience for most and greatly impact the quality of life as change advances indeed given the pace of change and consequent outcomes social machines have the capacity to greatly improve societal cooperation during the transitional shift of community to network locales

as humans become more and more immersed in a networked world of connected and mobile devices cooperation and sociability to achieve valued outcomes within geographic locales appears to be waning in favour of extended personal networks and interaction using semiautomated agents to support communications transportation and other services from a messaging structure that is complex multiplexed and much of the time asynchronous conditions emerge that disrupt symmetry of information exchange people thus encounter circumstances that seem unpredictable given the information available to them resulting in limited or failed cooperation and consequent quality of outcomes we explore the role of social machines to support change and enhance human cooperation within a blended reality context• humancentered computing computer supported cooperative work • humancentered computing collaborative and social computing devices • applied computing anthropology • computing methodologies mixed augmented reality

introduction cancer is the second leading cause of death for people experiencing homelessness due to limited access to cancer prevention services this study aimed to coadapt the health navigator model integrating endusers and organizations voices in the design of a care delivery model combining patient navigation and patient empowermentmodels that have been shown to benefit different health outcomes by reducing health inequalities and improving access to cancer prevention services methods participatory qualitative research was conducted through focus groups between december 2021 and january 2022 across four european countries seven focus groups with an overall sample size of 56 participants were conducted including 41 professional stakeholders and 15 peh focus groups were audiorecorded transcribed verbatim and thematically analyzed results analysis identified four key features of the hnm including assessment of needs and barriers to access health care promoting cancer awareness and selfmanagement facilitating access to preventive services providing practical assistance regarding the profile of health navigators a health or social care professional background accompanied by active engagement with relevant local stakeholders to improve intervention delivery is enhanced conclusions the hnm is a personcentered intervention to improve selfcare and build relationships with peh health navigators should provide practical assistance coordinate access to cancer prevention care and promote cancer awareness and selfmanagement the hnm is currently piloted and evaluated across four european countries as part of the horizon 2020 cancerless project key messages the health navigator model is a personcentered intervention responsive to the needs of people experiencing homelessness building trusting relationships and improving levels of selfcare health navigators should provide people experiencing homelessness with practical assistance and coordinated access to cancer prevention care while promoting cancer awareness and selfmanagement background health inequalities are an unjust and avoidable problem this study examines subnational geographical inequalities in allcause years of life lost and the association of socioeconomic factors in precoronavirus european economic area countries methods in this ecological study complimented with a longitudinal analysis demographic and socioeconomic data for 1390 small regions and 285 basic regions of 32 eea countries were extracted from eurostat agestandardised yll rates per 100000 population were estimated from 2009 to 2019 based on methods from the global burden of disease study inequalities were assessed using the gini coefficient and slope index of inequality the association between socioeconomic factors by ylls were assessed using negative binomial mixed models in 2019 findings over the period 20092019 ylls have decreased in almost all subnational regions the gc of ylls across eea regions was 14 for females and 17 for males greece and belgium had the highest relative inequalities in ylls for women and men respectively subnational regions with the lowest income 1á39 ci 1á23 to 1á58 and levels of educational attainment and highest poverty risk were associated with increased ylls with stronger associations observed in central and eastern europe interpretation differences in ylls remain within and between eea countries and are associated with socioeconomic factors this evidence can assist stakeholders in addressing specific health inequities to improve overall disease burden within the eea key messages the study highlights the need for public health policies targeted at the subnational level to reduce health inequalities in the eea the study describes the effect of existing public health policies targeting socioeconomic factors smoking unhealthy nutrition alcohol consumption and physical inactivity are leading risk factors for multimorbidity and tend to cluster within specific subpopulations little is known about how these clusters change with age in older adults and their association with multimorbidity repeated measures latent class analysis using data from waves 48 of the english longitudinal study of ageing identified clusters of respondents with common patterns of snap behaviours over time disease status was used to assess eight body system disorders multimorbidity and complex multimorbidity logistic regressions examined how clusters were associated with sociodemographic characteristics and disease status seven clusters were identified lowrisk lowrisk yet inactive lowrisk yet heavy drinkers abstainer yet inactive poor diet and inactive inactive heavy drinkers and highrisk smokers there was little evidence these clusters changed with age clusters characterised by physical inactivity were associated with lower levels of education and wealth the heavy drinking clusters were predominantly male compared to other clusters lowrisk and lowrisk yet heavy drinkers had a lower prevalence of all diseases studied in contrast the abstainer but inactive cluster comprised mostly women and had the highest prevalence of multimorbidity complex background an increased selfefficacy promotes better diabetes selfcare behaviours which help in achieving glycemic targets among patients with diabetes mellitus methods a quasiexperimental study was conducted among patients with t2dm living in rural areas of punjab north india a total of 283 in the intervention and 291 in the control arms were participated at baseline and a total of 242 in the intervention and 237 in the control arms at endline assessments summary of diabetes selfcare activities and diabetes management selfefficacy questionnaires were used at baseline and endline surveys outcomes were net changes in proportion of population having diabetes selfmanagement selfefficacy overall diabetes selfcare activities and net mean change in hba1c data were analysed using per protocol analysis principle difference in difference analysis using generalized estimating equation model was done to adjust for confounders p 005 was considered as significant results there was a significant net increase in participants proportion on diabetes management selfefficacy scale at the baseline assessment for overall selfcare behaviours only 4 of participants in the intervention arm were in the action stage and 12 were in the preparation stage however at the post intervention assessment this proportion increased to 24 for action stage and 67 for preparation stage there was a significant net increase in participants proportion engaged in optimal diabetes selfcare there was a significant net decrease in mean hba1c at post intervention phase conclusions diabetes selfcare intervention was successful in promoting selfefficacy and selfcare practices among patients with t2dm of rural areas key messages selfefficacy theorybased diabetes selfcare intervention successfully improves the diabetes related selfcare practices there is a need for a structured diabetes selfcare management education programme to improve the ability of patients with t2dm who live in rural areas abstract citation id ckad160363 longitudinal clustering of risk behaviours and their association with multimorbidity in older adults

the burden of unintentional pediatric injuries remains a significant concern for healthcare systems worldwide timely and accurate surveillance is critical for injury prevention and resource allocation however the diagnosis reported in the emergency department records is often not coded and the manual coding of these records is laborintensive timeconsuming and prone to errors to implement an automatic coding system using gptbased models to extract and classify injury data in the italian language from pediatric emergency department recordsthe study included 283468 admission records to the pediatric emergency department of padova university hospital from 2007 to 2018 each access is mandatorily registered in an electronic data collection system for each emergency department access both coded administrative and demographic data and freetext diagnosis information are reported a random subset of 40030 records underwent classification of freetext diagnosis as injury or not by an expert clinician gold standard openai was used for the classification task openai is an extensive language model based on the gpt architecture specifically the gpt35 variant was employed for the present work openai was accessed through a public application programming interface api using r softwarepreliminary results showed a classification accuracy of 962 the tools ability to correctly classify the injuries sensitivity was 95 while the specificity was 965 the performance of the classification task was excellent the present results demonstrate the feasibility of gptbased models for processing unstructured free text information from medical records

background fear of crime is an emotional reaction towards the individual risk of criminal victimization that leads to mental and physical poor health 12 moreover its socioeconomic and gendered unequal distribution makes it a possible social determinant not only of health but of inequalities in health previous research has mostly investigated fear of crime from a socioecological perspective 3 4 5 and to the authors knowledge there is no literature on the underpinnings of socioeconomic inequalities in fear of crime the present study seeks to contribute to filling this gap in the literature using as the point of departure northern sweden a comparatively socially equal and secure setting fear of crime is increasing in the swedish context despite being lower than in other nonnordic european countries 6 for example according to the recent 2016 swedish crime survey 7 as many as 19 of the respondents felt unsafe outdoors late at night with the youngest and oldest women being the most fearful and the proportion of respondents concerned that fear of crime affects their quality of life almost doubling since 2015 7 at the same time the increasing income inequalities in sweden 8 also raises worries about exacerbated inequalities in fear of crime these observations imply that inequalities in fear of crime may be an important albeit understudied public health issue particularly with regard to the underpinnings of such inequalities which have not been comprehensively investigated nor explicitly conceptualized from a public health perspective this leaves little guidance for policymakers to work towards an equal and safe life for all in 1981 garofalo described a conceptual framework called a general model of the fear of crime and its consequences 1 a revised version of which is presented in fig 1 modified to more clearly frame the role of fear of crime from a public health perspective in the model position in social space includes for example socioeconomic status gender age country of birth or ethnicity and sexual orientation by being the basis of social inequalities social position has an ubiquitous influence on the other elements in the model including experiences of and vulnerability to fear of crime 19 two components of particular interest to the present study are income and gender that determine the individual position in social space by operating within a socioeconomical structure according to wilkinson and pickett income inequality contributes to violence and crime which causes increased fear of crime in all layers of society 3 an alternative perspective is offered by hummelsheim et al 4 who instead argue that crime rate has only a minor impact on fear of crime while income inequality seems to be positively linked with fear of crime independently of actual crime levels 45 thus individuals who are worseoff might experience more fear which would imply income inequalities in fear considering that income inequalities are increasing across the european region including sweden 8 income inequalities in fear of crime represent a particular cause of concern fear of crime is like economic inequalities also intricately tied to gender where women tend to report more fear of crime than meneven though men are victimized to a greater proportion than are women 10 this apparent paradox further demonstrates fear of crime as a phenomenon at least partly independent of and distinct from actual crime levels and risks and can from a feminist perspective be explained by the oppressed position occupied by women in the gender structure maintained in patriarchal societies marked by a male dominance 11 the deeply entrenched perceptions related to hegemonic ideologies about masculinity and femininity prescribe that women are more likely to be victimized because of their perceived vulnerability 12 and the apparent paradox can thus be traced to the inequitable gender structure rather than to womens actual vulnerability explanatory factors in fig 1 refer to conditions or experiences that could explain inequalities in fear of crime those that might contribute to fear of crime and also are potentially unequally distributed by income socioeconomic and material conditions are fundamental to the investigation of income inequalities in fear of crime fear of crime is principally incited by social inequities and economic disadvantages 1314 and individuals can only respond adequately to fear if they have appropriate socioeconomic resourcefor example buying a car instead of using a potentially unsafe public transportation 1 therefore inequalities such as income inequality affect the quality and intensity of the response to fear by providing possibility to access different resources 1 furthermore psychosocial conditions play a major role in the presence of inequality in fear of crime for example social participation and social capital can decrease the level of fear of crime 15 lastly residential context seems to influence fear of crime 19 for instance urban areas where crime rates are higher fear of crime is correspondingly greater than in rural and low crime rate areas 16 17 18 according to garofalo 1 individual responses to fear of crime can produce negative social outcomessuch as social distrust alienation from social life and political distrust throughout individual responses to fear of crime 19 however fear of crime is also influenced by the social outcomes themselves since social outcomes can also play the role of explanatory factors and a vicious circle or protective feedback may thus occur furthermore individual responses to fear of crime lead to negative health outcomes 22021 such as poor mental health and depression 21 and a decrease in physical activity to avoid fear and possible victimization 2021 which in turn may impact on social outcomes and vice versa with the presented model as a conceptual point of departure the present populationbased study aimed 1 to estimate income inequalities in fear of crime 2 to identify and measure key explanatory factors of income inequalities in fear of crime and 3 to explore gender inequalities in fear of crime income inequalities in fear of crime and determinants of income inequalities in fear of crime in northern sweden methods study population and data secondary data were obtained using the norrland health on equal terms national crosssectional survey from 2014 that has been carried out by the county councils in collaboration with the public health agency of sweden details about the survey procedures and questionnaire are found in technical reports 2223 the questionnaire was distributed in a collaboration between the swedish national public health agency statistics sweden and the respective county councils of the four northernmost counties of sweden västernorrland jämtlandhärjedalen västerbotten and norrbotten all residents aged 1684 years were identified as the target population the sample frame comprised 704099 individuals sampling was carried out with a twosteps probabilistic procedure first a random national and unstratified selection was performed from the national het survey second a regional random sample stratified by gender age county and municipality was conducted the overall participation rate was approximately 50 leading to a sample size of 25667 individuals who answered either the postal or web questionnaire further inclusion or exclusion criteria were not applied and item nonresponse was handled by using complete case analysis resulting in a total analytical number of 22140 observations 10220 men and 11920 women the het questionnaire covers domains such as health health behaviours healthcare use and psychosocial and material conditions in addition the survey data were through the swedish personal identity number linked to individuallevel sociodemographic data such as annual income education level and country of birth retrieved from the total population registers of statistics sweden measures the fear of crime outcome variable was based on the question do you ever avoid going out alone out of fear of being assaulted robbed or otherwise victimized and coded as no or yes the answer options yes sometimes and yes often were collapsed since the frequency of yes often was rather small 15 in the total sample annual disposable individual income was obtained from the 2012 registers of statistics sweden reflecting the remaining income after tax deductions and all positive and negative transfers the mean individual income was 205553 swedish krona per year in the total sample 232602 sek among men and 182362 sek among women explanatory variables were chosen to capture the individual and social context of fear of crime in accordance with the literature 6 and grouped together under four categories sociodemographic characteristics residential context socioeconomic and material conditions and psychosocial conditions as presented in fig 1 in the sociodemographic characteristics category the following five variables were included a gender coded as man lgbq consequently forming a binary variable of sexual orientation residential context covered the following two factors a municipality size coded as municipalities with population more than 50000 municipalities with population between 10000 and 50000 municipalities with population less than 10000 b residential ownership coded as residentowned rental and other arrangements socioeconomic and material conditions covered the following five factors a annual disposable income was also included as explanatory variable to avoid overestimation of other explanatory variables which could correlate with income as suggested by wagstaff et al 25 it was divided into quintiles 24 26 27 28 29 b education coded as high medium and low c labour market position coded as working studying retired and nonemployed d low cash margin was based on whether the respondent would be able to get hold of 15000 sek in 1 week those who could get hold of 15000 sek were coded as no those who could not as yes e difficulties to make ends meet whether the respondent had had difficulties in managing the regular expenses during the last 12 months coded as no and yes in the psychosocial conditions category the following four variables were included a social participation was based on whether the respondent had taken part in activities during the last 12 months such as study circlecourse at your workplace study circlecourse in your free time trade union meeting other association meeting theatrecinema art exhibition religious gathering sporting event written to the editor at newspapersperiodicals demonstration of some kind public entertainment eg night club dance or similar large family gathering private party at someones home or none of the above a positive response to one or more activity was coded as yes with no activity coded as no b social trust was based on whether the respondent can generally rely on other people coded as yes and no c subjected to threat or violence variable was based on the combination of two items whether the respondent had been subjected to the threat or menace of violence andor whether the respondent had been subjected to physical violence in the last 12 months coded as no and yes d degrading treatment was based on whether the respondent had been treated in a way that was perceived as humiliating in the last 12 months coded as no and yes data analysis first a descriptive analysis was run on the total and gender stratified samples then to fulfil the first aim concentration curves and concentration indexes were used for estimating the degree of incomerelated inequality in the distribution of the outcome variable fear of crime the cc plots the cumulative percentage of the outcome on the y axis and the cumulative percentage of the sample ranked by the socioeconomic indicator from the poorest to the richest on the x axis 3031 a 45°diagonal line of equality indicates equal distribution of the outcome along the ranked indicator c is defined as twice the area between the cc and line of equality the c is equal to 0 if the cc equals the line of equity but also in cases where the cc crosses the line of equity and the areas below and above the line are cancelling each other out when cc lies above the line of equity the value of the c is negative signifying that the outcome is concentrated amongst the worse off the value of c is positive when the cc lies below the line of equity meaning that the outcome is concentrated amongst the better off 3031 to address the second and third aims decomposition analysis was used 32 decomposition of the c is a regressionbased analysis where c is decomposed by a set of determinants 3032 and quantifies the individual independent contributions of the included determinants to the c the c of fear of crime by income was decomposed by all the explanatory factors described above the c was decomposed by using the socalled wagstafftype of decomposition analysis 30 accordingly the c for any linear additive regression model of health such as γ ¼ α þ x k β k x k þ εð1þ can be expressed as follows c ¼ x k β k x k μ à á c k þ gc ε μð2þ where μ is the mean or in case of binary factor the proportion of the outcome variable β k is the coefficient for determinants k from a linear regression model x k is the mean of x for k c k is the concentration index for x k and gc ε is the generalised concentration index for the error term as stated in the eq ∁ equals the weighted sum of the concentration indices of the k determinants where the weight for x k is the elasticity of y with respect to x k 30 the last term gc ε μ of the eq captures the residual component that expresses the incomerelated inequalities in the outcome that the systematic variation in the determinants k across socioeconomic groups could not explain 30 as the outcome variablefear of crime was binary the normalisation procedure suggested by wagstaff 283032 was applied to the decomposition analysis and to the c the outcome of this present study was binary thus we applied a statistical technique which was developed for such nonlinear settings the world bank technical notes proposes using marginal effects from probit models to restore the underlying linear assumptions of the decomposition analysis 30 specifically to substitute the β k in the eq for the marginal effects from a probit model and thereby use these marginal effects to calculate the contributions of the k explanatory variables 30 we chose to apply this method in the present study the linear approximation of the nonlinear setting can be described as follows c ¼ x k β m k x k μ à á c k þ gc ε μð3þ the results of the decomposition analysis summarized as the estimates of coefficient elasticity concentration index of the contributing factor and absolute and relative contributions to the total concentration index and adjusted relative contribution the coefficients are the marginal effects from the probit regression model show the magnitude of the relationship of the variable with the outcome the elasticity depicted as ðβ k x k μþ in eq indicates the frequency weighted marginal effect 30 ie the marginal effect multiplied by the mean of the explanatory factor in question therefore it might happen that a high coefficient has a low elasticity due to disproportionately low frequency of that variable category the contributing factors are the determinants of the outcome that theoretically can explain the income inequality of the outcome the fear of crime variable in this present study the concentration indices of the contributing factors denoted as c k in the eq are the relative measure of inequality of the contributing factors thus the same interpretation can be applied here as for the total c ie a negative ci indicates that the category is concentrated among the poor and vice versa the contribution can be calculated in both absolute and relative terms the absolute contribution is the multiplicative product of ci and elasticity ðβ k x k μþ 30 and is as such expressed on the same scale as the overall concentration index the relative contributions instead show how much percentage of the inequality in the outcome is attributable to the inequality in the contributing factor relative contribution of a factor is calculated by dividing its absolute contribution by the total inequality of c and then multiplying it with 100 additionally the adjusted relative contribution expresses the factor contribution in relation to the sum of those contributing in the same direction as the concentration index ie those that contributes towards the observed inequality 30 finally variance inflation factor was used to establish whether multicollinearity between the variables was present but all were below the threshold of 5 the dummy retired variable of the labour market position had the highest vif of 471 all analyses were done on the total sample and stratified by gender to capture any genderspecific patterns all the statistical analyses were performed with stata 130 software results table 1 displays the descriptive statistics on the total and gender stratified sample with absolute and relative frequencies of the studied variables fear of crime was reported by 128 of the total sample 208 among women and 35 among men in general there were more individuals who reported fear of crime among those aged 1629 nonswedishborn widower or lbgq as well as among those who had rental or other living arrangements lower income financial difficulties or were studying furthermore fear of crime was more common among those who reported unfavourable psychosocial conditions or former exposure to threat violence or degrading treatment and in those who reported lack of social trust overall the descriptive results thus pointed to fear of crime being more frequent in disadvantaged social groups regarding the first aim substantial income inequalities were observed among the total population men and women the negative values of these estimates demonstrate that fear of crime was concentrated amongst the worst off also illustrated by the ccs on total and genderstratified samples presented in fig 2 corresponding to the second and third aims table 2 and fig 3 present the results of the decomposition analysis on the total and genderstratified samples of the overall c 786 769 and 760 of the inequality was explained by the included variables in the total sample the sociodemographic characteristics together contributed the most amounting to 465 of the income inequality in fear of crime while in the stratified samples the same group of explanatory factors but excluding gender contributed with 239 and 165 for women and men respectively such a high contribution in the total sample was mainly attributed to the individual contribution of 362 by gender and a less sizable contribution came from age with 86 for women age independently contributed positively with 259 which was the highest contributing factor in this group of variables in contrast in men age counteracted the inequalities so its net contribution to the inequality was insubstantial instead the most important contributing factor for men was the unmarriednot cohabitating variable with 161 the contribution of socioeconomic and material conditions was the second most important set of variables in the total sample with a 218 contribution to the inequality of which the individual contributions of the specific variables were rather small in the stratified sample this group of factors was instead the most dominant one contributing with 374 in women and 341 among men in women the strongest contributing factors were education labour market position and income quintiles and in men low cash margin also displayed a large contribution in addition to education and labour market position the psychosocial factors accounted for 115 in the total sample contrary to the previous two instances psychosocial factors were numerically more important for the inequalities in men than in women for all three samples social trust was the major contributing variable 76 in total sample 99 in men and 149 in women degrading treatment was a quite important factor for men explaining 72 of the total inequality while it had a marginal contribution for the total sample and women the residential context was the least vital discussion to the authors knowledge this is the first populationbased study aimed at exploring income inequalities in fear of crime and the determinants of these inequalities the results indicate substantial income inequalities in fear of crime to the disadvantage of the less welloff and that these inequalities were largely attributable to a range of social determinants with partly different patterns in women and men in our study crime was limited to fear of being assaulted robbed or otherwise victimized but there are several other types of crime eg violent burglary gang violence arson cybercrime domestic abuse etc which did not fall under our scope therefore we limit our findings only to fear of crime as it was defined in our conceptual framework our finding of income inequality in fear of crime reflects that fear of crime is more common among those who are socially disadvantaged which corresponds with the literature 3 4 5 and adds to the observation of vieno et al 5 that income equality in a society is associated with low levels of fear of crime however we also found that the bestoff women experienced slightly greater fear of crime than did the middleincome women a possible reason for this could be that those who are bestoff have the most to lose in terms of property in an incidental victimization and in such situation women are viewed as more vulnerable compared to men a pervasive finding throughout the analyses was indeed that fear of crime was highly gendered with the prevalence of fear of crime among women almost six times higher than in men but with a slightly larger income inequality in men than in women moreover the genderstratified analyses also showed notable differences in the degree of income inequality between the total population men and women where the total population had the highest inequalitymost probably due to a reflection of gender explaining a large portion of the inequality since women had lower income and also reported a higher level of fear of crimewhile men reported a higher inequality than women taken together the finding emphasizes the intertwinement of gender and fear of crime as suggested by the literature 1018 and by our conceptual model in fig 1 as noted in the introduction such an ubiquitous role of gender may be rooted in hegemonic ideologies of femininity and masculinity 10 sociodemographic characteristics exemplifying the position in the social space in fig 1 seemed to be the most important group of factors explaining inequalities in the total population and as noted above gender was a particularly dominant contributor the literature has also established a prominent role of age and income among the determinants of inequalities in fear of crime 46 33 34 our findings suggest that socioeconomic and material conditions contributed considerably to the fig 3 relative contributions of groups of variables to the concentration index of incomerelated inequalities in fear of crime in the total sample men and women in 2014 northern sweden inequalities particularly in the genderstratified analysis where education low cash margin in men and labour market position in women emerged as strong contributors recent research from the european region 6 suggests that younger women and the elderlygroups which also tend to have lower incomehave a higher proportion of fear of crime findings that resonate with the mentioned female oppression and perceived vulnerability theory 1012 in accordance with this our study found that the age groups 1629 in women and 6584 in both genders are important factors in the explanation of income inequalities in fear of crime corresponding with vulnerability theory 3435 these groups might feel themselves unprotected against an eventual crime through belonging to the less affluent part of society which could provide an explanation to their contribution to income inequality in fear of crime psychosocial conditions seemed to have a moderate importance in explaining income inequalities in fear of crime with social trust and degrading treatmentalready established as important determinants for fear of crime 1636 being prominent contributors in particular as depicted in fig 1 psychosocial conditions such as degrading treatment might make individuals more susceptible to fear of crime which in turn may contribute to negative health outcomes for example depression or anxiety residential context emerged as the least important group of explanatory factors in this present study although residential environment can be an important upstream risk factor for fear of crime 14151837 it might not be independently relevant to reducing the income inequalities in fear of crime taking into account the other factors in the model according to the gender gap report 2016 38 sweden was ranked fourth by closing more than 81 of its gender gap however such measures do not take into account victimization and fear as a gendered phenomenon giving a false impression of an equitable setting when it comes to gender the present study instead paints a worrisome picture where prevalence of and income inequality in fear of crime are both substantial and highly gendered in the northern swedish setting our findings imply a need for a strengthened gender and public health perspective on inequalities in fear of crime to provide a safe life for all methodological considerations strengths of the study included the large populationbased sample with linked register data which might decrease potential reporting bias selection bias might also be an issue since the response rate was around 50 moreover we cannot disregard that the outcome fear of crime might be underreported 39 while the selection of the explanatory variables was in accordance with the conceptual framework depicting a hypothetical causal chain the crosssectional design and analytical methods do not allow for causal inference which is the everpresent drawback of crosssectional studies the possibility of feedback loops or unconsidered third variables is still unaccounted for and presents a challenge for any empirical research investigating complex phenomena the decomposition analysis do not support stronger causal inference than linear regression and should therefore should be seen as descriptive rather than causal the secondary data was not specifically collected for this study therefore not all the plausible determinants could be included which reflects the 21 unexplained residual of the inequalities in the total population moreover although the outcome variable fear of crime has been used by the public health agency of sweden for monitoring purposes since 2005 has been used in previous research 243640 and is similar to other measures used in the literature 4131541 it has not been formally validated which could introduce error in the estimates additionally a conceptual framework is at best an approximate and simplified depiction of a complex reality and the one used as point of departure for the present study might have led to the exclusion of unconsidered determinants of income inequality in fear of crime conclusions the present study shows that income inequality in fear of crime exists even in a comparatively equitable setting like northern sweden ones position in social space involves a risk for a range of socioeconomic and psychosocial exposures that are directly linked to fear of crime where gender inequity seems to be the most central aspect for fear of crime and its incomerelated inequality the existing gender inequity needs to be treated as a greater structural level problem together with socioeconomic inequalities to mitigate fear of crime and thereby potentially inequalities in health too in order to reduce the income inequalities in fear of crime for both genders policymakers should prioritize intervening at the structural level for example by empowering women from all socioeconomic backgrounds and ensuring a safe public space for all as supported by actual legislation abbreviations ccs concentration index ccccs concentration curve cis confidence intervals het health on equal terms lgbq lesbiangaybisexualquestioning sek swedish krona vif variance inflation factor authors contributions bvb developed the conceptual framework and drafted the manuscript supervised by peg who also guided the interpretation and presentation of analyses and results mss obtained the data read and revised the manuscript for intellectual content all authors approved the final draft competing interest all authors declare that they have no competing interests

background fear of crime is not solely an individual concern but as a social determinant of health structured by gender it also poses a threat to public health social inequalities are thought to represent a breeding ground for fear of crime which subsequently may contribute to social inequalities in health however little research has focused on social inequalities in fear of crime particularly in sweden where the level of fear of crime and income and gender inequalities are comparatively low with a conceptual model as a point of departure the present study aimed to estimate and decompose incomerelated inequalities and explore gender differences in fear of crime in northern sweden methods participants n 22140 10220 men and 11920 women aged 16 to 84 years came from the health on equal terms crosssectional survey with linked register data carried out in the four northernmost counties of sweden in 2014 disposable income was used as the socioeconomic indicator fear of crime as the binary outcome variable and sociodemographic characteristics residential context socioeconomic and material conditions and psychosocial conditions as explanatory factors concentration curve and concentration index were used to estimate the income inequality in fear of crime and decomposition analysis to identify the key determinants of the inequalities in collapsed and genderstratified analyses results substantial gender differences were found in the prevalence of fear of crime 208 in women and 35 and men and among the contributing factors to fear of crime additionally the analyses revealed considerable income inequalities in fear of crime in the northern swedish context c 0219 gender socioeconomic and material and psychosocial conditions explained the most in income inequalities of fear of crime in the total population conclusions the existing gender and socioeconomic inequities need to be approached as a greater structural problem to mitigate inequalities in fear of crime further research is needed to reveal more aspects of income inequalities in fear of crime and to develop efforts to create safe environments for all

introduction back in 1970 84460125 international migrants were recorded representing 23 of the planets population by 2019 this number had risen to 271642105 people 35 of the global population that is today every 30 th inhabitant of our planet is a migrant statistics indicate that 74 of all migrants are in the employable population aged from 20 to 64 of whom 52 are men and 48 are women europe alone now accepts as many immigrants as there were in the whole world 50 years ago the migration process is difficult not only for the migrants themselves but also for the host or transit countries and their states of origin intrinsically migration processes can be provoked by many reasons they may be of political social economic cultural and other nature even though recent academic works pay considerable attention to some of these factors not enough consideration has been given for example to the influence of the culture of migrants on the very essence of the migration process this is confirmed by the analysis conducted by un experts as barbashin notes migrations connect communities and states not only in economic and social relationships creating a single socioeconomic space but also in cultural ones barbashin argues that modern sociology considers the high cultural attractiveness of a state to be one of the factors favourable to migration in this context migration is a function of the relative attractiveness of countries of departure and entry with culture playing the role of a push factor for migration flows in the countries of emigration and conversely an attracting factor in the countries of immigration considering that migrants have a natural need to preserve their cultural traditions and customs this fact sometimes hinders rather than facilitates the acculturation process so the social adaptation of migrants becomes an important process on both personal and institutional levels the main results of the analysis of barbashin suggest that the study of migration requires an interdisciplinary approach in which the role of the integrator of interdisciplinary scientific research regarding migration should be assumed by sociology relevant today is the theme of considering cultural capital in social integration and cohesion as well as in the development of human capital introductin floods occur when a river exceeds its storage capacity forcing the excess water to overflow the banks and fill the adjacent lowlying lands this phenomenon represents the most frequent disasters affecting a majority of countries worldwide specifically indonesia flooding is one of the most devastating disasters that yearly damage natural and manmade features there are flood risks in many regions resulting in great damage with significant social economic and environmental impacts the effects include loss of human life adverse impacts on the population damage to the infrastructure essential services crops and animals the spread of diseases and water contamination food accounts for 34 and 40 of global natural disasters in quantity and losses respectively with the occurrence increasing significantly worldwide in the last three decades the factors causing floods include climate change land structure andvegetation inclination andhumans other causes are landuse change such as deforestation and urbanization the high rainfall in the last few months has caused much flooding in the subdistricts of the west kalimantan region thousands of houses in 18 villages in melawi regency have been flooded in the past week due to increased rainfall intensity in the upstream areas of west kalimantan this occurred within the nanga pinoh police jurisdiction including tanjung lay village tembawang panjang pal village tanjung niaga kenual baru and sidomulyo village in nanga pinoh spectacle melawi regency the flood disaster in melawi regency should be mitigated to minimize future consequences by mapping the risk various technologies such as remote sensing and geographic information systems have been developed for monitoring flood disasters this technology has significantly contributed to flood monitoring and damage assessment helpful for the disaster management authorities furthermore techniques have been developed to map flood vulnerability and extent and assess the damage these techniques guide the operation of remote sensing and geographic information systems to improve the efficiency of monitoring and managing flood disasters in the age of modern technology integrating information extracted through geographical information system and remote sensing into other datasets provides tremendous potential for identifying monitoring and assessing flood disasters understanding the causes of flooding is essential in making a comprehensive mitigation model different flood hazard prevention strategies have been developed such as risk mapping to identify vulnerable areas flooding risk these mapping processes are important for the early warning systems emergency services preventing and mitigating future floods and implementing flood management strategies gis and remote sensing technologies map the spatial variability of flooding events and the resulting hazards the recognition of cultural manifestations of inequality and poverty the development of policies to make culture accessible to all increasing the quality and quantity of cultural events and cultural services the services mentioned are related to the activation of public spaces through cultural expression and the democratization of culture through the decentralization of cultural spaces in this context the study of the economic and cultural reasons for migration can contribute to the improvement of these processes of cultural assimilation the symbiosis between culture and economy is also encouraged through tourism and creative industries to reduce the negative impacts of the dynamic process of migration on all its subjects it is necessary to review the main aspects regularly within the framework of assimilation policy this question has become especially relevant since 2020 given how migration played a role in the spread of covid19 and the outcomes of this global pandemic have exerted a destructive impact on all spheres of human activity resulting among other things in a drop in the migration rate and a deterioration in immigrants living conditions the experts of the international centre for migration policy development have highlighted four key migration issues to be addressed by national governments in europe in 2022 first the rise of irregular migration in europe due to the growing instability in countries of origin exacerbated by the economic impact of covid19 second the migration effects of a power grab by force and the growing humanitarian crisis third the reformation of the european asylum system and ensuring a fair sharing of responsibility and solidarity among the member states willing to accept migrants and fourth a discussion of the channels for legal migration based on the most recent data on international migration our study aimed to explore the economic and cultural causes of migration in europe in the present realities our goal of establishing macrosocial patterns and trends in our interpretation of migration practices implied a mixed approach combining qualitative and quantitative data sources we hope that our results will be useful in creating and revising policies regulating and coordinating migration flows as well as in reinforcing and enhancing already available research results with new data the obtained findings may induce researchers to investigate the problem of migration more comprehensively to bring this process to the lowest cost for all its participants according to contemporary researchers the reasons compelling individuals to leave their home countries and seek alternative places of residence can vary significantly these reasons range from the desire to improve ones wellbeing to escaping from wars or the aftermath of natural disasters in general migration has both positive impacts and negative consequences manifested in economic social political cultural and other spheres what is more these results can be a threat to both host and home countries for example by the brain drain from lands of origin or an increase in crime and social tension in receiving or transit states the issue of migration consequences has attracted considerable interest from the world academic community many researchers have focused on the impact of migration on the economies of destination countries underlining the positive impact of migration on the gross domestic product per capita as a result it is widely argued that through remittances immigrants provide lucrative investments that even if spent for consumption purposes stimulate production by a multiplier effect thus for example in new zealand 115 thousand migrants have been estimated to contribute to a stable 02 increase in the states gdp per capita as the practice shows in the area of migration immigrants can transform the social economic and government institutions of the host country thereby creating a socalled diversity capital as an important agent of change in several sectors immigrants tend to be more entrepreneurial than natives actively participate in the civic responsibilities of the host society and bring their customs and traditions to the social and cultural aspects of life through the distribution of food culinary traditions etc given this the governments of various states worldwide and in particular of the european union have adopted various measures to control and regulate the flow of migrants these measures include measures to support the reception of refugees the legalization and adaptation of migrants the conduct of language training courses migrants protection and the like one widely adopted way to increase the population of a country is to attract international students this tactic is designed so that after training young qualified and already adapted to local realities specialists will remain in the country permanently in this case benefits to the host country are as obvious as losses to the country of origin to avoid a brain drain some states try to return citizens to their homeland by offering monetary compensation however many of them fail to take into account the benefits of such a situation linked to already established social ties with peers potential hirers family members and friends who in turn provide streams of knowledge and direct foreign investment residents of some countries consider migrants to be the cause of economic political social and criminal problems this issue has become especially acute after a series of terrorist attacks for example in paris in 2015 as a consequence many states have adopted a controlling stance and sometimes even completely resisted the flow of migrants and tightened the border crossing regime in europe these include italy spain and greece through whose borders the main flows of refugees have recently been increasingly directed as a global player europe represents a link between the colonial past and the current multicultural society the history of european migration goes back many decades but its duration differs across countries for instance migration to the united kingdom and some other european zhibek syzdykova et al states began long before world war ii as of today many nations like italy spain portugal greece and ireland which used to be countries of origin for the emigrant population have recently become receiving or transit states due to becoming a pathway into legal integration in the eu in parallel germany one of the most popular host countries of today is in line with france and austria in terms of supporting immigrants acculturation while the uk sweden and holland stand for multiculturalism since migration processes are likely to be extremely dynamic during globalization constant revision and updating of available data on the matter based on the latest statistics is essential this study aimed to explore the economic and cultural causes of migration in europe in contemporary realities to achieve this goal three steps were followed first to review migration practices in europe second to identify the causes and factors of migration that were contributing to its further growth and third to substantiate migration practices in the context of economic and cultural bases while taking into account factual evidence the novelty of this study resides in providing an analytical framework of european migration practices based on the economic and cultural aspects of migrant integration statistics in the context of national migration and other policies methods the current study was wholly based on the statistical analysis of data for the year 2020 retrieved from the international organization of migration the international monetary fund the european commission the organization for economic cooperation and development world bank data and world migration report these statistical sources were used first to provide an overview of migration processes second to expand the knowledge on migration causes and factors and third to provide an empirical basis for assessing european migration practices in the context of economic and cultural factors the set of methods applied within the investigation included statistical analysis monitoring rating and summary statistics this research was carried out in three stages step 1 the starting point in the review of migration practices in europe was data reflecting it in four subregions it should be noted that small countries with a population of fewer than 3 million people were not included in the analysis because their statehood is not associated with real economic and political independence compared to large countries understanding the extent and trends of migration provides knowledge on the mobility of people and the development of the socioeconomic space of european societies to visualize migration practices this study benefited from the conditional formatting microsoft excel tool used with histogram rule series of distribution of measured values the maximum value in a given histogram became the benchmark number for a high level of migration the minimum value is low migration rates other values were placed on a scale between the values 11 and 100 the result was given as a summary table in excel which converted the data to summarize it into a report the results obtained in the report are confirmed by a secondary analysis of the previous years data this analysis distinguishes between countries of origin of migrants and final destinations by region in europe step 2 to expand the knowledge base on european migration practices an analysis of factors influencing migration patterns and processes was performed using general statistics on migrants integration in europe to visualize the data a diagram showing the proportions of reasons that boost the likelihood of migration was created the result of any of the four reasons would be the category issuance of residence permits therefore it is not included in the list of comparable reasons in the chart step 3 in the third and final stage research results were analyzed in terms of economic and cultural factors and migration in this context issues related to differences in visa receiving the impact of residence conditions and the mobility of people in the practice of european countries were studied on the one hand these differences captured the cultural context of migration in terms of the cultural attractiveness of national policies and mobility as well as capturing the economic context of migration in terms of overall quality of life it should be noted that the fragile states index is based on a comprehensive social science methodology distinguishing three primary data streams quantitative qualitative and expert making it possible to reflect realities and patterns of conduct of countries at the national level in terms of sociocultural processes the empirical substantiation of migration practices was carried out for european countries occupying leading positions in the analyzed ratings as of 2021 the result was the production of summary statistics of the key indicators presented through a line chart with accumulations to compare parts of the whole value in three categories overall quality of life legal culture and the countrys status in the international community result and discussion migration is a complex phenomenon that affects both economic and noneconomic fundamentals at the end of 2021 an estimated 867 million people migrated from one country to another in europe for comparison this is an 185 increase from 2010 with its 706 million people it should be noted that the share of international migrants varies considerably among european nations as the most recent data on the number of migrants in international statistical databases are available for 2015 the analysis is based on a comparison of migrant ratios to the total population the analysis of figure 1 suggests that the largest shares of migrants in eastern europe are in ukraine and belarus for northern europe these are sweden and ireland for southern europe spain and croatia for western europe austria and germany the lowest migration rates are in poland finland portugal and france respectively thus one can state that the countries of northern and western europe are the most attractive destinations for migrants and the countries of southern and eastern europe are the least attractive the established trend contributes to the structural restructuring of the economy through the redistribution of human capital and the formation of multicultural societies to confirm the findings in table 1 the data analysis from 2020 is renewed in an attempt to distinguish between countries of origin and destination in terms of number and share of the total population the results of the secondary analysis confirm the fact that in most cases the region of origin of migrants is eastern europe and the final destinations are western and northern europe to identify the factors that encourage the movement of people from one country to another the reasons for international migration were monitored the causes of international migration here work motives were considered to be an indicator of economic factors while those related to the foundations of state cultural policy were embodied in the institution of the family legal culture and education figure 1 shows that taken together the ratio between the proportions of economic and cultural factors is 2575 the determining economic reason for migration is the desire of the individual family and community to improve the overall quality of life through labour the determining cultural reasons for migration are the search for justice in the area of human rights and safe living conditions accordingly it can be stated that today the push factor of migration is the violation of fundamental human rights in the state cultural policy guided by the society of the migrant recognizing the importance of the impact of the cultural context associated with the institution of the family and human rights assuring the ability to develop and express ones humanity and worldviews makes it relevant to empirically justify migration practices from two perspectives public cultural policies and human mobility a review of the evidence on migration practices in europe in the context of overall quality of life and migration opportunities in terms of access to visas and safe residence demonstrates that the availability of migration options is partly related to nationality and in general reflects a countrys status in the international community and its attitude towards migrants from a particular state the primary migration routes in europe are depicted in figure 3 22 note the term migrant includes working migrants persons of working age of 15 years and older who move from their state to another state for employment a refugee a person forced to flee their country because of a threat to personal security source oecd international organization for migration and un migration world bank data summarizing the data the following macrosocial patterns and trends in european migration practices can be highlighted first all european countries are characterized by migration growth in which migrant mobility acts as a contributor to the redistribution of a countrys wealth and the formation of multicultural societies the main factor driving migration is human rights violations secondly the development of the modern migration process requires a migration infrastructure that would provide the opportunity to turn to legal migration and assure the maximum contribution of migrants to the development of the socioeconomic space of the country the collected findings contribute to a better understanding of the state of migration in europe by providing statistics on migrant integration driving forces in migration patterns and processes and an empirical grounding of migration practices in economic and cultural contexts northern and western european countries were proven to be the most popular destinations for migrants within the studied area also migration was found to promote macrochanges through the contribution of human capital to the development of the socioeconomic spaces of european countries estevens claims the 21 st century to be a century of migrants since global mobility is now a highly stratified phenomenon from the global tourist to the undocumented employee from human trafficking to refugees forced to leave their country of origin because of climate changes poverty or war migration practices have become a global process with multilateral population movements between states in todays world in the great scheme of things international migration has joined the ranks of the most important elements in ensuring sustainable development the reason for this resides in the fact that it provides an opportunity for advanced nations with depopulation and demographic ageing to maintain the growth rate of national economies in the meantime in developing states with a progressive age structure international migration solves the problem of excess labour resources and high unemployment another explanation for the interest in migration is that it is not infrequent that the local population sometimes regards immigrants as an economic or cultural threat here the perceived economic threat stems from the increasing competition in the labor market while cultural one is associated with the possibility of influencing the language lifestyle customs cultural values and beliefs of natives accordingly migration brings noteworthy changes in structures and institutions in global political economic and social relations which is fully consistent with the findings of this research bygnes and erdal examined the novelty of migration flows triggered by the 2008 financial crisis based on the subjective assessment of adult polish and spanish migrants in norway researchers found that family concerns economic factors and working life conditions in countries of origin were as prominent in migrants reflections on the future hence income differences were confirmed to be one of the main reasons for migration as evidenced by the results of this study peoples priorities have changed over time at present migration is first determined and shaped by an individuals desire to improve the overall quality of life and only then by the observance of fundamental human rights in the national culture primarily determined by a persons place of birth and residence similarly to the current work callens and meuleman studied migrations economic and cultural factors in european countries though their key emphasis was set upon a threat perspective they uncovered that migrants living in countries with more inclusive integration policies in particular policies aimed at access to the labour market and political participation are characterized by lower economic and cultural threat perceptions all in all culture is considered an integral part of economic development as the experience shows all migrants either adhere to their culture or become part of the culture of the host state this studys interpretation of migration relies on the prioritization of intangible factors in migration decisions related to the alignment of human legal status standards its deductions are confirmed by lanati and venturini who found that accounting for cultural indicators is a more important determinant in migration patterns and processes than traditional economic variables the scholars also demonstrated that positive changes in cultural relations facilitate bilateral migration over time hence the results of our research not only corroborate but also expand upon the findings of previous studies according to the empirical evidence presented in this study the disparities in protecting human rights between highly developed countries and other nations emerge as a dominant cause of contemporary migration the reliance on the henley passport index the fragile states index and the human development index allowed delivering comprehensive data to understand key features of migration practices in european countries in increasingly uncertain times of epidemics and escalating humanitarian crises especially in the east conclusions by carrying out an indepth study of data on international migration for 2021 this research found that in europe the largest migrant populations are in the north and west which is confirmed by actual data from the secondary analysis of the previous years migration data a thorough analysis of the causes and factors of the migration pattern and process revealed that this phenomenon is driven by violations of agreed human rights standards in migrants home countries these aspects contribute to the forced movement to countries with high cultural attractiveness to meet the basic need for a fair assertion of ones rights host countries assure analysis of the evidence suggests the following macrosocial patterns and trends in european migration practices migration enhances the quality of human capital and maximizes the contribution of peoples competencies and knowledge to the socioeconomic development of the country migration is driven by the human rights violations in the national cultural policy guiding the migrants society migration assessment in the context of economic and cultural factors highlights significant differences between countries with different levels of human development in terms of human mobility and cultural values the person acquires by birth and residence the results of this research may have implications for politicians and statespersons working in the field of regulation and control of migration as well as scholars studying migration processes and their causes further work will be aimed at investigating a correlation between global upheavals and population migration to consider the impact of various drivers on migration corridors evolution funding this research received no specific grant from any funding agency in the public commercial or notforprofit sectors conflicts of interest the authors declare that there are no conflicts of interest related to this article data availability statement data will be available on request

this research aimed to identify the economic and cultural factors of migration in europe within the context of contemporary economic and social realities to achieve the research objective a comprehensive multistage research project was developed and implemented incorporating the advantages of statistical analysis monitoring rating and summary statistics the research relied on harmonized and validated statistical data from 48 european countries divided into four subregions serving as the informational foundation for the study using summary statistics on migration factors in the context of economic and cultural factors made it possible to demonstrate the importance of considering cultural human rights in the countrys migration policy an interpretation of migration practices in europe by this means enables us to highlight the cultural context as a determining indicator based on an analysis of objective indicators in the development of migration processes furthermore the study shows that the high quality of life and cultural attractiveness of the national policy stimulates the migration intentions of a person to seek out countries with more developed economies the findings of this study hold relevance for policymakers and specialists in public administration particularly those involved in the regulation and control of migration additionally academic researchers can benefit from the empirical regularities established in this research and the identified prospective avenues for future investigations

introduction pasar badung is the largest traditional market in bali indonesia this market is a shopping center for daily needs for balinese people and tourists visiting this island along with the development of tourism in bali the badung market has undergone significant changes both in terms of size structure and culture however even though the badung market has undergone significant changes women workers are still an important element of this market the female workers in the badung market are goods carriers they work from morning to night for very low wages even though they have an important role in the sustainability of the market women workers in the badung market still experience discrimination and difficulties in obtaining their rights in addition they are also often ignored by society and the government the creation study was very important in bringing attention and awareness about the lives of women workers in badung market documentary photography was chosen as a tool to capture the daily life of women workers in the badung market because of its ability to objectively record everyday life and allow observers to contemplate and appreciate the photographs to ensure a successful creation photographers need to gain a good understanding of balinese social and cultural conditions as well as the lives of women laborers in the badung market research and studies on women workers in the badung market and other traditional markets in bali need to be carried out to gain deeper insight into their daily lives the challenges and obstacles they face and the efforts that can be made to improve their conditions as well as will help promote the preservation of local balinese culture and the sustainability of the badung market as an important cultural heritage of bali through the photographs resulting from this creation the balinese and the international community can gain a better understanding of the lives of women laborers in the badung market and their role in maintaining the sustainability of this traditional market in this context documentary photography can be an effective tool for producing visual works that can give voice to women workers in the badung market documentary photography can objectively record the daily life of women workers and can give viewers a different perspective and touch the heart these photos can also be a tool to raise awareness and understanding about the lives of women workers in the badung market and the challenges they face the creation of this documentary photography can also be a tool to give voice to women workers in the badung market and encourage social change in order to produce quality and effective documentary photography works photographers need to carry out indepth research and studies on balinese social and cultural conditions as well as the lives of women workers in the badung market this could include visiting a badung market and talking to female workers as well as learning about the history of the market and its role in balinese life overall this project has the potential to produce visual works that give voice to women workers in badung market while also increasing awareness and understanding of the lives of women workers in badung market and their role in the sustainability of balinese traditional markets in addition this creation can also trigger broader discussion and dialogue on issues of employment and gender equality in bali and indonesia as a whole in recent decades the role and contribution of women in the social and economic life of bali is increasingly recognized but there are still challenges and gaps that need to be addressed the working conditions of women workers in the badung market also often experience gender discrimination they are seen as weaker and more vulnerable to harassment and violence both at work and at home in addition women workers also face various challenges in maintaining health and safety in the workplace despite this the women laborers in the badung market continue to work hard and struggle to make a living for their families they often work more than 12 hours a day and sometimes have to take their children to work because they dont have a babysitter however despite the challenges they face women workers in the badung market also have extraordinary strength and endurance this project can be part of a larger movement to promote social change and womens empowerment through documentary photography this creation can give a voice to women workers in the badung market show their often overlooked stories and raise awareness about the issues they face this can also encourage the community and government to take action and provide the necessary support for women workers in the badung market to achieve this goal photographers must pay attention to the ethics of documentary photography including respect for the privacy and dignity of the women workers who are photographed photographers must build a trusting relationship with their subjects and ensure that they are treated with respect and dignity this creation must also include the participation of women workers as partners in the process of creating and distributing documentary photographic works this can ensure that the voices and perspectives of women workers are taken in an authentic way and can provide opportunities to empower and upgrade their skills in order to achieve the desired goals this creation will require support from various parties including local organizations the government and the balinese community as a whole with good cooperation and collaboration this creation has the potential to create a significant impact in driving social change and empowering women in bali and indonesia based on the background that has been stated it can be formulated that the problems to be discussed are first how can documentary photography be used to show the life of women workers in the badung market in a strong and effective way second what are the benefits of a documentary or art photography project that focuses on life female freight forwarders at the bali badung market in raising awareness about social and gender issues fighting for the rights of women workers and promoting responsible tourism and respecting cultural diversity in bali third how to visualize the daily life of women workers in pasar badung through documentary photography many studies have been carried out on women workers in traditional markets especially in indonesia several studies reveal that hard working conditions low wages and the gender gap that still exists in traditional markets however not many studies have used documentary photography as a data collection method to describe the daily life of women workers in traditional markets especially in badung market a study by suastika revealed that working conditions in pasar badung were very hard for women workers they have to work from morning to night with minimal wages apart from that they also have to face various problems such as intense competition changing consumer trends and everincreasing economic challenges other research by sulasmiyati reveals that women workers in badung market experience a gender gap in recognition and appreciation for the work they do the gender gap can be seen from the difference in wages between male and female workers who work in traditional markets in addition women workers also experience discrimination in terms of opportunities to obtain the necessary training and education to improve their work skills however these studies used data collection methods such as interviews and direct observation not many studies have used documentary photography as a data collection method to document the daily life of women workers in traditional markets particularly in badung market one of the studies that used documentary photography as a data collection method was a study by murniati which described the lives of fisherwomen in karangasem regency bali in this research murniati uses photographs to show the daily activities of fisherwomen and the challenges they face in their work this documentary photography method is very effective for describes daily life and provides a clear picture of the conditions faced by respondents therefore this study uses the documentary photography method as a data collection method to document the daily life of women workers in pasar badung it is hoped that this method will clearly show the working conditions of women workers in traditional markets as well as provide a deeper understanding of the challenges they face in their daily lives methodology the research methodology was carried out using a qualitative descriptive research design with a case study approach the data collection technique used next the researcher will apply for a permit to the badung market management to observe and take photos in the market during the observation researchers will take photographs of women workers at work including photos of their interactions with customers coworkers and families who come to visit in addition researchers will also obtain data by conducting structured interviews with a number of female workers in the badung market to find out more about their daily lives the challenges they face and their hopes for the future after the data is collected the researcher conducts data analysis using a qualitative approach by identifying themes that emerge from the photos and interviews those themes will be used to answer the formulation of the problem and research objectives that have been proposed the analysis techniques that will be used include descriptive analysis qualitative analysis and thematic analysis as an additional data collection technique the researcher will also conduct a literature study related to this research topic the secondary data will be used to support the results of primary data analysis so that a more complete conclusion can be drawn this study will also use the triangulation method as an effort to obtain data validity data triangulation was carried out by comparing data obtained from various sources namely photographs interviews and literature studies in terms of research ethics researchers will maintain the confidentiality of the identities of the respondents and avoid manipulating photos or data that could harm other parties researchers will also obtain written consent from the respondents before conducting interviews and taking photos in order to ensure research validity researchers will obtain data validation from respondents and a number of experts related to this research topic data validation will strengthen research results and make them more reliable like diatmika et al and gunawan et al do the research method in this study is a qualitative method with a case study approach the data triangulation method will be used to ensure the validity of the data data collection techniques used include observation interviews and literature studies data analysis techniques used include descriptive analysis qualitative analysis and thematic analysis results and discussion documentary photography is an art form and photographic technique that aims to show real life in an objective way and maintain reality without excessive influence or manipulation in the context of this research documentary photography can be used to show the lives of women workers in the badung market in a powerful and effective way one of the ways in which documentary photography can be used to show the lives of women workers in the badung market in a powerful and effective way is by using visual storytelling techniques this technique involves using images and narration that complement each other to draw the audience into the story conveyed in the images in the context of this research pictures can be used to show the lives of women workers in the badung market while narration can be used to provide background on the lives of these women workers as well as describe the challenges they face in carrying out their work this documentary photography approach that uses visual storytelling techniques is also supported by documentary photography experts according to the american documentary photographer wright morris good documentary images must be able to bring the audience into the story shown in the image in addition other documentary photography experts such as dorothea lange and lewis hine also emphasize the importance of using accurate and objective narration to strengthen the story to be conveyed through images in the context of this study the opinion of the documentary photography experts can be applied by combining visual storytelling techniques with the use of accurate and objective narratives through the use of this technique documentary photography can be used to show the lives of women workers in the badung market in a powerful and effective way images showing the lives of women workers in the badung market can provide indepth insight into their conditions while the narration conveyed in these images can provide a complete background on the lives of women workers in the badung market however apart from being a medium to show the lives of women workers the creation of documentary or art photography can also provide other benefits in promoting awareness of social and gender issues fighting for the rights of women workers and promoting tourism that is responsible and respects cultural diversity in indonesia bali which can act as a tool to educate the public about the lives of women workers and social issues related to their profession and can see firsthand the lives of women workers including the difficulties and challenges they face in carrying out their daily work this can help increase public awareness of social and gender issues that are often overlooked the creation of documentary photography can also be a means to fight for the rights of women workers by showing the lives of women workers through powerful media such as documentary photography it can give voice to those who were previously marginalized the presence of documentary photography can help arouse public and government attention on the importance of womens labor rights chris jordan a famous documentary photographer confirms that documentary photography can influence social change through works of art photographers can showing the lives of others and giving voice to those who often do not have a voice this can fight for social change and a better humanity in terms of tourism a documentary photography project can also contribute to promoting responsible tourism and respecting cultural diversity in bali which can help change tourists perceptions of bali which is often seen only as a beach destination and cultural tourism destination by showing the lives of women workers and cultural diversity in pasar badung bali through documentary photography it can help elevate the dignity of the female labor profession and provide a more authentic and sustainable tourism alternative source putra 2023 figure 1 rest for a while the photo shows a woman worker resting in the overhang of the badung market the woman worker is very tired after several hours of working as a laborer transporting shopping goods in the badung market carrying a bamboo basket that is usually placed on her head the light used is available light with the direction of light from the side the use of side light will form a contrast between the parts that are exposed to the light directly with the shadow area in conditions like this it creates a dramatic impression and brings out a more realistic light the photo shooting is done using a selective focus technique the focus of the photo is on the female worker by showing a female worker rest and background to show depth in the photo the lens used for shooting is a 55250mm zoom lens at a focal length of 89mm this is done to be able to reach the object distance due to the crowded badung market conditions and the presence of market visitors passing by so that the lens is used in order to get a sharp photo with a fairly far object distance the photo shoot was carried out at the badung market with the angle of taking photos using an eye level the use of this angle can depict objects in their actual conditions using an aperture of f45 iso 2500 and a shutter speed of 1200s aims to be able to record still objects after shooting proceed with the photo editing process using adobe photoshop and adobe lightroom to increase the brightness and contrast in order to sharpen the photo source putra 2023 figure 2 happy smile what makes this photo interesting is the expression of a woman worker who looks very reel without any engineering by carrying a bamboo basket above her head this photo using an eye level angle and placing women workers as a point of interest in the photo the photo shoot was carried out at the badung market by being right in front of the object and the angle of taking the photo was using an eye level the use of this angle can describe the object with the condition which is actually with the camera position parallel to the object in the photo and the light used is available light the lens used to shoot the photo is a 55250 mm zoom lens at a 220 mm focal length this is done to be able to reach objects that are too far away use an aperture of f45 iso 800 and a shutter speed of 1400s aims to be able to record moving objects after shooting in addition the editing stage also needs to be done to add sharpness to the photo by increasing the brightness and contrast using adobe photoshop and adobe lightroom this stage is passed before entering the stage of presenting the work source putra 2023 figure 3 transport the photo shows several female workers carrying bamboo baskets that are placed on their heads to deliver groceries to the lower parking lot which has been used by visitors to the badung market the light used is available light with the direction of light from the side of the object the use of side light will form a contrast between the parts that are exposed to the light directly with the shadow area in conditions like this creates a dramatic impression and bring out a more realistic light the photo shoot was carried out on the 3rd floor of the badung market to get an angle from above the angle used is birds eye that is the camera position is at a very high position as if it were the point of view of a bird flying in the sky the lens used when shooting is a 55250 mm lens at a focal length 55 mm is used for getting distant photos apart from that the use of an aperture of f4 iso 100 and a shutter speed of 1320s is done to get sharp photos and get light enough on the photo in addition the editing stage also needs to be done to add sharpness to the photo by increasing the brightness and contrast using adobe photoshop and adobe lightroom this stage is passed before entering the stage of presenting the work conclusion based on the discussion above it can be concluded that a documentary photography project that focuses on the lives of female freight forwarders at pasar badung bali has significant benefits in raising awareness of social and gender issues fighting for the rights of women workers and promoting sustainable tourism responsibility and respect for cultural diversity in bali documentary photography has strong visual power and can convey messages effectively about the lives of women workers in pasar badung documentary photography can reveal the lives of women workers who may not be seen by the wider community and can trigger positive social change in this case documentary photography can be used as a tool to raise awareness about social and gender issues faced by female workers in pasar badung creating documentary photography can help fight for the rights of women workers in pasar badung by producing clear and believable images of the lives of women workers this project can help fight for their rights in terms of living wages fair working hours and safe and healthy working conditions however this creation needs to be supported and promoted in order to achieve better results and have a positive impact on the people of pasar badung and bali in general

capturing the everyday life of women workers in the badung market through documentary photography is a work that reveals the lives of women workers in the badung market in a powerful and effective way by using visual storytelling techniques this technique involves using images and narration that complement each other to bring the audience into the story presented in images that can be used to present the lives of women workers in the badung market while narration can be used to provide background on the lives of these women workers as well as describe conflicts they face in carrying out their work the purpose of creating this work is to provide a visual depiction of the daily life of female workers to use documentary photography as a medium to reveal the beauty and dignity of the work of female laborers as porters at badung market bali the research method used in this study is a qualitative method with a case study approach data analysis techniques used include descriptive analysis qualitative analysis and thematic analysis the result of creating this work focuses on the lives of female laborers transporting goods at the badung market in raising awareness about social issues able to describe the activities carried out by women workers in the badung market in each photo so that they can provide indepth information