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overview and relevance the rapid development of professional social networks and online labor markets is affecting the future of jobs and workers professional social networks such as linkedin are revolutionizing hiring practices an increasing number of individuals rely on such networks to find jobs and it is becoming common practice for head hunters and companies to examine ones profile on linkedin before contacting or hiring someone online job marketplaces are gaining popularity as mediums to hire people to perform certain tasks these marketplaces include freelancing platforms such as qapa and mistertemp in france and taskrabbit and fiverr in the usa on those platforms workers can find temporary jobs in the physical world or in the form of virtual microgigs such as help with html javascript css and jquery crowdsourcing platforms are a very popular type of online job marketplaces nowadays these platforms are fully virtual workers are hired online and tasks are also completed online examples of crowdsourcing platforms are foulefactory and prolific academic in europe and amazon mechanical turk and figure eight in the usa as the gig economy grows an important offshoot of this movement is flash organizations the popup shops that come together for a purpose such as developing and marketing an app they include entire teams that work closely together and when the project is complete the teams disband for example gigstercom is a smart development service that brings freelancers together into softwarebuilding teams on demand at any time or artellacom is designed for creating complex animated features offering teams of freelance animators sound designers and other talent at your beck and call from a conceptual standpoint online labor markets can be characterized as follows workers are the producers of work that are to be consumed by systems platforms or organizations workers need to be hired treated and compensated fairly they have to be assisted to accomplish their work or further their career on the other hand consumers such as business organizations or platforms need to hire an appropriate workforce to be able to accomplish their business goal in time with certain accuracy and within budget social science as well as datacentric research 57810131418232627 have developed disconnected and disciplinespecific approaches to solve different problems in online labor markets for example social science researchers have proposed conceptual frameworks visualization and software prototypes to recruit workers and form appropriate teams decompose complex tasks to assist workers or propose tools to enable interactivity and collaboration among workers database research on the other hand has addressed scalability and data management challenges of how to curate and clean data produced by online labor markets how to model the data and store it effectively or how to form appropriate teams 32122 machine learning research 71427 proposed models that are capable of aggregating workers contributions or inferestimate groundtruths when that is unknown finally psychology and organizational research 1725 proposed conceptual models that are required to understand and analyze human behavior in online labor market we will first describe different applications that rely on freelancing and online labor markets then we will revisit seminal and prominent works that came out from different research communities on the topic of online labor markets describe their approaches and summarize their impact on science society and industry finally we will outline the requirements of a unified framework that has the potential to combine the best of all these worlds and present modeling data management and algorithmic challenges to conceptualize it scope duration and structure the tutorial aims to gather existing work in several research areas and understand the new challenges and opportunities in the future of work that are of interest to the data management community it is intended for 15 hours and is organized into three parts part i applications in this part we will describe different applications that tap into online labor markets the applications range from freelancing crowdsourcing citizen science as well as flash organizations we will characterize these applications by describing the nature of the type of workbusiness and workers thereby highlighting the desirable properties that each must meet in particular we will characterize applications that are microgigmacrogig ones that require collaborationcould be completed independently and ones that require machine participation or humanonly part ii existing approaches this piece of the tutorial will revisit existing efforts and summarize them along three dimensions • data and problem modeling online platforms are bringing transformational changes in the process of recruiting and retaining the workforce and the nature of work either the work is fully online fully offline or hybrid jobs or work on the other hand are becoming more fluid and1 ondemand and workers need to be dynamically assigned to such jobs in that context the workforce is becoming volatile and with varying expertise levels the reliance on algorithms to match workers and jobs is today a reality such algorithms rely on a data model and are designed to solve specific problems the first part of the tutorial will review existing platforms and characterize them in terms of their data and problem modeling we will discuss how each of the aforementioned research communities ie social science data management machine learning psychology and organizational studies have modeled online labor market problems for example the traditional psychology or organizational management research have proposed conceptual models grounded on human psychology or sociocognitive behavior that empirically studies human performance based on motivation fun monotony etc we will study how social science 12231618 and psychology research have addressed human factors 2 modeling for the problems of incentive design task decomposition task assignment worker engagement and retention on the contrary even though these factors are recognized to be important in machine learning and data management research 24 to the best of our knowledge only a handful of existing works 20 consider these factors in problem model or algorithm design in fact these data centric communities put more focus in proposing models that are more platform specific leading to computationally rigorous models unfortunately humans or producers of works do not receive that much of attention primarily because human behavior modeling requires expertise in psychology and social science our objective will be to discuss these issues and do a deep dive on their proposed modeling techniques • solution techniques computational social scientists theoreticians data management and data mining researchers have proposed different approaches that solve the worker recruitment job selection worker engagement team formation and learning 115 as well as skill estimation problems 11 additionally the design of platforms raises a number of challenges that have been addressed in different research communities for example social science research has taken a semicomputational approach that business and organizations could make use of recent works have also studied automated approaches for workers recruitment team formationand task decomposition nevertheless social science researchers have spent significant effort in designing empirical and field studies that validate their hypotheses they have also developed visualizations and software to hire retain and augment the online workforce the database and machine learning communities on the other hand have taken fully computational approaches in fact the common practice in machine learning is to propose some models that are suitable for the underlying research problem for example task recommendation has been modeled as multiarm bandit and as matrix factorization problems and truth discovery result aggregation skill learning were studied as supervised learning problems where em types of solutions were designed such solutions aim to produce maximumlikelihood estimates of parameters when there is a manytoone mapping from an underlying distribution to the distribution governing the observation the data management community have studied most of the online labor market problems as discrete optimization problems and emphasized scalability and algorithmic challenges we intend to review and summarize these different solution techniques • impact we end this part with a review of the impact of existing works impact will be characterized from both scientific societal and industry viewpoints scientific impact computational solutions have been designed to address learning and augmentation feature engineering inferring skills 22 and learning motivation functions 19 societal impact empirical and computational approaches have been designed to address human capital advancement peer learning and distributed mentoring as well as adaptive workercentric solutions to account for evolving worker motivation additional approaches have been proposed to study transparency fairness and privacy in online job markets 69 industrial impact platforms and software that came out recently such as platform upwork or the true story software2 that hired freelance designers and writers to develop games part iii toward a unified framework this part is primarily forward looking and aims to discuss the challenges and opportunities that arise from bringing together empirical and computational approaches to unify the design of online labor markets we will look beyond and describe our take on how online labor markets can contribute to the growth of landscape of work in future the two big challenges we envision are capturing humans and their changing and unpredictable nature and designing approaches that address the variety of goals underlying job marketplaces this will require us to have the ability to process large amounts of data on jobs and workers in a scalable and fair way these two challenges raise new opportunities that will be discussed as open research questions in this part of the tutorial • modeling opportunities open questions include how to model humans with different roles and intents how to model teams and how to make the model evolve over time we will discuss the use of clustering and active learning approaches to capture context and different roles we will also discuss the role of indexing in managing different human models and their evolution • optimization opportunities open questions include how to best express and leverage optimizationbased approaches that blend humancentric and platformcentric goals we will discuss the need for multiobjective optimization approaches inspired from multiobjective query optimization and skyline queries to navigate in the space of solutions in a scalable fashion we will discuss the relevance of this proposal to optimize task matching multistakeholders fairness and peer learning in the presence of different affinities between workers target audience prerequisites the tutorial will be of interest to both theoreticians and practitioners who are interested in the development of novel datacentric applications in the areas of databases data mining machine learning social science and algorithms ranging from largescale analytics to emerging online applications tutorial attendees are expected to have basic knowledge in machine learning algorithms and data management knowledge in constrained optimization is not necessary relevance the proposed tutorial is timely as it addresses unsolved questions in the emerging area of the future of work the tutorial is relevant to the general area of data management and the web and more specifically to big data processing and transformation data mining clustering and knowledge discovery largescale analytics indexing query processing and optimization social networks analysis graph databases information retrieval the technical topics covered are constrained optimization hardness results ranking semantics and fairness algorithms and empirical evaluations the authors have published seminal papers on human modeling and scalable task assignment in crowdsourcing 319 on team formation for and human factor estimation 2122 and on fairness in virtual marketplaces 4 related tutorials while there have been a few tutorials on crowdsourcing and most notably the one mentioned below those tutorials do not address the convergence of multiple disciplines for the future of work or data management and scalability questions in relation to modeling humans senjuti basu roy is an assistant professor at the new jersey institute of technology senjutis broader research interests lie in the area of data andcontent management of web and structured data with a focus on exploration analytics and algorithms in recent years her research hasfocused on designing principled algorithms and systems that requiremanmachine collaboration senjuti has presented three tutorials onthe computational challenges related to manmachine systems invery large database conference international world wide webconference and international conference on extending databasetechnology she was the pc cochair of sigmod 2018 mentorshiptrack and the pc cochair of vldb 2018 phd workshop program senjuti was a coorganizer of exploredb 2016 and the ieee workshop on humanintheloop methods and human machine collaboration in bigdata she has organized an nsf workshop on converging human and technological perspectives in crowdsourcing research and will be coorganizing a shonan meeting on the topic of humanintheloop big data and ai connecting theories and practices for a better future of work

the goal of this tutorial is to make the audience aware of various disciplinespecific research activities that could be characterized to be part of online labor markets and advocate for a unified framework that is interdisciplinary in nature and requires convergence of different research disciplines we will discuss how such a framework could bring transformative effect on the nexus of humans technology and the future of work

introduction social capital is a measure of civic connections and social trust 1 or the degree of interaction with and trust in ones fellow citizens 2 social capital has been associated with improved outcomes in various sectors including economics education and public safety 1 2 3 it represents an important construct because individuals with higher social capital also have improved resilience after natural disaster improved economic performance overall and easier transitions through life changes 4 5 6 it is therefore fitting for public health to be interested in social capital as a means of understanding and preventing disease we piloted an exploration of how social capital varies across an urban landscape as does a correlated health outcome social capital is of particular interest to public health professionals because of its association with overall health 7 8 9 research surrounding social capital has occasionally represented contradictory associations such as in birmingham alabama when increased social capital corresponded with an increase in mental distress 10 however increased social capital has also been associated with a variety of specific positive health outcomes including successful cocaine quit attempts 11 decreased binge drinking 12 lower obesity rates 13 and even better overall health for older individuals 14 various theories have been proposed to explain the connection between social capital and health outcomes kawachi and berkman proposed three possible explanations for the association between social capital and health outcomes 15 first individuals share information through their social connections including health information those with higher social capital may receive more valuable health information second social capital may also enforce healthy behavioral norms such as physical activity and serviceaccessing behaviors finally social capital may provide a support system that facilitates healthy living each of these three proposed explanations focuses on individuallevel interactions which is consistent with the usual method for measuring social capital social capital is generally measured through individual surveys robert putnam one of the modern founders of social capital theory directs the social capital community benchmark survey which measures 11 components of social capital hpp through a lengthy questionnaire 16 in public health research a survey created by sampson et al is likely the most commonly used individual survey 1718 sampson et al measured social cohesion and informal social control through a 10item questionnaire 17 a scale developed by kawachi et al is also frequently used in public health research 318 kawachi et al uses existing data from the general social surveys on group membership perceived trust and perceived norms of reciprocity then aggregates this individuallevel data to the state level 3 while kawachi and berkman 15 focused on the individuallevel influences of social capital hunter et al 19 proposed an expanded explanation for the association between social capital and health outcomes they suggest that social capital may mediate the broader effects of the social determinants of health this proposal is supported by work from kawachi et al which shows that social capital explains much of the differences in life expectancy heart disease infant mortality and selfreported health even after adjusting for income 3 this view emphasizes the importance of social capital as a collective resource lochner et al similarly argued that social capital is a community characteristic and should be measured at the community level 20 they suggest direct observation of a community to measure social capital however the most effective way to measure social capital at the community level remains unknown it is still debated as how to quantify and measure social capital effectively given the context within each community is different and it may be difficult to apply the same variables across communities 21 several studies have used the built environment as a possible way to measure social capital within communities 22 23 24 25 the idea that social capital is related to the built environment is founded upon this same environment providing context for social interactionsthe relationship is reciprocal thus measuring features in the built environment can act as a proxy for social capital since these are the places that facilitate social capital development in this instance geospatial analysis is an important tool to measure the spatial arrangement of the built environment and can help to identify potential spatial variation in social capital this approach allows for the observation of individuals in the physical or social context in which they engage in daily activities that affect their health ie considering settings 26 while social capital has been the object of growing interest in the past decades no studies to this date have used geospatial mapping to examine the association between patterns of social capital and health outcomes the purpose of this study was to determine the spatial patterns of social capital and its association with disability in the atlanta georgia usa metropolitan area disability rates remain an important public health metric as they represent both the success of public health in primary prevention of disability and the secondary focus of mitigating barriers to health for disabled persons 27 we sought to answer the following questions is there a significant spatial pattern of social capital and is there spatial correlation between social capital and the health outcome disability we hypothesize there would be a significant pattern of social capital based on markeson and dellers 21 research that demonstrates patterns of social constructs and the growing body of literature around spatial patterns of health behaviors resources and outcomes materials and methods data measures and acquisition this crosssectional study employed a purposive sampling method was used in atlanta metropolitan area zip codes atlanta is a diversified metropolis with a population of 420 003 a demographic profile of 401 white 524 black or african american 48 latino and 4 asian 240 of individuals were below poverty level 28 communitylevel variables were identified from prior work by markeson and deller 21 the following communitylevel social capital variables were measured places of worship schools physical fitness facilities community centers country clubs labor unions farmers markets bowling centers and political organizations some of the variables like physical fitness facilities had variant search terms such as ymca recreation centers yoga studios la fitness anytime fitness recreation centers etc search terms for each variable and corresponding search terms entered into google maps physical structures that matched the specific variable criteria and fell within the circular metropolitan area of atlanta were included physical address and zip code were captured for each location each location was geocoded using the google my maps map creator to ensure it was within the 15mile radius of downtown atlanta data were collected during april 2016 zip codelevel census data were also collected including demographics transportation health insurance coverage and disability information gathered through the american community survey for 2014 data 29 zip codes that fell within the 15mile boundary were included in the study for the census data zip codes were also excluded if they did not include any homes these zip codes were primarily business or postal code so no demographic data was available from the acs a full list of the variables and search terms used are found in table 1 data analysis the address for each physical location variable were exported from google my maps and aggregated to zip codes using qgis geographic information system 32 social capital was reported as the density of social capitalpromoting entities in the physical environment per zip code a pattern of social capital across the atlanta area was determined using morans i test for global autocorrelation and local clusters of social capital were identified using local indicators of spatial autocorrelation 3334 qgis was used for spatial visualization and r statistical software was used for data analysis 3235 results we observed n 287 zip codes in the atlanta metropolitan region the mean number of social capital locations across the region was 458 the mean social capital density was 150 locations km 2 the mean disability rate across this region was 920 there was a significant global pattern for social capital clustering and disability local clusters are presented in figure 1 and figure 2 the relationship between these two variables is presented in figure 3 where there is a significant association between social capital variables and the percent of persons living with a disability in a discrete geographic location higher social capital within a neighborhood coincided with lower disability rates in that neighborhood when compared to random assortment models discussion we sought to determine if a significant spatial pattern of social capital existed in a large us city and if such a spatial pattern existed would it correlate with known patterns of health outcomes in our case disability as noted by foster et al in 2015 there has been little research performed surrounding the question of spatial social capital variables 36 our findings here further the utilization of spatial orientation within the social capital framework gis analysis of one major southern us city showed some correlation between spatial social capital variables and neighborhoodlevel disability rates this study described social capital as a product the built environment with physical locations serving as the primary metric of social capital regardless of the terminology used we have established in this study that the greater number of physical structures enumerated here the lower the disability rates in that location using physical locations as a measure of social capital we see that whether through selfselection or some other processindividuals living with disabilities in this city live further from these locations than can reasonably be termed random thus physical locations of social capital play some role in this specific health outcome we suspect that observations from this study are indicative of other health and social capital relationshipsthat they vary across space and time and are correlated with one another many possibilities coalesce to create the connection between disability rates and social capital for example shared knowledge is an important asset in the framework of social capital and these physical places allow people with physical and mental limitations to collaborate together to address both intra and interpersonal concerns the formal disability rate may also be depressed by the ability of a community to provide necessary aid to individuals in need quicker than would be available through the states designation of disabled through these and other pathways locations of social capital combine to lower disability rates in this major city social capital being a construct of civic connections and social trust is also a protective factor that builds resilience resilience being the ability of individuals or a community to use available resources to withstand risk factors and social capital are then intertwined 37 the development of resilience is an important byproduct of social capital and has been document in other studies that report the value of social connections among transgender youth nonmedical use of prescription drugs depression in the elderly and others 38 39 40 as seen in these other scenarios social connections provide opportunity to build resiliency share knowledge explore resources and develop a safety net to rely on that the resources to build social capital are not the same between neighborhoods can explain why social capital rates differ and are likely related to differing disability rates observed here this studys limitations represent many of the same limitations common to social capital research first our study only examined one large us city at a single point in time likewise it presents limited health outcomes data as this was a preliminary investigation future research should seek to compare multiple municipalities as social capital is inherently tied to the built environment the unique structures of each city are likely to produce unique social capital patterns additional examination of the spatial relationship between a wide variety of health outcomes and social capital will be insightful for understanding what conditions most benefit from heightened social capital as the 21st century push for health in all policies continues to gain traction all aspects of community development should be influenced by the understanding that locations of social capital have a known benefit to the societies in which they are located 41 increasing the density of social capital locations seems to benefit small and large neighborhoods alike while specific measures of geographic social capital should be further investigated the potential for health promotion to operate in both public and private space cannot be overstated ethical approval no ethical considerations are declared competing interests the authors declare that they have no competing interests

background social capital is a construct of interaction and social trust in ones fellow community members these interactions can provide a safety net for individuals in terms of information social support and adherence to social norms while a number of studies have previously examined the relationship between social capital and health outcomes few have examined the parallel relationship of social capital and geographic place with respect to health outcomes methods considering social capital as facilitated by specific structures we evaluate the relationship between neighborhoodlevel social capital and disability rates in a major southern us city disability rates were collected through neighborhoodlevel data via the american community survey acs and compared to a geocoded map of neighborhoodlevel social capital measures during spring 2016 results higher social capital within a neighborhood coincided with lower disability rates in that neighborhood r 014 p 0016

not participate in any leisuretime physical activity and are significantly less likely to participate in organized sports than white girls only 22 of black adolescent girls participate in physical activity at least 60 min a day on 5 or more days of the week and only 10 participate in physical activity 7 days a week physical inactivity among black adolescent girls places them at increased risk of developing chronic health conditions later in life the literature indicates that a key focus for many intervention studies aimed at children and adolescents are schoolbased approaches many schoolbased interventions have resulted in little to no change in physical activity outside the school setting moreover there have been few studies conducted in black adolescent girls therefore future research is needed to identify effective and culturally appropriate interventions for this population further explorations of physical activity programs that are communitybased and faithbased are needed that extend physical activity programs beyond the school setting and traditional academic term the few studies that were conducted in black girls revealed no statistically significant results regarding increased physical activity however these studies offer some insight for consideration in designing future studies aimed at increasing physical activity of adolescent girls barbeau et al found a need for physical activity programs to be offered at various times throughout the day the girls health enrichment multisite studies supported the feasibility and the importance of a culturally relevant focus in designing program for preadolescent african american girls and their parentscaregivers physical inactivity is higher in minorities than in whites but a clear explanation for these differences remain unknown therefore considering cultural differences in designing physical activity interventions for black adolescent girls may be warranted culture is defined by boyington et al as the unique shared values beliefs and practices of a group and can influence the behaviors of individuals by affecting their thoughts feelings acceptance and adoption of health education messages interventions that have been culturally tailored have been shown to be more effective when they were specifically designed for the populations they serve health promoting programs in black churches have proven to be beneficial and effective in meeting the needs of the black community and reducing health disparities churches can play an important role in health promotion efforts such as promoting physical activity because of their central role in spiritual guidance communication social support and networking the theory of reasoned action was the guiding framework for this study the theory hypothesizes that an individuals intention to engage in a given behavior is the most immediate predictor of that behavior intention mediates the effects of attitudes and subjective norms which are perceived social pressures to participate or not to participate in a behavior a person who has a favorable attitude toward a behavior is more likely to have stronger intentions to change that behavior intentions are influenced by social expectations and individual attitudes therefore strategies for changing the attitudes of black adolescent girls toward being more physically active were based on the tra other studies support that the more positive attitude a person have toward a behavior the more likely they are to engage in it strategies were directed at changing attitudes through selfmonitoring presenting physical activity as an enjoyable process setting goals regarding physical activity and increasing knowledge regarding the need and importance of physical activity research questions we hypothesized that the girls in the fitness •u•n joy study would have a more positive attitude toward physical activity as demonstrated by significantly greater enjoyment increase in fitness and activity levels and a lower bmi from pre intervention to post intervention we also hypothesized that perceived expectations of others and social support would be positively correlated with physical activity levels among black adolescent girls methods design and sample participants were recruited from two large urban black churches in the south inclusion criteria included selfidentification as black or african american ages of 1218 years and ability to read and speak english exclusion criteria included a medical condition that prevented participation in regular physical activity only two participants were excluded the institutional review board at the university of north carolina at greensboro approved the study a flyer placed on the churches communication board and jumbotron was used to invite mothers and daughters who were interested in the study to an information session consent and assent were obtained and an appointment to return the following week to collect baseline data was made participants received a 20 gift card after data collection at preintervention and midpoint and a 40 gift card at post intervention and mothers received transportation vouchers intervention the fun intervention was developed by the author specifically for black adolescent girls and grounded in spirituality expressive communication and interconnectedness the spiritual theme was taken from proverbs 226 train up a child in the way he should go and when he is old he will not depart from it this theme highlighted the importance of developing a positive attitude toward healthy behaviors early in development to assure adoption and maintenance of such behaviors into adulthood the interconnectedness and commonality were fostered in this intervention by focusing the study on black adolescent girls the research team members were all black participants were encouraged to sign up with friends and other family members dance and music are considered a form of expressive communication and has been identified as an effective and enjoyable form of physical activity for black adolescent girls the fun project was conducted over 12 weeks for 60 min each week divided into two 30min sessions the first 30min session was aimed at influencing attitude and enhancing selfefficacy and enjoyment the topics discussed included defining physical activity goal setting benefits and barriers to physical activity body image cultural differences women in sports the significance of family and friends hair maintenance and statistics on the health of black adolescents and women healthy snacks and water were provided at each session the second 30min session was an interactive dance aerobics class conducted by a certified aerobics instructor dance interventions were built on the social cultural and historic significance of dance in the african american community which have been shown to be wellreceived by black adolescent girls goal setting was a key strategy to assist participants to establish their individual goals for being physically active all participants were encouraged to set goals that were smart and to write down at least one measureable goal regarding physical activity weekly measures a physical activity readiness questionnaire was used to determine the safety or possible risk of exercising prior to consent and assent no information from the parq was used for data a demographic questionnaire collected information on age grade level home environment annual household income sport participation parents educational level and neighborhood safety and environment a health history profile questionnaire developed by the author elicited information about perceived health status health history allergies current medical regimes last monthly period birth control method and any physical or mental conditions data collection occurred at preintervention at midpoint and postintervention no classes were held during the data collection process because of the time requirement needed to collect data for each participant biophysical measures including height weight blood pressure and fitness levels obtained at preintervention midpoint and postintervention height was measured twice in street clothes without shoes using a stadiometer calibrated in 18cm intervals and averaged weights were obtained in street clothes without shoes to the nearest 01 kg bmi percentile was calculated twice overweight is defined as a bmi percentile ≥85th percentile and 95th percentile and obesity is defined as ≥95th percentile blood pressure was measured twice after sitting for 15 min and averaged an estimation of cardiovascular fitness based on heart rate variability was obtained with the polar s810i heart rate monitor two readings were obtained and an average of the two readings was used as the baseline for fitness omron hj112 digital pocket pedometers were used to assess physical activity levels at week 2 and week 8 of the study as well as a goal setting strategy the pedometers were worn from wednesday to wednesday to capture weekend activity selfreport questionnaires were collected at preand postintervention except for the social influences and family support scale which was completed only preintervention all questionnaires used in this study were scored on a 5point likert scale ranging from 1 strongly disagree to 5 strongly agree except for the social influences scale physical activity selfefficacy was measured using a modified version of saunders et al 8item selfefficacy scale which assesses confidence in ability to be physically active alpha coefficient was 81 for the total scale the 16item physical activity enjoyment scale was used to measure exercise enjoyment with higher scores indicating more enjoyment cronbachs alphas ranged from 81 to 88 the attitude scale was an 8item questionnaire modified by motl et al with higher scores indicating positive attitudes cronbachs alpha was 72 the intention scale was used to measure intent to be physically active the intention scale was a 4item scale with higher scores indicating a stronger intention to engage in physical activity in a study by dishman et al adolescent girls had a cronbachs alpha of 91 the sis addresses perceived expectations of others and contains 8items based on a 4point likerttype scale that ranges from 1 strongly disagree to 4 strongly agree a total score is obtained by summing items with higher scores indicating strong social support the internal consistency reliability was 72 the testretest correlation coefficient was 78 a 5item family support scale was used to assess family interpersonal support the fss is a 4point scale that range from 1 none to 4 daily a total score was obtained by summing items with higher scores indicating strong social support the cronbachs alpha was acceptable ranging from 60 to 72 a modified version of the adolescent physical activity recall questionnaire was used to assess physical activity the aparq is a selfreport tool that lists a number of common physical activities the girls were instructed to select the activities in which they have participated during the last week and indicate the frequency and duration of each activity responses were converted into metabolic equivalents using of the compendium of physical activities the program evaluation questionnaire contains 13items developed by the author and collected postintervention the questionnaire was rated on a 5point likert scale from 1 strongly disagree to 5 strongly agree and space for additional comments was available analytic strategy data were analyzed using statistical package for the social sciences 15 software descriptive statistics were calculated for age grade parent education family income and family structure means and standard deviations were run on all variables preintervention midpoint and postintervention pearsons correlation was run examining family and social support for girls physical activity repeated measures of anova were run examining fitness mets bmi at all three time points adjusting for age results fortyone black adolescent girls aged 1218 years were recruited almost onequarter of the participants attended all of the sessions and 41 missed only one session with a retention rate of 94 for 12weeks of attendance attrition was low with only two lost to followup all of the participants agreed that the educational sessions were helpful and informative almost all of the participants would recommend the program to friends and family almost half of the participants liked dance followed by basketball and walking the top three sports included basketball track and soccer a summary of study variables is seen in table 3 higher score at midpoint and post intervention on all scales except bmi indicated positive change or improvement no significant changes were noted in selfefficacy paces attitude and intention scores there were no significant changes in increased weekly physical activity participation however trends toward increased physical activity were found pearsons correlations were used to examine the relationships between perceived expectations of others and social support with regard to physical activity levels a significant positive correlation was noted between family support at baseline and midpoint mets scores showing that family support was positively correlated with physical activity although there were no significant changes post intervention there was an increase in vigorous intensity activities defined as mets ≥6 from preintervention to midpoint to postintervention and odds ratios showed that high baseline scores were associated with positive change post intervention repeated measures anova controlling for age was used to determine whether there were significant differences in fitness mets and bmi from week 1 to week 6 and week 12 fitness significantly differed after the intervention with or without age as a covariate mets significantly differed without age as a covariate bmi did not significantly differ without age as a covariate age significantly influenced bmi the changes in these variables were in the unexpected direction as shown in table 5 discussion this study tested the feasibility of a culturally tailored physical activity program that was age and gender specific for black adolescent girls aimed at changing their attitudes toward physical activity although findings from this study were not statistically significant other studies have shown attitude to be the key influence in the formation of intentions to participate in physical activity the study found a significant relationship between baseline family support and mets midpoint scores this is similar to the findings of a study by dowda dishman pfeiffer and pate which showed that girls with higher perceived support were more likely to have higher total mets than girls who had less perceived family support other studies have also shown that girls with supportive parents who model physical activity have higher physical activity levels in this study participants with the most positive changes in selected physical activity variables from pre to post intervention were from families with higher annual incomes and higher educational levels these findings are similar to those of other studies which have shown that children and adolescents whose parents have higher educational levels and higher socioeconomic status are more physically active clearly families are an important factor in adolescent physical activity emphasizing the importance of including parents in the development and implementation of interventions aimed at increasing the physical activity of adolescents positive changes were noted in selfefficacy scores pre to postintervention goal setting was used to help promote physical activity many of the participants set goals that were smart for example goals set were to walk 1 mile on saturdays and sundays on the school track near their home to walk on the treadmill for 30 min on tuesdays and thursdays and to ride bikes around their neighborhood for 2030 min on saturdays one girl had a goal to increase the number of weights she was lifting from 20 to 40 lbs by the end of the summer dishman et al found that individuals with high selfefficacy set higher goals furthermore when goals are set and achieved this increases the intention to perform a specific behavior intention to be physically active also is related to attitude there were positive changes noted in intention to engage in physical activity after the intervention prior studies have also shown that interventions to enhance intention are important in improving physical activity behavior the program evaluation showed that 97 of the participants enjoyed the aerobic dance classes in fact dance was identified as the most popular physical activity by 44 of the participants in the study making the program fun and enjoyable was directed at improving attitudes toward physical activity the program received large support from the church and excellent evaluations from the participants with 92 of participants recommending the program to friends and family the sessions were wellattended with retention rate of 94 for the 12 weeks 2317 of the participants attended all of the sessions with 41 missing only one session attrition was low with only two persons lost to followup educating young girls and the community about the importance of regular physical activity is important the preliminary findings suggest that similar programs could be implemented in other churches recommendations would include ensuring that cultural components are built upon and remain intact throughout implementation working closely with church leaders and establishing a good rapport and extending the time frame of the program and expanding the program to include other family members to strengthen future studies a control group will be included the events around summer vacation may have altered girls physical activity levels in comparison with the regular school year the dosage of this program was 60 min once per week for 12 weeks once a week session for 12 weeks may not have been adequate to produce changes in bmi fitness and physical activity levels time frames for other studies have ranged from 8 weeks to 24 months the physical activity measures were selfreported which may have resulted in physical activity levels being under or over reported maintaining an appropriate level of physical activity is essential to prevent or reduce obesity and other health related problems adolescence is a period of transition in which lifelong health habits and beliefs are adopted therefore fostering physical activity in adolescence can help establish healthy habits that carries over into adulthood black adolescent girls have a higher prevalence of physical inactivity than other ethnic and gender groups culturally tailored physical activity programs held in black churches for black adolescent girls are feasible and show promise for reducing the alarming decline in physical activity during adolescence and the associated increased in prevalence of obesity diabetes and cardiovascular disease pearsons correlation of family and social support for girls physical activity levels

objectiveto feasibility test a 12week churchbased physical activity intervention that was culturally sensitive ageand gender specific directed at changing attitudes of black adolescent girls to be more physically active design and samplea onegroup preand posttest design was used a convenience sample of black adolescent girls between the age of 12 18 n 41 interventiona 60min 12week churchbased program that included interactive educational sessions followed by a high energy dance aerobics class was used measuresdata were collected on biophysical measures surveys were used to assess the following variables attitudes enjoyment selfefficacy intention social and family support and pa levels resultspaired ttests and repeated measures anova revealed no significant changes in key variables positive changes were noted in the odds ratios for attitudes selfefficacy and intention body mass index metabolic equivalent tasks and fitness showed positive trends from pre to post intervention family support was significantly correlated with physical activity level p 01 the study showed that physical activity programs in black churches aimed at black adolescent girls are feasible participants evaluated the intervention very favorably family support may be a key factor in increasing physical activity levels in black adolescent girlsadolescents black churchbased intervention girls physical activity physical inactivity among black adolescent girls contributes to many chronic health conditions including obesity type 2 diabetes and cardiovascular disease which are higher in black women than white women american heart association 2011 kimm et al 2006 found that physical activity in girls deceased significantly between elementary and high school years lafontaine 2008 found that physical activity in adolescent girls decreased from 42 in 1991 to 33 in 2005 over half 56 of black adolescent girls do

introduction sports are consistently thought to have positive integrative functions that enable them to play a role in contributing to the resolution of complex social issues inherent to and existing within different communities more and more across both the developing world and within the uk sport is being used as a tool to bring divided communities together through the promotion of specific values that can foster understanding tolerance and peace the belief is that sport can contribute towards wider social objectives and can build bridges between people help overcome cultural differences and spread an atmosphere of tolerance clearly there are limits to this potential some of which we discuss below this paper is concerned with the potential of sport to act as a tool for facilitating social cohesion social cohesion is generally defined as solidarity and togetherness and is often used interchangeably with community cohesion cantle identifies cohesive communities as having a common vision a sense of belonging positive appreciation of diversity and strong relationships being built and maintained between people from different backgrounds and different neighbourhoods the local council for the borough focused upon here adopts a holistic view of community cohesion in its suggestion that a cohesive society is one which promotes civic engagement a sense of belonging interaction between communities and a safe and fair society that promotes equality of opportunity forrest and kearns identify a series of domains that characterise social and community cohesion these domains are common values and a civic culture social order and social control social solidarity and reductions in wealth disparities social networks and social capital place attachment and identity as will be demonstrated shortly these domains resonate clearly with the issues faced by participants within this research through an understanding of these domains this paper is concerned with asking whether a participatory community sport initiative has the potential to develop social cohesion within an ethnically segregated east lancashire borough 1 in the north west of england the borough in question has some of the highest levels of cultural geographical and educational segregation in the country and is therefore an interesting case study the potential of promoting social cohesion through sport within a divided borough is conceptualised here within a social transformation framework that acknowledges the possibility for sport to provide small scale social change through forms of cultural transformation in order to develop an initiative with the intention of delivering transformational aims and objectives it is crucial to take into account the possibility for methodological innovation and action participatory action research is in principle a group activity where people come together to work collectively and collaboratively on an issue of mutual concern it is considered to be a democratic equitable liberating and life enhancing form of qualitative research and enables knowledge to be jointly produced through critical interpretations and readings of the world which are accessible understandable and actionable for all those involved par was adopted based on these benefits but also with a recognition that implementation is fraught with complexity we discuss our approach to par in more detail below but it is worth highlighting here that our ultimate intention for adopting par was in order to ensure that any proposed interventions put participants at the heart of what we did and in an effort to produce welcoming and inclusive interventions which could lead to transformational outcomes however as we discuss throughout while clearly well intentioned this particular initiative failed against its initial objectives this paper begins by providing some much needed context including discussing migration and the north west of england and the impact of migration on existing communities next we provide an overview of the potential of sport to contribute to social cohesion before introducing our methods and in particular our par approach following this we present our data and reflect on the projects limitations and how future initiatives might fare better research context the north and migration this paper is underpinned by data collected in lancashire a county located in the north west of england and well known for its complex race relations across the uk racialised tensions between white and minoritised ethnic communities have been exacerbated since the turn of the century according to sanderson and thomas these have become symptomatic of a complex interplay across the country between territoriality and race they argue that how we understand race relations in northern england must be understood at the intersection of complex urban settlement and resettlement and the local configuration of the regions towns and the populations surrounding racialised tensions in northern england are not new a series of widely publicised riots and racial disturbances have occurred in bradford since the mid1990s which have often been attributed to the segregation that has been identified between the various ethnic groups present in the city in 2001 further riots in other northern towns oldham and burnley again culminating in bradford led some critics to describe northern england as britains main region for british and south asian 2 dissatisfaction during the postsecond world war and postcolonial periods britain needed cheap labour to facilitate national recovery directly related to british colonial rule on the indian subcontinent and caribbean families from these regions were encouraged to move to britain to fulfil this need due to its burgeoning industries lancashire was a popular settling place the vast majority of migrants arrived in lancashire following the partition of india and pakistan in 1947 many came to work within and support the manufacturing economy of the region in the main they came from the state of gujarat in india more specifically from the areas of surat and baruch their settlement was consistent with the process of chain migration facilitated by specific kinship networks this migration gained momentum due to periodic labour shortages within the main industries and although the initial migrants were male by the late 1960s and early 1970s wives and children joined them to settle in the towns with other migrants starting to arrive from different areas including kashmir and later pakistan and bangladesh in spite of the existence of migrant communities historically illustrations of northern england depict the region as a white monolith concealing the regions ethnic diversity like in other regions of northern england migrants faced an immediate postmigration phase of racial politics from both the government and the populace which often resulted in restricted access to leisure opportunities employment and other services that were taken for granted by the majority white population kelly explains how the local white population remained resentful towards migrants due to residual nationalistic fervour that remained from the war kelly also referred to lingering resentment about the decline of the british empire and more local concerns about how their own lancastrian working class traditions were in decline due to for example failing industry old housing stock and an ageing population the belief was that migrants from south asia in particular were introducing irreversible changes to the social composition of britain…they provided competition for jobs and housing had excessively large families and were reluctant to change this animosity would only increase as the textile industry and local economy went into further decline and unemployment began to rise due to their phenotypical appearance and conspicuous cultural differences such as clothing and culinary practices postwar migrants were racially marked such racialisation largely restricted access to cultural resources and spaces taken for granted by white people and contributed to racial prejudice and institutionalised racism we are conscious not to homogenise the migrant experience as one revolving around exclusion and prejudice from and by the white majority of course not all migrant and diasporic experiences and narratives are the same central to all migrant and diasporic groups are their internal differences according to brah migrant and diasporic communities are a heterogeneous collective of different narratives as the journeys undertaken by their members and their subsequent experiences in the host society are subjective we are not suggesting that all whom migrated to the north west of england were inevitably racialised and excluded there will have been instances of conviviality for instance but many certainly were for the majority of those who were a direct consequence was that regardless of their background or level of education premigration they were initially employed in lowpaid manual occupations as a result migrant groups would tend to gravitate to certain areas of towns and cities meaning that these areas quickly became enclaves associated with these groups and subsequently racialised such clustering served not only as a defensive function against racism but also led to the creation of essential infrastructure specific to the community such as places of worship community centres food stores and other specialist retailers therefore as dashper andfletcher argue cultural identities are contextually contingent influenced heavily by time and place and the extent to which they are embedded in the culture of their geographical location the next section provides further context on the research location an ethnically diverse and divided borough according to census figures for the borough in 1981 13 of the local population was born outside the uk of that number 8339 came from india 5692 came from pakistan and 1131 came from east africa the proportion of minoritised ethnic people has continued to grow over the last three decades according to the 2011 census the borough has a population of 147489 of which 41494 identified themselves as southbritish asian the proportion of southbritish asians residing in this borough is by far the highest in lancashire the long established and growing southasian british communities are fairly evenly divided between those of indian and pakistani heritage but almost all are muslim which makes it proportionately the second largest muslim population in the country outside of birmingham the borough also contains significant geographic separation in order to fully understand this separation the demographic composition of different wards 2 within in of which there are twenty three need to be analysed in greater detail this is not in any attempt to claim that geographical and therefore social divisions are the result of selfimposed segregation by the southbritish asian communities this would clearly distort the wider structural and ideological challenges they have faced in the past and continue to face today rather it is being analysed to explain the current situation within the borough and to highlight how this impacts on social cohesion now and might in the future thirteen wards within the borough have a white british population of over 90 a further two wards have a white british population of over 75 in contrast there are four wards with a population of over 60 southbritish asian and four wards with a more mixed profile this does not tell the full story however as those wards with a mixed profile have experienced quite a significant drop in the white british population between 2001 and 2011 of between 10 and 23 and those four wards with a higher percentage of southbritish asian residents have seen a reduction in the white british population of between 26 and 47 the borough has one of the youngest populations in england thirtyone per cent of its citizens are under the age of 19 with the southbritish asian community having a particularly youthful profile as 46 currently are under the age of 19 this means that both the number and proportion of southbritish asians within the overall population is likely to continue to grow on current projections by the next census ethnic separation is anticipated to rise further geographic segregation is strongly associated with other forms of social and cultural segregation particularly education and is also closely aligned with patterns of deprivation from an economic perspective the borough was ranked 13th of all local authorities in england and wales on the 2015 index of multiple deprivation as a result there is an understandable concern over threats to scarce resources such as jobs and welfare as became evident after the uks decision to leave the european union following the referendum on june 23 2016 negative perceptions of immigration alongside wider issues of austerity and deprivation is more marked for economically marginalised groups within society within the borough 136 of the population are in fuel poverty and wages are 18 lower than the national average in total 103 of the population are unemployed with 207 claiming some form of working age benefit and 312 of the population are economically inactive given this context what role might sport play in facilitating greater social cohesion and if so with what effect sport and social cohesion uk government and policy rhetoric over the last two decades has consistently emphasised the positive role sport can play in building more cohesive empowered and active communities at the community level sport has been advocated as a mechanism to promote a socially cohesive society encourage strong community bonds reduce crime rates and offer access to positive mentors these positive impacts are particularly important for communities with high numbers of young people from disadvantaged backgrounds researchers point to the potential for sport to build relationships and social cohesion across religious ethnic and economic lines but there is little explicit evidence to support this assertion in more recent times research into sport for development and peace has advocated how sport may be used as a tool to intervene within complex and deeply divided societies and to promote a greater level of mutual understanding and conflict resolution at grassroots level between different cultural groups within a specific community sport based interventions are growing evermore popular as a tool to engage with young people mainly because they are viewed as a way to alleviate the distorted relations that exist between young people and the agencies who engage with them they provide the opportunity for social interactive and cooperative behaviour contributing to cultural learning trust and the establishment of networks if facilitated in the correct way positive experiences will dominate and the creation of multiple inclusive social identities can be achieved while the positive impact of participation in sport on individuals and communities is widely promoted sport can also exclude individuals and groups and further divide communities sport is certainly not a social panacea perkins et als review of youth programs in the us for example notes that ethnic minoritised youth particularly those living in nonaffluent communities do not participate equally in organised sport this means they can become alienated from broader national and community networks and support that enable access to social and economic resources spaaij suggests similarly criticising any notion of sport as a harmonious multicultural meeting point as unrealistic this is not to say that sport cannot play a role in minimising inequality but it cannot solve societys ills independently sport must form part of a series of wider processes which aim to tackle the root of inequality methodology background and context david meir originally moved to this borough as a studentteacher in 2003 and took up a position at a local college it takes time to understand a town especially as an outsider but as an outsider you are also in a position where you notice what is obvious to you yet highly normalised by those who have established roots as meir spent more time in the borough that there were high levels of ethnic division became more and more apparent utilising his role as a lecturer in sport at the college meir started to think about ways in which sport might be utilised as a tool for trying to reduce these divisions he wanted to develop a project that would enable the young people to address these divisions for themselves not unlike the objectives of the organisation football 4 peace international meir contacted the organisation and made a visit to a project in jerusalem in july 2013 to undertake some primary data collection the intention of this research was to look at the ways in with f4p implemented their approach and to see whether good practice could be transferred to a project within the borough a key finding from this research was that for a value based sport project to have an impact on the wider community they must be undertaken in collaboration with individuals and communities in which the programmes will be delivered ensuring both a level of ownership for the participants and a level of cultural understanding for the organisation it was from this understanding that the initial ideas emerged for the project discussed in this paper naturally the authors appreciate that what works in one context is not necessarily transferrable into others indeed it would be highly misleading t0 describe the project herein as being guided by the same kind of sdp principles underpinning projects like f4p as this is not the case this initiative always had localised social cohesion at its core and any engagement that meir had with f4p was in order to understand broadly if and how sport can be applied in divided community contexts this is an important distinction to make for as coalter has previously argued sdp is often vaguely theorised with some academics being too quick to refer to their work as sdp when in reality it is not he argues that some sport programmes are guilty of among other things confusing potential microlevel individual outcomes with community and broader macrolevel impacts and seeking to solve broad gauge problems via limited focus interventions the project discussed in this paper is best described as community sport development as rather than being concerned with addressing development goals on a national or even international level it is more local and community focused with the aim of resolving a specific community issue through participant engagement the fundamental belief of the initiative described here was that it should be participantled and developed from the bottom up ensuring participant ownership of and throughout the process the intention of being participantled is of course limited by participants understanding of the approach alongside the intention of those participants to truly own the approach however it was also acknowledged that to have imposed an approach on participants would have led to the initiative being researcherled top down and didactic in structure all of which we wanted to avoid the project was initially designed by meir taking into account some of the good practice witnessed while observing the f4p initiative before engaging local youth centre practitioners in further codevelopment the youth centre was approached in the acknowledgement that while meir felt he had developed an understanding of applying sport in divided community contexts he did not necessarily have a sufficiently nuanced understanding of the local environment or its communities meirs experience of sport initiatives and the youth workers experience of working with local young people provided the necessary expertise to develop a sports project that sought to address social cohesion through participatory approaches participatory action research contemporary society has seen a shift in rhetoric around the engagement of young people in decision making processes especially their roles in social science research in part this rearticulation has emerged from ideas associated with a social justice agenda including the importance of fairness equity and citizenship this kind of thinking has led to an increasing recognition that there is a need to value and listen to the voices of young people to better understand their experiences the result being that young people have become positioned as experts in their own lives rather than deemed incapable of making useful observations about themselves and the world they occupy as we have suggested already any sport programme attempting to engage young people in activities aimed at enhancing social cohesion must be designed with the complexity of the environment in mind there is a need therefore to seek methodological approaches that provide participants with a voice and ensures that any programme is culturally socially economically and politically relevant relying exclusively on wellestablished methods raises the question of whose interests are actually being served via stated interventions holland et al argue that much research privileges those who are already privileged those considered to be emotionally literate and those for whom white male middle class and nondisabled means of communication are the norm there is a need therefore to decolonise traditional methodologies in an attempt to understand the complexities of negotiating dominance and consent and locate the possibilities of emancipation and social change one such approach is par par was chosen to promote engagement from participants and to gain their understanding of the role that sport could play in tackling ethnic divisions across the borough that threaten social cohesion it fits the ethos and ambition of the project as it promotes both the engagement and involvement of the participants at each stage of development and creates opportunities for collaboration between participant and researcher thus ensuring authentic local voices are not missed or dismissed in the evaluation process the belief is that local knowledge is pivotal to the success of community driven ideas and the greater the level of community participation that exists the greater the likelihood that participants will develop an attachment and engage with the ideas and solutions to resolve the issues that affect their daily lives data collection and analysis design and implementation of the initiative was expected to involve three broad stages in stage one meir with the help of youth workers would develop a skeleton of the initiative to later pitch to local young people as a starting point meir needed to establish what challenges young people currently experience in their local communities this baseline understanding would be established via group discussions facilitated by meir in stage two the young people would engage with the youth centre practitioners to collectively plan a sports project that they would subsequently deliver to other young people in stage three and with the input of the young people and youth centre practitioners meir would evaluate the initiative as discussed in the next section however a number of challenges were revealed that disrupted these plans data were indeed collected in three stages with a variety of participants and stakeholders from both a local college and youth centre but the overall outcomes were not as planned in stage one following the granting of ethical approval from university centre blackburn and having gained their informed consent 28 young people recruited via the college and youth centre participated in seven focus group discussions about various social issues within the town and how they impact upon their daily lives their views were also sought on the potential role that sport could play in contributing towards social cohesion discussions were undertaken by meir at both a local college and youth centre findings from these discussions are presented in the next section the participants were a mix of boys and girls and were aged between 1519 years the participants were from either a white british or southbritish asian background participants were interviewed in ethnicityspecific groups with the rationale being that they would feel much more comfortable and at ease in that setting all participants identified to varying degrees as having an interest in sport this inevitably limits the generalisability of any findings but as is identified below an interest in sport does not necessarily resonate with a positive view of sport in general the second stage of data collection began with all 28 participants being invited to take an active role in the planning and delivery of a sport initiative at first this would involve informally engaging with the youth centre practitioners and learning about the types of initiatives currently on offer of the 28 only 10 took up the offer these 10 participants consisted of seven boys and three girls who participated in four further focus group discussions the intention of this stage of data collection was for the participants to ascertain what their shared issues were and then to work towards cocreating and eventually delivering a sport initiative in collaboration with youth centre practitioners it is here where the research process moved from one of engaging young people on their ideas and views of their community to a participatory process whereby they became active agents in developing change it was intended that participants would be given almost complete responsibility for the development of the initiative thereby transferring any power that may have been held by the researcher onto participants however crucially despite the best intentions of meir and the youth workers the project never progressed beyond the focus group discussions as described in stage two and for a variety of reasons the intended outcomes failed to materialise as will become clearer later in the paper reasons for this breakdown included lack of participant commitment the timeframe of the project the prescriptive nature of the original idea a lack of conceptual clarity in relation to the proposed outcomes and finally the participatory nature of the project the nature of the issues encountered meant that stage 3 of the original project had to be amended instead of evaluating the impact of the initiative delivered by the participants and their experiences of that our focus changed to assessing the value of the process up to the point of breakdown in an attempt to suggest ways in which future projects could be developed and delivered more successfully this stage involved a further three interviews one with two youth work managers another with an individual youth worker and one focus group with three young participants if nothing else these failings and subsequent changes to the research process provide clear evidence of the complexity of seeking to deliver a project in a nontraditional and participatory way which is not currently discussed in the literature all data collected during stages 13 were subjected to rigorous thematic analysis the data were read and reread to look for key themes or ideas that informed the overall narrative we were specifically looking to establish pertinent themes existing at the intersections between participants raceethnicity and gender our analysis revealed three such themes 1 perception and impact of cultural divisions 2 development and understanding of social cohesion and 3 the potential role of sport it is to each of these that we now turn findings perception and impact of cultural division data collected during stage one showed that the young people felt a strong sense of ethnic separation exists within this community separation in and of itself is not necessarily problematic however accompanying those perceptions of separation were feelings of fear and contempt and to some extent misunderstanding and blame which are more insidious related to this a view that came through strongly from young white participants in particular was that separation was natural something that has become almost ideological this comment from paul was typical of many white respondents views its just the way it is we havent been brought up to integrate with them ethnic minorities instantly have we separation was not view unproblematically though nicole confirmed pauls view that young white people have not necessarily been encouraged to mix and integrate with other ethnic groups but continued by saying the same could probably be said for the way other ethnic groups approach white people it is really important for everyone to mix together it is a twoway thing it is important that you try to accept everyone obviously there will be people that you just dont like but that is just the way it is equally craig described the ethnic separation he witnesses as ridiculous and attributed separation to damaging cultural stereotypes which he believed the vast majority of people did not fully understand i just think that the communities are just so stereotypical because of other things that are happening in the world that we dont understand the majority of people dont understand and just jump to conclusions people are stereotypical and this is where the majority of the problems are caused the white respondents tended to talk about the here and now issues that exist within their community the southbritish asian respondents were also concerned with these but were also quick to identify the longerterm implications of ethnic separation on both the community and future generations of young people faheens testimony was indicative of the views of other southbritish asian girls and boys in this study if it segregation carries on there wont be opportunities for our children or our childrens children a lot of people dont know but we are living for our next generation as well so if we are setting a bad example now it is not going to look good in the future given the historical antagonisms within this region between white and southbritish asians young people from both ethnic groups were cynical about any proposition of developing a more socially cohesive borough that being said there was a clear belief that segregation is unnecessary and ought to be addressed take this comment nicole i think it is ridiculous it is a pointless argument just because you are a different colour of have different beliefs you should not be fighting over that people do because they think they are better they basically see other people with different beliefs as lower than them you should just treat people equally though respondents advocated against segregation they recognised its inescapable existence and attributed it to two issues of cultural division that exist within the borough these were related to concerns over economic and social disadvantage these issues are expressed succinctly and powerfully by danny at the end of the day right it does not matter where you live but in borough there is a division of whether you have money or if you havent got money deprivation remains highly influential on social cohesion and continues to be experienced disproportionately by minoritised ethnic groups but we would caution against any view which assumes deprivation and social cohesion are mutually exclusive when local authorities voluntary organisations and others work in partnership and provide the necessary support there is no reason why communities with high levels of deprivation cannot build and develop cohesion through community programmes socially there was evidence of a concern that continuing migration would dilute any coherent sense of localregional identity for some this perceived loss of identity had contributed to increasing levels of hostility towards different minoritised ethnic groups for example hassan remarked that they white people are seeing like that the asians are taking over and they are saying that this is britain this is our country they dont want this to happen and this is where we see problems with racism happening some of the young white people spoke of the visual presence of southbritish asian people and in so doing expressed a concern that white people were becoming a minority in their community spaces for example according to matthew if it continues there will be a lot of separation and stuff like that there will end up being more of them than us there probably already is while the perception that there will end up more of them than us is a clear misconception it is worth reflecting on where such concerns might have emerged from between 20002010 the ethnic composition of the borough changed substantially with the southbritish asian population growing from 20 in 2001 to 28 in 2011 the rate and scale of change in this community has clearly created tensions between the southbritish asian communities who were attempting to establish or maintain their identities and a white british community that has grown increasingly insecure over its identity this is not the view of the poor or the uneducated but has seemingly become a kind of post millennial cultural diktat for explaining all manner of social and cultural issues throughout the uk reflecting on concerns over cultural identity paul referred to the challenges of adapting to increasing diversity currently facing young people with our generation now you know like our mums and dads did not have lots of different cultures in the town but there is lots of immigration now you have just got to adapt to it really but i think we are finding it hard according to bhabha multiculturalism is an almost impossibility because the homogeneous framework surrounding white culture is unable to accommodate significant levels of cultural plurality bhabha argues that as different cultures are constructed with different interests and evolve out of separate histories and conflicts they will rarely share political identities and thus are more likely to conflict consequently arnot advocates for a more fluid conceptualisation of diversity by suggesting that cultural difference should not be conceptualised as the contrast between static majority and minority cultures in addition to problematising the relationships between ethnic groups there must also be a recognition of their internal diversity qasim for example alluded to the importance of family roots as a marker of identity there are problems between asians from one place and asians from another it is not always based upon your colour it is more based on where you live acky reflected similarly that south asian communities are not necessarily harmonious with one another either i have a lot of problems with asians from a different area some of them come and bully you it is just stupid they are trying to make a rep and show that they are hard the key here is in acknowledging the individual contexts in which initiatives take place combined with the tremendous diversity within ethnic groups and creating interventions that are specific to those groups for brah race and ethnicity are not unitary they are multidimensional processual and require meticulous appreciation of power and differentiation we argue that the potential to include different ethnic groups in and through sport is achievable but strategies to engage must address individualised social needs and circumstances rather than be superficial and tokenistic development and understanding of social cohesion stage one provided the opportunity for the young people to critically discuss complex issues that affect them on a daily basis all respondents were able to articulate clearly the impact these issues were having on their everyday lives but understandably they were less clear on ways in which these issues might be addressed this was the task undertaken during stage two of this research in which respondents were encouraged to engage with youth centre practitioners and one another on potential mechanisms and strategies that might be employed to encourage greater social cohesion through a sport initiative irrespective of their ability to articulate solutions to the issues discussed in the previous section the young people were initially very enthusiastic about getting involved in a community project and they showed a great sense of belief that they could make a difference mohammed one of two youth workers consulted during this research said that is the one thing that they have achieved that through their own minds they have understood the issues that affect the town they have a real concern about what is going on and they feel responsibility about how they can change something … they thought they could change the world and this is the attitude that we want young people to have mohammed went on to say that a primary consideration for youth worker practitioners was managing the young peoples expectations about what could be achieved and what success might realistically look like the starting point for stage two was developing an understanding of what social cohesion meant for the young people all participants were able to articulate some sense of what social cohesion meant ie developing harmonious communities others however went further than simply describing what it meant to also developing ideas about how it might be facilitated and the potential impacts of this as andrew one of two youth centre managers involved in the project said for some within the group it has been an opportunity to channel their ideas and passion around cohesion for others it has been a process where they are learning about cohesion and how it can impact on their lives and communities the young people spoke about the importance of not only bringing different groups of people together but doing so in a sustainable way rohaib used the metaphor of a bridge to express the value of sustainable development if you think of people joining together to make a bridge we need the foundations there together to keep the trust together to keep the bridge together without that foundation the bridge is nothing we need to build the trust together it is the foundations that keep the bridge stable developing greater levels of social cohesion within the borough is clearly a huge challenge on a number of levels for many years causative factors such as ethnic segregation have been allowed to manifest largely unchallenged whilst steps have been made to address this issue there is still a large amount of ethnic separation for the purposes of this paper we asked participants about the potential roles of sport in contributing towards social cohesion within this divided community their views are reflected in the next section the potential role of sport respondents spoke positively about their own experiences of participating in sport and of the wider role of sport in their lives while clearly influential on a personal level respondents questioned the overall capacity of sport to play any meaningful role in working towards greater levels of social cohesion in particular respondents were quick to observe the limited impact sport can make towards challenging deeply entrenched inequalities and perceptions of difference held by various ethnic groups as matthew said i dont think that sport can probably play any role in bringing people together in the community well not a right lot anyway it has the potential to work but i doubt that it will it is hard to get your views across to people and for them to listen it is going to be hard for them to change the way they think about certain groups more positively however there was evidence that through studying and participating in sport at the college and through being involved in sport at the youth centre some respondents identified a number of instances where their experiences had challenged their attitudes and perceptions towards people from different ethnic groups reflecting on the changes witnessed since the youth centre opened ismail said i can remember when this first opened and we came in and that night there was a fight but things like meetings trips posters and interactions have made the lads get on there were shit loads of fights but now we are further down the time line people are just chilling out and getting along similarly jamaal spoke of the positive integrative effects of attending the youth centre and playing in mixed ethnicity football teams it has changed my opinion i am not saying that i hated white people but i never used to hang around with them so i didnt know how it was to be with white people right now when i see my white friends from here i think they are actually really good guys my opinions have changed a lot this evidence suggests that where there are clearly significant issues within the borough in terms of segregation the opportunity is still there to instigate an element of meaningful change but the literature is divided on the transformative potential of sport hutchins for example discussed how sport can exacerbate difference rather than overcome it reinforcing group boundaries and intergroup relationships rather than breaking them down in a clear statement of his position he proposes that rather than ask how sport can contribute to social cohesion we should consider how sport can help negotiate the inevitability of cultural conflict and difference the position adopted in this paper is that where sport matters in peoples lives it can lead to meaningful change however irrespective of its level of importance change must be cocreated reciprocal and participatory involving young people from design through delivery and evaluation the importance of involvement and ownership was reinforced by andrew anything led by young people has an amazing strength too often things are done to people rather than done with it can enable young people to make a lasting change the success of any developmental approach that centralises the involvement of young people is highly contingent on their commitment as we have already suggested the young people involved in this research were less committed in practice than they were in theory they spoke enthusiastically about the idea of the sport initiative and made excellent and meaningful suggestions for its implementation but when it came to the point where they were going to have to deliver their ideas a number of young people withdrew from the process leading to the abandonment and ultimate failure of the initiative reflections on the process their decision to disengage has to be put into context and so it is worth briefly reiterating the type of young people the project involved in general they were from a low socioeconomic background and had a history of disengagement within both education and society we are conscious of avoiding essentialism and of reinforcing negative stereotypes but they were in the truest sense of the phrase hard to engage and for a variety of reasons this was unlikely to have changed through their participation in this initiative sohaib believed that the principal barriers facing most of the young people were issues in their daytoday lives that neither the youth work practitioners nor meir were ever fully enlightened on they have faced a challenge with committing to the project they have faced basic challenges in terms of attendance a lot of them have failed with this to be honest due to the other issues that are going on in their lives this point should not be understated we maintain that the notion of coproduction is fundamental for many community sport initiatives with young people but if those young people are not suitably skilled to lead these any initiative becomes like the blind leading the blind as heather stressed we have promoted the idea that the young people are the drivers of the project we have stood off and hoped that they would take the lead and to take on the responsibility further issues were caused by the nature of the intended outcome ie an initiative based around sport criticism from those involved within the project emphasised that the initiative was overly prescriptive from the start and that they would have preferred to have greater autonomy over the focus of activities andrew for instance believed that greater emphasis needed to have been placed on empowering the young people through skill development what we have asked them to do is a big task there needed to be skills built in to the programme to identify the needs of the young people they needed to be asked what they needed to make it work this comment opens up further criticism over the nature of the intended participatory approach favoured by the research team and questions whether the project actually realised its participatory ambition andrew continued to reflect on the need for greater participation and autonomy it needs to be a case of them determining the process it was perhaps too rigid and narrow i would still use a participatory model but i would be more open and less prescriptive about what direction it could take for andrew because the initiative was not allowed to emerge organically it was at its core prescriptive and therefore flawed furthermore for heather increasing engagement and understanding relies heavily on emphasising positive experiences ideally you want the project to develop from a flashpoint it can come from something that someone has said or from what young people have been speaking about with each other then you say what shall we do about this and you can start the project from there andrew captured this argument in his suggestion that a more fruitful approach might have been to focus on a greater number of smaller projects aimed at specific communities if i was to do it again i would look to work with small groups from different communities and get them to plan and develop smaller projects in each others communities rather than creating something large making it bigger does not necessarily make it better or more appropriate for the development of cohesion in the town the suggestion here is that participants must be enabled to develop a sense of civic engagement and critical awareness which goes beyond either sport or community development emphasising instead wider sociopolitical contexts for development conclusion the purpose of this paper was to reflect on the challenges associated with coproducing a participatory community sport initiative in working towards greater social cohesion in an ethnically segregated borough in north west england our starting point was to establish the nature and extent of this division as experienced by a group of 28 white and southbritish asian young people living in this borough we have demonstrated through both the primary and secondary data that ethnic divisions do exist within this borough these divisions are in large part due to perceptions that localregional white identities are under threat such perceptions have emerged due to among other things significant levels of migration and settlement from people of south asian descent the associated promotion and protection of white cultural traditions direct and indirect racism and the creation of and subsequent racialisation of portions of the borough it is important to acknowledge however that diversity and division are not the same thing and that those who work in sport development and campaign for greater social justice must establish new mechanisms for developing and embracing diversity without reinforcing divisions the most effective way of doing this is to develop a strategic approach that connects individual development and community development with social change if implemented effectively par is one such approach we have discussed already how the initiative proposed at the outset of this paper failed to materialise the original intention was to deliver a community sport initiative that was developed and designed by young people the complexity of applying par methods to developing social cohesion through sport within the borough was clearly underestimated however it can be justifiably argued that while the intended project was a failure the project did bring about valuable secondary outcomes primarily through learning opportunities experienced by the participants researchers and youth practitioners some of which we have extrapolated here criticisms of the project as reflected upon by the young people and youth practitioners alike highlight the potential limitations of both sport as a standalone entity being used to address highly complex issues such as social cohesion as well as the application of par in this context we do not dispute these flaws but we do maintain that there are benefits of using this approach such as its potential to engage young people the way it encourages participants to take ownership of an initiative and how it ensures that those who are directly affected by the issues have the opportunity to resolve them independently and through consultation this paper reinforces the view that there is no silver bullet the only way to fully extrapolate what is required and therefore to instigate meaningful change is to fully understand the needs wants and desires of those for whom the change is intended sport in the context of this research does not have the capacity to transform the social system it does however have the capacity to instigate change on a micro level to create a shift in the collective consciousness of community members which should not be discounted the original ideas behind the project discussed here were unashamedly utopic though by no means unrealistic but were tempered by the reality of application there are many positives that can be taken from this process not least a greater understanding has been realised about how participatory work may be applied in similar contexts in the future this paper is unable to provide solutions to the many complex issues facing residents of this borough in north west england but it does provide a starting point for resolving them through a desire to adopt participatory methodologies such as par within a social transformative framework there is clear value in approaching complex problems in an emancipatory way but this must be supported more widely by other organisations policy makers etc the goal of creating a socially inclusive world which is both necessary and realistic cannot be solely a matter of the right policy or the right time if racism and racial inequality in all aspects of life are to cease to be of significance then any analysis needs to be related to broader relations of power in the culture of sport and society the original aims of this project were clearly not met though ironically perhaps this papers greatest strength is the very acknowledgement of that when reading academic work we assume in large part that the data therein reflects project success after all this is largely why we seek to publish to share our findings and wisdom in the hope that they might be transformational and promote positive impact whatever that might be in a specific context why would we want to showcase failed research of course research will not and does not always succeed in what it sets out to do as researchers we ought not to shy away from reflecting on our failures indeed while we are less likely to boast about our failures and our failures certainly do not make their way into university news headlines or get included in ref impacts case studies 4 in communicating failure we are sharing valuable lessons that can be taken and translated into other contexts notes 1 in the case of this paper we use the term borough rather than town because the borough on which this paper is based contains two distinct towns data pertaining to each town individually is not available therefore it is impossible to refer to one without the other hence their conflation 2 we employ the term south asian to describe individuals and communities with roots on the indian subcontinent the term british asian is used to refer to those british citizens who trace their ancestry back to or who themselves migrated from the indian subcontinent it is employed as a dynamic category and its application has no firm boundaries 3 a ward is a local authority area typically used for electoral purposes 4 the research excellence framework was the first exercise to assess the impact of research outside of academia impact was defined as an effect on change or benefit to the economy society culture public policy or services health the environment or quality of life beyond academia

sports are popularly believed to have positive integrative functions and are thought therefore to be able to galvanise different and sometimes divided communities through a shared sporting interest uk government and policy rhetoric over the last two decades has consistently emphasised the positive role sport can play in building more cohesive empowered and active communities these positive impacts are particularly important for communities with high numbers of young people from disadvantaged backgrounds the purpose of this paper is to reflect on the challenges associated with coproducing a participatory community sport initiative with 28 young people in working towards greater social cohesion in an ethnically segregated borough in north west england although a great deal was learnt from working towards this the initiative was ultimately unsuccessful as young people for a variety of reasons removed themselves from the process a major contribution of this paper is how we reflect on the realities of project failure and how future community sport initiatives might have greater success in particular we argue that for sport to make a difference participants must be enabled to develop a sense of civic engagement and critical awareness which go beyond either sport or community development emphasising instead wider sociopolitical development

introduction feminism is defined in oxford learners dictionary the belief and aim that women should have the same rights and opportunities as men the struggle to achieve this aim as by another online source merriam webster feminism is basically a perspective which explores inequalities and inequities between genders sexes sexualities and gender identities historically feminism has evolved so much from being specifically talking about sexes to gender identities and sexualities feminism aims to focus on inequalities created by intersectionality of sex gender class race and sexualities to know more about feminism its history needs to be explored as where and how it was started and what were the purposes and journey of it feminism is spreaded over three waves but before even that these women were already facing issues and also working to resolve them there are not many absolute proofs about this protest but it is believed that in 3 rd century bce roman women gathered on capitolline hill to resist against marcus porcius cato who was limiting and bashing the womens right of usage of expensive goods it was only the start but limited recorded history showed few evidences regarding women struggles in france late 14 th and early 15 th century the first feminist philosopher christine de pisan raised voice for derogatory attitudes towards women education to know more about feminism its history needs to be explored as where and how it was started and what were the purposes and journey of it feminism is spreaded over three wavesin mid 1800s sufferage moment started which is considered as a major milestone of feminism in 1848 lucretia mott elizabeth cady stanton and other social activist women and few men gathered in a small town of new york seneca falls seneca falls convention holds a lot of significance in the history of feminism as stanton drew up declaration of sentiments this declaration consisted upon 11 resolutions in which she demanded the most radical right right to vote when voices were rising by white women about right to vote and education there was also a voice of black woman sojourner truth truth raised voice for differentiation in treatment of elite class and lower class women her iconic speech aint i a woman made everything clear how white upperclass women are being treated and how black women are dealt with mainstream feminist leaders such as elizabeth cady stanton succeeded to secure some of the rights but right to vote was still out of sight in 1920 19 th amendment was passed and it was a major success for american feminist this all era is also considered as first wave of feminism second category was of radical feminists they aimed to change the institutions and society entirely as they considered it inherently patriarchal they thought that society and institutions are hierarchical and filled with traditional power and relationships they wanted to make it nonhierarchical and antiauthoritarian finally cultural or difference feminists were the last category they believed that men and women are naturally same and it should be celebrated they considered it condescending for women to be more like men finally there was a third wave of feminism which started in mid 90s in this era many things were readopted by feminists which were thrown away in second way by declaring it as a form of opression by patriarchy the notion of universal womenhood body gender and sexuality was dismantled lipsticks high heels and other feminine products were used proudly as they can be subjective rather than object of sexual suppression women of third wave stepped up as empowered females in the world they mimicked the terms slut or bitch as normalizing it to deprive others from wordly weapons in pakistan women related activities which talk about rights and interests is aurat march in their acclaimed 2012 look at entitled position of pakistani women withinside the twenty first century dr jaweria shahid and khalid manzoor butt outlined feminism as equality for ladies and freedom from gender discrimination in unique components of life keeping this under consideration one may argue that feminism in pakistan is a whole myth ever due to the fact its independence in pakistan it had been scuffling with exploitative remedy on the palms of their male counterparts the social financial and political surroundings making it tough for them to develop and combat for their rights there has nearly constantly been a few backlash towards ladies who want to empower themselves be it via way of means of studying running or maybe selecting a partner for themselves it was seen in researches that ngos and different establishments that were trying to assist oppressed women were accused of deceiving and brainwashing them most of those ladies internalised their suffering both out of worry or a loss of assets to show to and the enormously affluent knowledgeable higher magnificence in reality turns a blind eye hoping to preserve their popularity quo according to literature there are some forums such as politics where people used feminism for different purposes and it can be seen now by advances in media and education for example fatima jinnah fearlessly encouraged thousands of women to defend their welfare even before the establishment of pakistan soon thereafter begum raana liaqat ali khan established the pakistan womens association in 1949 with the purpose of promoting the moral social and economic status of women across the country womens action forum was also established in september 1981 women lobbied and defended that women were dependent upon themselves however due to the controversial implementation of the hadud ruling of general zia ur haq the real wave of feminist struggle emerged in 1980 the ruling required rape victims to provide four witnesses in order to accept their claims wma publicly expressed its opposition and raised public awareness of unjust punishments imposed under the law women from all walks of life participated in the forum those who opposed the government in the media protesting on the streets carried out educational campaigns in schools and put forward the famous slogan men money mullahs and military not surprisingly feminism was very popular during the two terms of benazir bhutto as prime minister during this period ngos and focus groups gained considerable power and urged the government to make changes unfortunately as afiya sherbano suggested in her study of the history of feminism in pakistan when nawaz sharif took office in 1997 at that time the momentum slowed down and women lost ground due to political conservatism and religious revival in 1997 the islamic ideological committee recommended the mandatory implementation of burqa and the reputation of murder reached a new height after general musharraf joined the rights of women and encouraged women to participate in the media sports and other social and political activities some lost lands were restored exercise continues to this day albeit at less intensity than before many laws that favor women such as the criminal law amendment the sexual harassment law the criminal law the womens protection law the sexual harassment law the womens status law and various condemnations of honor killings and pakistani society faces other vices as literature showed waf was a colaborative forum of different organizations and individuals with different views on religion and tradition the reason for this diversity was the need to bear the greatest number of people to resist oppressive regimes body gender and family like many members were religious and conservative and deeply rooted in the traditional family system talking about body sex and freedom of expression had not yet become part of the wafs official public agenda ironically while waf members avoid public debates about physical and sexual behavior state and religious clergy were not so intimidated when waf was not highlighting and discussing about sexual rights of women publically while seeing that young women decided to take charge in their hands its when the new wave of women movement started after the uprising of women maledominated believes started to shake these movements started in 2018 as aurat march held on 8 th march these marches are still criticized by many because of controversial slogans and being open about such issues which are always considered private a lot of researches have been done on feminism internationally but pakistan does not have much research studies done on feminism present study focued on young urban women and their understanding of feminism in current age of technology this study will contribute in pakistani literature on feminism and aurat march review of literature the word feminism has acquired many definitions over the period and has a long history of women struggle linked to it the term feminism was established by a french philosopher charles fourier in 1832 in the focused research various aspects were under study but mainly effect of education level and social media usage on understanding of feminism it also focused on how socioeconomic status affects the participation in women movements and feminist activities the role of education there are not many studies done which shows the relation of education level and improved knowledge of feminism very few researches came across while finding the literature relevant to the current study firstly it is to be understood that if education level increases ones learning and knowledge is not guaranteed to be increased too according to authors of turning learning right side up putting education back on track education is more likely to be linked with memorization and not with improving learning and knowledge educational institutes are working with the aim to improve students memory rather than working on their knowledge they are not supposed to be turning students into computers or robot by improving their memory their sole purpose should be improving the knowledge and have better learning outcomes education and teachers should be focused on what humans can do better than machines and work on their learning experience in education world forum education of economic success was focused in the conference of 75 countries this conference was based on to improve educational facilities and increase the enrolment rate all these efforts were put to lower the poverty rate but even after increasing the enrolment the condition was right there where they left it reason of such outcome was by improving the enrolment rate learning skills and knowledge was not improved hence by increase in enrolment rates and education level it is not necessary that knowledge will also be improved in another study it was observed that in american colleges when they increased the number of students the quality of knowledge and even education was not in better condition students were spending less than half of the time studying than their ancestors 50 years ago it was also seen that in later years when these students in working sector employers complained about not having skilled employees these employees lacked basic problem solving and writing skills many students were just after increasing their degree level rather than skill improvement and gaining knowledge to see whether education level have any impact on knowledge of feminism or not there is to see if education level improves knowledge a study conducted on 2200 us college students over 4 years of time in related study tests were designed to assess the analytical skills of students according to arum and roksa 45 of students did not improve after two years of college in critical thinking reasoning and writing results also showed that 37 students did not improve after four years it concluded that with an increased education level understanding and educational skills do not improve much role of social media in this age of computer and technology life has become easier than ever in almost everything technology is present to help humanity mode of transportation education health finance and many other fields are relying on modern technology now if we talk about education and knowledge then they are no more different than other aspects of life in old times knowledge was passed through books newspapers pamphlets or it can be said that paper was the main source now technology has taken its place and fastest way of transmission is social media social media includes all social platforms ie facebook instagram twitter pinterest snapchat and many more but the point is what amount of knowledge is accurate on these platforms it is also needs to be considered that whether the knowledge is giving out the same meaning and understanding as it was supposed to or not social media mainly is used for communication and knowledge sharing in a study about the impact of social media usability and knowledge collecting on the quality of knowledge transfer almeshal jasser conducted quantitative research on 426 saudi participants in which 70 was the response rate ttest and correlation was used as analysis technique and there was a significant statistical impact of social media usage on collected knowledge and its quality this research concluded that social media effects the quality of knowledge and it can be difficult to rely on it now coming towards the main topic of this research feminism luckily there is some literature present now which tells how social media can alter the image of feminism as discussed above that social media does not provide authentic knowledge all the time but it does help in sharing people can support any social cause online regardless of distance social media can cause a change as it connects the world where it has negative impacts on the other hand it is doing good too a study was conducted on pakistani culture regarding the effect of media feminist approach on youth by minhas et al a survey was conducted online and in person from which 150 responses came back participants age range was 16 to 30 years old results clearly showed that 7375 people agree that pakistani media is promoting western feminism which is against our religion and culture in 2013 while people were gathering in texas for approval of abortion bill there were some who could not join they started a hashtag on twitter standwithwendy and protested online just like that in 2014 hashtag feminism was on top on twitter another example of social medias power can be seen when ray rice a professional football player had a domestic violence scandal many women were suffering a bad marriage or relationship and to show the support women shared their stories of domestic violence with a hashtag whyistayed social media have changed many things lately and internet is flooding with such examples hashtag activism is a term which is not much known in our country but it is used to pressurize companies and politicians to bring changes for betterment following are top 3 feminism related hashtags which have trended on twitter  bringbackourgirls it reached 55 million  yesallwomen it reached 34 million  heforshe it reached 17 million as the positive aspect of social media is in the spotlight there is another hashtag which has been re tweeted internationally and turned into an online movement the movement called me too started in 2006 by an activist tarana burke she used this phrase to raise awareness in people regarding abuse although women are still underrepresented in media field but when it comes to social media platforms women are more active than men for example in pakistan women have more followers on twitter and google than men even after having more following womens tweets are not retweeted because they do not use traditional hashtags socioeconomic status to discuss if socioeconomic status has any impact on participation of social movements or not there is a need to understand what socioeconomic status refer to socioeconomic status is the level of education occupation and income due to different socioeconomic classes people go through power differences in many fields in a research of 2010 on protest participation the data was utilized from 1990s protest of america all participants were the participant of a protest and their data was focused to make hypothesis to find what pattern did the protesters had logistic regression ttest was used to analyze the results results showed that most of the participants were young well educated unmarried no children and had higher family incomes this study also concluded that these participants did not had any major responsibility and were zealous to participate as the topic in spotlight is wheather it affects the participation in social movements or not there is not much literature found on this area still there are some according to which it affects the participation a study was conducted in hong kong in which 134 college students were selected for survey all participants were 18 and from different institutes this study concluded through regression that parents support their children a little in participation of movements and parental support is influenced by socioeconomic status of the family same status people encourage each other to participate in such events in another study regarding civic engagement showed through survey that volunteering in movements is highly influenced by socioeconomic status in 2000s 85 of the people who belonged to the higher socioeconomic class tend to join the movements as compared to 73 people of lower class author gaby also mentioned that these percentages have increased over time as in 1970s 79 of higher class people volunteered as compared to 65 of lower class for this study upto 350 students per school were selected from different schools of us an european study highlighted the facts about influence of socioeconomic status on participation it shows a clear impact of income on participation in this research author compared elections and referendums of netherland and ireland there are basically two theories about peoples participation in protests one says that people with lower socioeconomic status tend to participate in protests and on the other hand it is said that higher socioeconomic class participate more let us have a look on the first perspective which focuses on people with lower ses tend to protest when state is not fulfilling the needs and people have to face depravity of resources and money they raise their voices against it this is called grievance theory when material conditions are unbearable there is another theory of relative deprivation which states that when a person feels unsatisfied and frustrated due to their conditions they are prone to protest same thing happens in social movements participation and what encourage people to join now coming towards what cause higher class to indulge in social events there is a theory of social change which informs that when people are out of their financial problems and no longer worried about it they are motivated if a person is not worried about finances then it clearly shows that they are doing well in that sector this encourage and motivate them to now meet nonmaterial needs study in taiwan was done when data was collected through world value survey march to june 2012 sample size was 1238 regression analysis was run to get results and to check if higher ses participate in protests than lower ses statistically it proved that with the increase in ses the participation also increases by 528 it also supports the above theory of social change and not the grievance and relative deprivation theories theoratical framework the theory which supported this study was stand point theory proposed by dorothy smith in 1987 as the name defines itself stand point theory states that people have their point of views according to their position in the society one persons view point will be different from another because of their specific status in society it clearly does not mean that we cannot see someone elses point of view rather it states three main points 1 no one can have complete objective knowledge 2 no two people have exact standpoint 3 one must not take own standpoint for granted smith summerized her theory in very simple words through these points it is a known fact that nobody has the complete knowledge and also cannot be objective being humans everyone is different from each other which means two standpoints can never be the exact copy in third point a person might belong to the any category of the society but they have some position in it so they must never ignore their own standpoint what is the impact of feminism on young urban women feminism mainly refers to equality of women in all spheres of life and it has a huge impact on womens life current study examined different perspectives to see the understanding of feminism and how it is impacting womens life young urban women of pakistan are being enlightened about their rights and raising their voice against gender discrimination feminism is improving womens condition as their pleas are finally being heard by the society on average 53 which is more than half of the participants agreed that feminism has positive impact on womens life as feminism is relatively new term for pakistan in comparison to the world so remaining participants did not agree with the new concept of women equality in all spheres feminism includes many perspective and openended questions focused on main perspectives of it decision making is an essential part of life and to study who should has the power of it and why the question was asked about who the decision maker of the house should be and why to which 7212 participants responded as both partners 1969 of the participants gave opinion that men should make the decision and only 636 said women there were also 181 participants who said that it should be regardless of gender according to caprino men and women have different capabilities and decisionmaking qualities men tend to take risks more whether success is assured or not but women think things through to reach assured success whether its small or big by having both genders involved in decision making process can help make the best out of any situation figure 01 represents the high ratio given to whom should be the decision maker of the house as womans identity matters a lot and has a solid impact on her life next question asked in qualitative part was whether women should change their surname or not after marriage 3727 participants responded that it should be entirely womens choice 4939 of participants were not in favour and 1181 of participants were in favour of women changing the surname after marriage but this question will be judged on the basis of religion as pakistan is an islamic country according to a video uploaded by mufti menk on youtube he briefly described that there is no compulsion in islam to change the surname after marriage he explained that due to affiliation women have her fathers name as her surname as it represents her identity family background and orientation but if she changes her surname after marriage then she will be leaving her identity and it is supported by literature last question of the study was how these marches are contributing toshaping identity of young women 3336 said positively 4272 said negatively 515 said not contributing at all and 106 said it is contributing both ways as mentioned in above discussion that feminism is not represented in the aurat march and extreme language is being used too so most of the participant responded that it is affecting them negatively because it is decreasing the thread line difference between assertiveness and aggressiveness behaviour it is also confusing their immature minds and with the help of social media added with marches identities are being shaped under societal pressure it was seen that education level did not affect the understanding of feminism 46 of the participants education level was graduation while 43 participants had intermediate level of education 7 participants were having post graduate level all levels had different understanding of feminism literature has also shown that quality of knowledge is not based on education level as ones education level can be higher than others but their quality can be down how social media usage effects the understanding of feminism most responses received for this question represented that social media has positive effect on the understanding of feminism as 3969 participants stance was it helps in increasing awareness about women rights alleviating oppression helps women raise voice and share their opinions 3606 responses stated the negative effects of social media on understanding of feminism these responses explained how it is affecting it negatively asknowledge without authentic source is uploaded and people do not do their research before believing it can be dangerous for uneducated people as their knowledge is not that vast these responses also shed some light on how information can be unauthorized bad representation of ideas promotion of radicalism and misleading information it also presented a very valid point that pakistan has a patriarchal society so people tend to oppose women and inclined towards negative images presented on social media 2242 of the respondents stated that it depends on the content perspective of viewer portrayal of images and naive influencer who do not know what power they hold it is somehow true that social media presents many perspectives and contents it depends on both parties how they present information to viewers and how viewers perceive it according to literature social media does have issues in authenticity of knowledge so it all depends on source of content content itself and writer lower class has mobility issues other classes do not have time to participate as they are working to make both ends meet doing it for fame lower class has accepted the situation to observe womens day internationally and to impose their beliefs on everyone 203 participants were not in the favour of this stance as everyone is participating in aurat march people stated that participation does not depend on socioeconomic status this march is not only for specific class all women participate to support equality it also depends on family background and transgender are participating too according to a study it is proved that most of the activists participating in protests belong to higher socioeconomic class as the results also showed that specific socioeconomic class participate in aurat march and respondents briefly explained activists belong to elite class the question regarding aurat march was asked about what opinion they had about it 3727 participants gave a positive opinion while 3424 had a negative opinion there were also responses which had both opinion and it made 2575 of the results only 1515 agreed that aurat march was representing feminism properly this march was showed like western media but many aspects were not showed it helped women in voicing their opinion advocating women rights see and try in eliminating violence highlighting all women issues and it was also giving women a platform to raise voice 909 participants had mixed feelings about it as they explained it depends what one sees on media slogans are extreme but otherwise idea behind it is good needs to work on narratives then it can be more representable it was also said by one participant that no doubt women are facing discrimination but that does not mean that every man is discriminating women in present study the main purpose of conducting the research was to measure young urban womens understanding of feminism in respect to education level it also helped in getting their opinion about aurat marchs purpose and social media usage data of 330 participants were analyzed through oneway anova and descriptive statistics to explore opinions hypothesis h1 there will be no significant difference among different education levels and their impact on understanding of feminism findings clearly showed that there was no statistically significant difference among different education levels in terms of understanding and knowledge of feminism f 988 p 399 results of computed variables showed that level of education does not guarantee quality knowledge about feminism as the literature and other research also proved that education level cannot significantly improve knowledge a study was conducted on 2200 us college students over 4 years of time in related study tests were designed to assess the analytical skills of students according to arum and roksa 45 of students did not improve after two years of college in critical thinking reasoning and writing it concluded that with an increased education level understanding and educational skills do not improve much which is also supported by existing literature conclusions the present study focused on young womens understanding of feminism based on their education level and socioeconomic status it also covered history of feminism and how it is developing in pakistan through aurat march many studies have been done on feminism but it lacked how feminisms understanding is being impacted by education and socioeconomic status this study fulfills its objectives as majority of urban women has better understanding of the concept of feminism results of present study clearly showed that education does not impact the quantity and quality of individuals knowledge while socioeconomic status contributes to understand such social phenomenon the current study can contribute to the literature of feminism and factors influencing its understanding exploring the concept of feminism among young urban women participation in women movements on the basis of education social media usage and socioeconomic status objectives  to find out perception of young urban women about feminism based on socioeconomic status education and social media influence  to find out the role of aurat march movement in the concept of feminism  to find out the role of socioeconomic status of women in participation of aurat march research questions 1 what is the impact of feminism on young urban women 2 how education level effects the understanding of feminism 3 how social media usage effects the understanding of feminism 4 how socioeconomic status effects the participation in aurat march 5 how is aurat march affecting the concept of feminism hypothesis h1 there will be no significant difference among different education levels and their impact on understanding of feminism method the topic under consideration is focused to explore the understanding of feminism among young urban women current researh examined the effect of education social media usage and scioeconomic status on understanding of feminism and participation in aurat marchto conduct this research quantitative survey method was used this research focused on exploring the concept of feminism among young urban women to know more about the focused area quantiative survey research method were selected sample purposive sampling technique was used to collect data for present study as it focused on young urban women all participants were of 15 to 24 years old and from lahore city procedure objectives were selected for the study which led to formation of research questions and hypothesis semistructured questionnaire was made based on literature as well as

aurat march is held every year to highlight the issues of women the present research was conducted to see how much women know about feminism along with aurat march quantitative method with survey design was used for the present research and semistructured questionnaire was developed to collect data from 350 young women of lahore pakistan and15 to 24 years of age range was selected standpoint theory by dorothy e smith was taken as theoretical framework to study the results this research mainly covered the concept of feminism its growth over the time how aurat march had played its role in development of feminism and how it was contributing in shaping the identity of young women content analysis was used for openended questions and oneway anova along with descriptive statistics was used for closedended ones results showed that education plays no role in increment of knowledge and in its quality this study will help in filling the gaps in pakistani literature and be base of the future studies

introduction chile has seen in recent years nearly a million migrants enter its borders coming mainly from latin america and the caribbean where factors such as political stability security levels and constant economic growth throughout the last decades have turned chile into a pole of attraction for people seeking better employment and development opportunities this human movement has brought along thousands of children and adolescents who have been integrated into the chilean school system representing a significant number of municipal school enrollment in the districts with the highest index of habitability of immigrants in this way it can be observed that in santiago the capital of the country there was a significant percentage increase in foreign students enrolled in public schools in just 3 years where it went from 89 of foreign students to 155 in 2017 modifying the cultural and ethnic composition in the classrooms in relation to studies on migrant adolescents in contexts of southsouth movements that is massive displacement of people from developing countries to others in the same condition but with better economic and human development indices chile constitutes a case and studies by alvites and jiménez and tijoux begin to shed light on the problems experienced by migrant students due to challenges that the stress of acculturation process implies the immigrant paradox theory suggests that this movement may have an effect in school performance and the persistent gender differences in detriment of girls in the latin american context may also have consequences in different psychological constructs in the case of young foreigners who now live in a country other than their own their behavior may be shaped by the sum of environmental factors behavioral and personal aspects in direct interaction with the degree of stress involved in moving to a geographical place that is not the place of origin with new customs and values in order to adapt to the new reality of a different community in the case of chile migrant adolescents have evidenced depressions anxiety and nostalgia regarding the place of origin which may play against the necessary emotional and sociological resetting required to adapt into a new society the stage of human adolescence whether in natives or migrants is traditionally considered as conflictive and includes questions and difficulties inherent to its evolution and gender among the psychological resources related with a good psychological adjustment and social integration of adolescent in the school experience the following constructs can be found selfconcept selfefficacy and subjective wellbeing selfconcept widely studied from its multidimensionality since as indicated by shavelson et al this construct of selfperception is the result of interaction and experience with others on levels such as the academic emotional and social among others in this sense it can be assumed that the school experience in a new sociocultural and educational setting puts into play the selfconcept of migrant adolescents since as studies carried out in spain show students who presented low socialization and selfconcept obtained a low academic performance in the case of the adolescent population academic selfconcept is one of the most relevant personal characteristics when it comes to explaining for instance subjective wellbeing the studies by mccullough et al concluded that academic selfconcept was the main predictor of wellbeing and that measuring it was a good way to understand the wellbeing of adolescents the previous point suggests that the adolescents selfconcept will play a fundamental role in selfassessment as well as with respect to psychological wellbeing and the affirmation of ones own identity to the best of our knowledge there are currently no studies in chile measuring academic selfconcept indices neither in migrant adolescents nor in natives however it is a relevant issue since authors such as hay et al affirm that high selfconcept is positively related to performance integration and relationships in the school context while it is negatively correlated with anxiety in terms of gender differences on academic selfconcept the study by costa and tabernero did not launch statistically significant gender differences however studies by padilla carmona et al showed that girls surpasses boys in terms of academic selfconcept in chile studies such the one of gálveznieto et al did not evidence statically significant differences following this same line it can be considered that one of the most relevant challenges faced by migrant adolescents is the adaptation to a school setting different from that of their country of origin where selfefficacy understood as the capacity perceived by an individual to successfully face situations of daily life this construct plays a crucial role in the inclusion and interaction of individuals in this case migrants who join the new group according to briones et al selfefficacy in the experience of migrant adolescents suggests a very positive aspect between the level of selfefficacy and the degree of satisfaction with the achievement obtained likewise students who report higher levels of social selfefficacy also notice a greater degree of comfort in environments aimed at sociocultural interaction and better skills in the field of integration studies such as that of juárezcenteno indicate that migrant families with a low level of selfefficacy experience higher levels of depression which affects the behavior of adolescents studies carried out in colombia such as that of gómezgarzón with people who are victims of forced displacement suggest that there would be a positive relationship between selfefficacy and other constructs such as belonging inclusion and social wellbeing the study of fan and mak in australia found that migrant students show lower level of selfefficacy compared with natives as well in chile however there is still no comparative research in adolescents on selfefficacy of local residents compared to migrants in terms of gender contributions made by blanco vega et al in the latin american context suggest that boys tend to have greater indexes of selfefficacy similar results were obtained by junge and dretzke and huang quality of life an important motivational factor in migratory processes has been conceptualized and measured in different ways one of them is the concept of subjective wellbeing which is positioned within the hedonic tradition and serves as an approach to the satisfaction and happiness of individuals with their own life in the context of migration studies suggest that factors such as time of residence legal status size of the social network and coverage of basic needs would be positively related to subjective wellbeing while factors such as discrimination would be negatively related along the same lines studies such as that of panzeri point out the importance of postmigration subjective wellbeing as a valid measure related to future labor productivity mental health and social integration from the otherness and needs of the migrants themselves regarding the perception of subjective wellbeing among the native population and the migrant population bilbao et al herrero et al muñoz and alonso and hendriks and bartram have found that migrants they tend to exhibit lower levels similar results have been found in chile in studies carried out by alfaro et al regarding adolescents in this regard gender differences in favor of men in the iberoamerican context could lead to the assumption that the migration process in girls could have a negative effect in terms of some psychological constructs this is evidenced by studies by oyanedel et al and alfaro et al in chile where boys have higher scores on this scale similar results were obtained in studies in spain such as that of gonzálezcarrasco et al where it is concluded that the homeostatic system of girls is probably more sensitive to external variations and that there is a relationship between physical and cognitive aspects that occur in girls as well as their specific pattern of subjective wellbeing in this regard studies on subjective wellbeing in the adolescent population have been carried out under crosscultural formulations such as that of casas et al with adolescents from latinspeaking countries with adolescents from the two latin american countries having the lowest scores in terms of subjective wellbeing however studies comparing subjective wellbeing in migrants and locals are still needed to provide key information to different actors and thus guide decisionmaking in preponderant sectors positioning wellbeing as the center of attention in the development of public policies and as part of the strategies to improve the quality of life now regarding to the constructs of selfconcept selfefficacy and subjective wellbeing literature has reported relations among them for example the three of them operate at the level of selfperceptions in social emotional and behavioral terms similarly these three constructs are sensitive to the context and are built or modified according to lived experiences and social interactions so they are not stable but rather dynamic in the educational context selfefficacy is linked to confidence since students evaluate this ability in order to solve problems while selfconcept is related to the perceived personal competence when executing a task both constructs emerge as personal competencies in adolescence which serve as positive development indicators in the case of subjective wellbeing this construct is positively related with selfconcept and selfefficacy in the educational setting as explained various studies show a positive correlation between subjective wellbeing and other variables such as selfconcept and selfefficacy however there is still a lack of studies of this nature in chile in the same line literature has reported that selfefficacy would play a mediational role between subjective wellbeing and other constructs such as meaning in life life satisfaction and even personality traits such as extraversion and openness to the best of our knowledge the relations between selfconcept and subjective wellbeing have been widely described but no contribution has been made regarding the mediational role of selfefficacy between these two constructs for this purpose the following conceptual mediational model of selfefficacy in the relationship of between selfconcept and subjective wellbeing has been proposed considering the information above it can be noted that in the chiles school context there is a gap in the literature regarding the differences between migrant and native students regarding the relationship between selfconcept selfefficacy and subjective wellbeing one might think that there would be an effect on the part of the levels of selfconcept and selfefficacy on the subjective wellbeing exhibited by these students but there are indications to affirm how this relationship between natives and migrants could be differentiated facing a new educational context adapting to new models new relationships and especially to a whole new society could put to the test all the cognitive and affective areas that would influence the global satisfaction of migrant students hence a different configuration of the relationships between selfconcept selfefficacy and subjective wellbeing for them could happen not only due to the condition of local or native but because of the gender in this respect works by oyanedel et al and alfaro et al in chile evidenced gender differences in terms of subjective wellbeing and satisfaction with life with male scoring better in these constructs similar records were obtained by gonzálezcarrasco et al in spain finding statistically significant differences however studies comparing migrant adolescents with locals in terms of subjective wellbeing as well as selfconcept selfefficacy and gender to the best of our knowledge are not available in this new scenario where chile is a recipient of migrants this study aims to constitute a contribution in the investigation of relationships on academic selfconcept and selfefficacy regarding the subjective wellbeing of migrant adolescents versus the local population including also gender differences the importance lies in the fact that both groups will coexist to form part of the productive and intellectual assets of chile where a clear understanding of behavioral aspects of these groups would guide the efforts of central and local governments in improving public policies for the optimal personal development of all the countrys adolescents in the same line this research may serve as input to improve school experience for both locals and migrant students this research has set as objective to compare the levels of selfefficacy academic selfconcept and subjective wellbeing among migrant adolescents and local adolescents this research also aims at exploring gender differences on the other hand the objective is also to analyze how the variables of general selfefficacy and academic selfconcept are related as well as to observe their effect on subjective wellbeing for each of the study subsamples materials and methods sample the present study is quantitative and considered a crosssectional design the sample was made up of adolescent students belonging to 7th and 8th grade of the chilean educational system the students correspond to four municipal public educational centers located in the district of santiago metropolitan region of chile regarding the selection of schools two criteria prevailed convenience and percentage of migrant enrollment as a criterion to calculate the sample size a 5 error was considered with a confidence level of 95 the sample is made up of 406 students distributed evenly among the four participating establishments 5665 of the students were women and 4335 were men 4581 were in 7th grade and 5419 were in 8th grade while the age fluctuated between 12 and 16 years with an average of 1336 years regarding the key variable of the study the sample consisted of 5591 of students born in chile and 4409 of migrants with similar percentages of school vulnerability index 2809 of the migrant students were from peru 2135 from venezuela 1854 from colombia and 3202 from other latin american countries and the rest of the world the average residence time of migrant students in chile was 259 years for the purposes of this study chileanborn students were considered as chilean and foreign students with at least 1 year and a maximum of 5 years in chile as migrants instruments af5 academic selfconcept the af5 scale emerges as an improved version of the afa scale the af5 scale has been developed taking selfconcept as a multidimensional construct based on the works of shavelson and marsh the af5 scale was validated in chile by riquelme mella and riquelme bravo showing validity and internal consistency under these conditions the present study showed a high internal consistency general selfefficacy scale the general selfefficacy scale is an instrument developed by schwarzer and jerusalem and measures individual perception in relation to the abilities to cope with daily situations in stressful circumstances in chile cid et al demonstrated internal consistency or homogeneity when obtaining a high cronbachs alpha coefficient similar to the results obtained in other spanishspeaking countries in this study the observed cronbachs alpha was 0859 personal wellbeing index school children 7 the personal wellbeing index was developed and validated by cummins and lau its validity and reliability being demonstrated later there was an adaptation of this instrument to apply it in populations of children and adolescents generating the pwisc 7 scale which is a version of seven questions that has been validated in chile by alfaro et al this instrument uses 11point scales for responses ranging from strongly disagree to strongly agree in the different applications carried out in chile the instrument has shown a good factorial fit observing in this study a high internal consistency with a cronbachs alpha value of 0864 in addition to these variables participants were also asked about the different sociodemographic variables age sex country of birth time they have been in chile if they were not born in this country and parents country of birth procedure the selfreport questionnaire was applied to the students after having obtained the corresponding permits from the directors of the educational centers and subsequent authorization to be taken at agreed times on the other hand an informed consent form was given to the students and their tutors the application was developed in regular school hours of adolescents during the 2018 school period the material was delivered to the students the instructions were given and then the time they needed to respond was allowed in each application a responsible teacher and one or more researchers were present in the classroom schools in the metropolitan region of chile were contacted for convenience considering the criteria established for the study the only exclusion criterion was that of handling the spanish language students from nonspanishspeaking countries who had not yet managed the spanish language to understand the instructions and content of the applied instrument were left out analysis of data first descriptive analyzes were performed for the total scores of each scale subsequently ttests were performed for independent samples for each of these variables with the aim of comparing the mean scores obtained for each subsamble subsequently two multivariate models of simple mediation were constructed one for the subsample of natives and another for the subsample of migrants which assumed subjective wellbeing of the students as a dependent variable academic selfconcept as an independent variable and general selfefficacy as a mediating variable in both models gender was considered as a control variable abca bootstrapped ci based on 5000 samples was used to calculate the confidence intervals of all the models used the statistical analyses were carried out through ibmspss v24 and the modeling tool process for spss v210 results descriptive and comparative results table 1 presents the mean and standard deviation of the scores obtained on the academic selfconcept general selfefficacy and subjective wellbeing scale for the total sample and the subsamples of migrants and natives in addition independent samples ttest are also presented to establish differences between these groups for the three comparisons equality of variances was assumed based on levenes test the differences were statistically significant for the case of academic selfconcept and general selfefficacy no statistically significant differences were observed for these groups in the case of subjective wellbeing table 2 presents the mean and standard deviation of the scores obtained on the academic selfconcept general selfefficacy and subjective wellbeing scale for the total sample and the subsamples of girls and boys in addition independent samples ttest are also presented to establish differences between these groups equality of variances was assumed for the case of general selfefficacy and subjective wellbeing while different variances were assumed for the case of academic selfconcept the differences between the mean scores were statistically significant only for the case of general selfefficacy where boys had higher scores than girls mediation analyzes the results of the simple mediation models are presented below which considered subjective wellbeing as a dependent variable academic selfconcept as an independent variable general selfefficacy as a mediator variable and gender as a control variable model 1 considered the subsample of natives while model 2 considered the subsample of migrants the results of the regression analyzes that make up the mediation model 1 are presented in table 3 while the general diagram of this model is presented in figure 2 a partial mediation can be observed in this model where the total effect the direct effect and the indirect effect of academic selfconcept on subjective wellbeing were statistically significant on the other hand the results of the regression analyzes that make up the mediation model 2 are presented in table 4 while the general diagram of this model is presented in figure 3 a total mediation can be observed in this model where the total effect and the indirect effect of academic selfconcept on subjective wellbeing were statistically significant while the direct effect was not statistically significant discussion regarding the study variables statistically significant differences were found in terms of academic selfconcept and general selfefficacy but not in subjective wellbeing in relation to the highest scores obtained by migrant students in academic selfconcept the results contradict those found in spain by león del barco et al and plangger as well as results obtained in israel and in greece the explanation for these results could lie in the fact that migrant students come from family environments where the importance of study as a tool for social mobility has been understood and that in the case of migrant families the situation is exacerbated as a result of arriving in a country in search of opportunities and substantial changes in their socioeconomic situations the cultural weight that migrant families bring in terms of intentions of progress and substantial improvements in the quality of life could be generating in their homes a discourse favorable to study and trust in the capacities of adolescents which would be reflected in that they feel appreciated by their teachers and that they work a lot in class the fact of feeling good at an academic level is reflected in the grades obtained by migrant students where selfconcept is built in interaction with teachers and classmates who positively reinforce these attitudes giving as a result a student who feels competent and works to achieve its objectives in relation to general selfefficacy an important contribution of this study is the differences found in the total score of the scale the results contradict the literature in that migration could show a negative correlation with selfefficacy in this sense the family environment and somewhat more adverse economic situations could be generating more independent adolescents and with a greater sense of responsibility affecting their perceptions of the capacities they have to solve problems and the range of possibilities they have to face difficulties immigration can bring with it worldviews other than local ones that could be beneficial in terms of innovation flexibility and other soft skills this is where transculturation comes into play since this cultural fusion recovers the best of migrants and natives which could be generating positive changes in the chilean educational system by enrolling more competive students in connection with subjective wellbeing studies corried out in other countries by bilbao et al herrero et al muñoz and alonso and hendriks and bartram have found that migrants evidenced lower levels of subjective wellbeing than their native counterparts similar results were even found in chile by alfaro et al this research exhibited differences favoring natives however they were not statiscally significant these results could be attributed to various factors that are possibly attributable to the fact that the perception of material wellbeing health achievements and future is being managed in a good way by both migrant and native students as a result of the equal integration of both groups in the health and educational systems with possibilities of personal development through the laws of fee exceptions in higher education and reforms to the system for example in terms of satisfaction with health literature has widely documented the migrants arrive in the host country with better health condition compared with locals situation that it is likely to be maitained in time in the specific case of migrant students they seem to have been successful in restructuring their network of interpersonal relationships in the host country with no impact on subjective wellbeing despite the fact that the literature suggests that the social capital of migrants in general is lower and that this has high correlations with subjective wellbeing and that it can be a predictor of satisfaction with life studies such as those by martínez garcía et al establish a close relationship between subjective wellbeing and social support the latter being of great importance in situations of high stress that usually accompany migratory experiences local governments have made remarkable efforts to integrate migrant students which seem to have resulted in similar subjective perceptions of wellbeing among native and migrant students the absence of statistically significant differences between migrants and natives could suggest that the migration process has not been a traumatic experience for adolescents and that they view their future with optimism regarding gender differences this study found no statically significant differences in terms of academic self as were also encountered in the contributions by costa and tabernero and the one of gálveznieto et al this may be related to the fact that selfefficacy is related to academic achievement and social adjustment and both boys and girls would have similar perceptions regarding the achievement of goals the results obtained are a good incentive since the government of chile has highlighted the need to narrow the gender gap in the educational context these results are important because adolescence is a particularly complex period and the literature has reported that it is a more difficult process for girls presumably the results speak of a similar social adjustment in both genders and good socialization which is especially important given that selfconcept is a social product that is generated through the interaction and valuation of others in terms of roles rooted in latin american societies male provider and female housewives it could be expected that girls would show a lower academic selfconcept in relation to boys based on expectations the results do not mirror these assumptions on the contrary they could be indications that chilean society is advancing in terms of equality and equitable treatment in terms of gender and it is also providing a supportive social context this situation could also be determined by a good attitude of the teachers toward their students regardless of their gender and that the perspectives and aspirations of both girls and boys are not being affected by discrimination and machismo now the results on selfefficacy mirrored those of junge and dretzke blanco vega et al and huang the differences evidenced could mean the level of achievements and goals will be different in men and that this fact would have repercussions for example in the choice and concretion of professional careers and ventures that they decide likewise these results could give indications that the higher levels of resilience in boys could lead to greater wellbeing in them compared to girls in the future the fact that boys feel they have more resources to solve unexpected situations and that they feel more confident in their abilities could have repercussions in the world of work and for example perpetuate salary gaps by feeling that they deserve better positions and salary conditions because they are more selfeffective society must advance in this regard and promote selfefficacy as an engine in achieving goals and equality in terms of subjective wellbeing this study found no statistically significant differences regarding gender these findings are not in line with those of oyanedel et al and alfaro et al in chile and in studies in spain such as that of gonzálezcarrasco et al factors such as material health and relations satisfaction could be operating at similar levels in both groups in line with casas this finding highlights the importance of conducting studies on subjective wellbeing in adolescent populations in developing countries contrasting genders in order to advance a conception of wellbeing beyond meeting basic needs and focusing on the development of adolescent potentials since happy adolescents are later happy adults in terms of social support which is highly related with subjective wellbeing girls and boys seem to have been successful in structuring their network of interpersonal relationships exhibiting similar social capital which has high correlations with subjective wellbeing and that it can be a predictor of satisfaction with life in this line the size of the social network and coverage of basic needs would be positively related to subjective wellbeing the results suggest that at least in this sample social and structural factors such as access to opportunities expectations and roles which have traditionally favored men in latin american contexts may have a window to experience changes that can be reflected in similar subjective wellbeing indexes for both groups these changes can also lead to more equal and democratic spaces of study and better opportunities at work places as explained various studies show a positive correlation between subjective wellbeing and other variables such as selfconcept and selfefficacy literature has also suggested that selfefficacy may mediate the relations between subjective wellbeing and other constructs such as meaning in life life satisfaction and selfconcept in the case of nativeborn students the results controlled by gender assume a direct relationship between academic selfconcept and subjective wellbeing however general selfefficacy also presents a mediational role this partial meditational relation can be explained by the fact that academic selfconcept highly predicts subjective wellbeing in chilean adolescents however academic selfefficacy would exercise a mediational function since the literature has reported in many studies that higher selfefficacy comes with greater selfconcept in the case of migrant students selfefficacy would exercise a total mediational role according to the results obtained it could be assumed that migrant students came to chile with a more solid academic selfconcept and therefore it would not predict their subjective wellbeing the results obtained could constitute a contribution to the theory of achievement goals outlined a few decades ago which could help us to propose the mediational role of selfefficacy in the relationship between selfconcept and subjective wellbeing personal goals according to nicholls would be understood as determining agents of behavior and would therefore be mental representations regarding objectives set in an achievement oriented environment and that determine behavior affectivity and cognition in different situations and in the case of migrant students they face contexts where they put their competences and skills to the test in a setting with new motivations which ames understands as a subjective evaluation of the goal structure that is emphasized in a given situation in order to achieve social approval and status in a group the mediational role of selfefficacy would indicate that a more selfeffective individual would show higher levels of subjective wellbeing a situation that has been supported by previous evidence and where selfefficacy would turn out to be the greatest predictor of subjective wellbeing in native and migrant students in this line the selfconcept of individuals would have the ability to generate relevant changes in their attitudes so that in terms of achievements it could have effects on subjective wellbeing directly in the in the case of native students and via selfefficacy in the case of migrant students the results obtained in this study should be taken with the appropriate caution since more extensive studies and other informationgathering techniques as well as different scales will be required in the future to study in greater depth selfconcept selfefficacy and subjective wellbeing and especially the possible causal relationships between these constructs new lines of research could emerge from this study for example the study of the mediational role of selfefficacy with subjective wellbeing with other constructs such as meaning of life selfesteem and social support among the limitations of this study it can be mentioned that nonrandom samples and a crosssectional design were used the lack of similar studies in the chilean context to use as a point of reference was also a limitation in some cases the new inhabitants of chile have been looking for quality of life and the importance of studying subjective wellbeing in adolescents and its influential constructs lies in the possibility of generating inputs for the development of public policies that can arise from the systematic study of the chilean and migrant population in such a way as to provide key information to relevant actors to make decisions that affect minors in chile 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 comité de ética de la facultad de administración y economía de la universidad de santiago de chile written informed consent to participate in this study was provided by the participants legal guardiannext of kin conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

in the last decade the migrant population in chile has substantially increased where the rates have not only increased in the adult population but also among children and adolescents creating a potential for social and cultural development in the educational system the present work analyzes the relationship between selfconcept selfefficacy and subjective wellbeing in native and migrant adolescents in santiago de chile the sample consisted of 406 students 5665 women with an age range that fluctuated between 12 and 16 years with an average of 1336 years sd 096 students ttests were used to compare the average of the constructs evaluated between nativesmigrants and boysgirls participants subsequently two multivariate models of simple mediation were constructed one for natives and another for migrants which assumed subjective wellbeing as a dependent variable academic selfconcept as an independent variable and the general selfefficacy as a mediating variable in both models gender was considered as a control variable results show that migrant students present higher levels of academic selfconcept and general selfefficacy than native students there are no differences with regard to wellbeing in the case of gender differences are observed only for the case of general selfefficacy where boys present higher levels on the other hand a partial mediation is observed for the model of native students and a total mediation for the model of migrant students the study yielded interesting results regarding the differences in the evaluation of the constructs of selfconcept selfefficacy and subjective wellbeing in both groups such data can be used as inputs for the development of public policies for adolescents

background excessive alcohol consumption among university students has been linked to a range of adverse outcomes including educational difficulties psychosocial problems antisocial behaviours injuries risky sexual behaviours and drink driving 1 in the united kingdom alcohol consumption levels amongst university aged adults increased rapidly during the 1990s 2 recent studies suggest that just over half of uk university students binge drink at least once per week 34 whilst as many as 80 binge drink at least once a month 4 one recent study estimated average alcohol consumption at 25 units per week for 1 st year male uk undergraduates and 16 for 1st year women 5 significantly above current public health recommendations recent uk government policy of increasing the percentage of young people going to university has perhaps had the effect of exposing a larger proportion of the population to this highrisk drinking environment alcohol consumption amongst university students has to date proved highly resistant to intervention efforts 6 one approach which has shown some promise in experimental studies is addressing the perceived social norms that are posited to influence alcohol consumption 7 perceived norms take the form of descriptive norms with behaviour modelled through observation of the behaviour of significant others or injunctive norms where the individual perceives that their peers expect them to behave a certain way interventions underpinned by the social norms approach argue that normative perceptions are highly fallible with students often overestimating real alcohol consumption patterns among peers 8 hence through providing feedback and correcting misperceptions regarding the behaviours and social expectations of peers alcohol drinking behaviours may be reduced social norms interventions have typically involved provision of mailed webbased or facetoface feedback on individuals drinking behaviour and how this compares to norms for their peer group or social marketing campaigns to promote awareness of actual norms a recent cochrane review concluded that feedbackbased interventions delivered via the internet or facetoface on a onetoone basis appeared to reduce student drinking behaviours though mailed or group feedback were less effective and findings for social marketing campaigns were equivocal 7 whilst demonstrating promise such interventions have typically been examined in isolation from the contexts in which they operate and significant questions remain to be addressed regarding how they might be applied in practice no such studies have taken place in wales with the limited number of uk based studies suffering substantial weaknesses such as high levels of attrition 9 furthermore universities are complex systems whose overall ethos policies and practices may provide a context supportive of change or of maintaining the status quo 10 interventions which aim to achieve longterm change through simply targeting cognitive factors such as normative perceptions without addressing the characteristics of the setting which support the status quo are likely to fail in the longer term 11 some communitybased interventions to reduce alcohol consumption in adolescents have for example been shown to be more effective in rural settings than urban settings where impacts of the intervention are perhaps drowned out by the multitude of proalcohol stimuli in the urban environment 12 in welsh universities university managed accommodation blocks primarily house students in their first year of attendance with approximately half of students living in halls during their first year given that first year students are at greatest risk of excessive alcohol consumption 5 halls of residence offer potential as a means of reaching those students most at risk for alcohol related intervention the proposed research therefore aims to assess the value of a social marketingled social normsbased intervention implemented in university halls of residence across four universities in wales a survey of first year students was conducted in participating universities in may 2011 in order to establish levels of drinking and the prevalence of alcohol related consequences as well as normative perceptions findings from the survey fed into the development of materials by an intervention steering group to communicate areas of normative misperception to be distributed within halls of residence all halls of residence participating in the study will experience a universitywide alcohol harm reduction toolkit with half randomised to additionally receive the social norms intervention an exploratory cluster randomised design with nested process evaluation will be used to identify appropriate outcome measures and data collection methods test randomisation processes assess the extent of contamination across trial arms and establish recruitment and retention rates and intracluster correlations to help inform sample size for any future definitive trial it will also identify whether the intervention effectively mobilises the underpinning theory and that this is sufficient to bring about hypothesised responses in terms of awareness engagement and changed perception of norms whilst intervention acceptability and implementation processes will be assessed within the process evaluation methodsdesign the intervention the intervention is a social norm marketing campaign which aims to correct misperceptions regarding the behaviours and social expectations of peers and in so doing influence alcohol consumption the campaign will be delivered in two phases between october 2011 and may 2012 in intervention halls of residence in four universities and will use a variety of materials encompassing posters beer matscoasters leaflets meal planners and drinking glasses the campaign will be implemented by university accommodation staff social norm messages were based on the results of a survey of first year university students conducted in study universities in late aprilmay 2011 which identified discrepancies between norms and behaviours table 1 highlights the intervention materials and main social norm messages within them universities in the study also receive a toolkit to promote institutional responsibility for prevention audit current alcohol misuse policies and practices and which provided advice and guidance on prevention the toolkit was developed by a national union of students intervention project officer in consultation with the universities in the study it was distributed to key university stakeholders in october 2011 with the intention of developing a supportive environment for the intervention control halls will be exposed to the toolkit only the toolkit and social norms intervention were developed collaboratively by drinkaware nus wales and the welsh government following a review of previous interventions and support from an academic supervisor their implementation was facilitated by a dedicated nus project officer given the nature of the intervention it was not possible to blind participants to condition recruitment six universities who had collaborated on the development of the intervention were approached by the evaluation team to participate in the study with four agreeing to implement the intervention in the study period reasons for nonparticipation were related to difficulties in implementing the intervention and obtaining university consent within the evaluation timeframe informed consent for the study was obtained from directors of student services and halls of residence managers the universities varied in terms of the number of fulltime first year students and location with a mixture of urban and rural locations inclusionexclusion criteria the four universities had a total of 51 on campus university owned halls of residence one female only hall was excluded due to lack of trial arm balance all remaining halls were eligible for inclusion and consented to randomisation although 5 halls in one site were empty during the first phase of the campaign due to renovation randomisation blind remote randomisation was used to allocate halls of residence to receive the social norms plus toolkit intervention or toolkit only halls were stratified by institution and halls allocated alternately in a list ordered by size with the group allocation determined by one random number within each stratum measures primary outcome units consumed per week daily drinking questionnaire the primary outcome is alcohol consumption in units per week assessed via the daily drinking questionnaire 13 the measure asks students for details of a typical week rather than exact quantities for the last 7 days in order to ensure that it reflects habitual drinking the ddq has emerged as a favoured measure within rcts with students due to its brevity its convergent validity with more laborious drinking measures 13 acceptable internal consistency good 2month testretest reliability for volume and adequate testretest reliability for frequency 14 and established ability to detect postintervention changes importantly the measure also provides comparable estimates regardless of whether administered via the internet or as a pen and paper exercise 15 secondary outcomes weekly alcohol consumption behaviours daily drinking questionnaire responses can also provide a measure of i number of days per week drinking in a typical week ii number of units per sitting and iv number of heavy drinking episodes per week prevalence of higher risk drinking audit the consumption subscale of the alcohol use disorders identification tool each scored on a scale of 04 in primary care studies a total summed score of 4 or above for men or 3 or above for women has been shown to optimally identify potentially hazardous drinkers 17 alcohol related consequences rutgers alcohol problem index secondary outcomes include the 18item version of the rutgers alcohol problem index 18 the index is a well validated measure of alcohol problems with well established psychometric properties among clinical and general population samples ranging from 12 to 21 years it is commonly used among general university populations in evaluations of alcohol based interventions all items are typically summed to provide a single continuous variable for alcohol problems although the factor structure in the current population will be carefully checked descriptive norms in order to assess whether the campaign achieves the hypothesised mechanism of changing perceived descriptive norms for drinking the evaluation requires a measure of perceived descriptive norms the drinking norms rating form has been widely used in rcts and cross sectional studies and involves rewording the ddq to reference others rather than self therefore having the advantage that perceived normative behaviour is measured in exactly the same way as own behaviour injunctive norms whilst most previous studies have focused on descriptive norms many psychological models argue that injunctive norms are equally important in shaping behaviour a scale previously used by neighbors et al was therefore included demographics measures of gender age ethnicity internationalhome student status course studied and place of residence will facilitate an examination of the representativeness of the sample to assess comparability between groups of students assigned to receivenot receive the social norms intervention and assess potential contamination between trial arms acceptability of objective measures students will also be asked to indicate whether they would be willing to provide hair samples as an objective measure of alcohol consumption although it will be made clear that this is a hypothetical question and that we will not be attempting this at any point in the present study the question is simply included to evaluate the acceptability of this method among university students if we were to seek funding for a larger definitive trial using more objective measurement approaches in the future data collection at four months after initial implementation of the intervention measures will be collected via a survey to all 1 st year university students offered in web and paper format they will be recruited via nominated university distribution contacts who will circulate the link to first year students via email and electronic notice boards between midfebruary and the end of march 2012 at least one reminder will be emailed to students during the data collection period on completion of the questionnaire data will be captured and processed by a market research company who will prepare a complete anonymised dataset for analysis heads of student services provided consent for the conduct of the survey and students will not be able to complete the survey without completing informed consent tickboxes students will not be asked to provide any identifiable information other than email addresses which will be used purely for the purpose of selecting a winner for the £100 prize draw in each university offered as an incentive for participation email addresses will be separated from responses to the web survey and destroyed after the prize draw in an attempt to boost student responses residence hall managers will be asked to promote the survey and the prize draw to residents to compare the efficacy of two data collection approaches a paper copy of the questionnaire will be distributed to student halls of residence via accommodation managers inviting students either to complete the paper copy and return it to the research team in a freepost envelope or to go to the webpage to complete the survey online questionnaires completed in paper form will be returned to the research team in freepost envelopes these will be stored in a locked cabinet until the web survey datafile is received from the survey company at which point questionnaires will be retrieved data entered into the datafile and questionnaires returned to the cabinet participants will be offered the opportunity to enter a prize draw with £100 offered to one winner in each participating university by supplying a university email to be kept separately to questionnaire responses email addresses will be recorded on a detachable sheet at the start of the questionnaire which will be separated from the questionnaire once received with the email address entered into a separate spread sheet and the paper copy destroyed sample size assuming a student response rate of 40 1600 completed questionnaires will be available for analysis an average of 32 students per hall assuming an intracluster correlation of 003 fifty halls of residence will therefore provide 80 power to detect a 02 standard deviation difference in units of alcohol consumed using a twotailed alpha of 005 assuming a student response rate of 25 1000 completed questionnaires will be available for analysis an average of 20 students per hall assuming an intracluster correlation of 003 fifty halls of residence will therefore provide 80 power to detect a 023 standard deviation difference in units of alcohol consumed using a twotailed alpha of 005 it is not anticipated that the effect size will be of this magnitude with a much larger trial likely to be necessary to detect realistic effect sizes below 01 standard deviation this study is therefore designed as an exploratory trial to assess the value of the intervention and plan a larger scale study if warranted process evaluation universities are complex systems whose ethos policies and practices may provide a context supportive of change or of maintaining the status quo 10 within evaluations of complex interventions process evaluation is crucial in order to understand what was implemented how it was received and ultimately how outcomes were produced a process evaluation will run alongside the implementation of the programme throughout the 201112 academic year the process evaluation is concerned with 5 core research questions i what role does alcohol play in students social life during the transition to university and throughout university life ii how are the toolkit and social norms activities developed and what are their underlying logic models iii how are the toolkit and social norms activities implemented iv how for whom and in what circumstances does the toolkit brings about change in university practices v how for whom and in what circumstances does the social norms intervention influence alcohol related beliefs and behaviour the process evaluation will encompass 1 group interviews with up to twenty 2 nd and 3 rd year students in each university focusing upon experiences of alcohol throughout student life 2 visits by a researcher to each intervention residence hall in order to monitor the distribution and placement of materials 3 group interviews with up to 6 students in 2 case study halls in each university exploring awareness and responses to the intervention 4 interviews with stakeholders in each university involved in delivering the intervention in addition all residence hall wardens will be asked to complete a brief questionnaire to assess changes in practice over time permission will also be requested from university representatives to use routine public data gathered during audits forming part of the toolkit finally within the survey described above to assess intervention reach students will be asked to indicate whether they had seen the intervention materials in their own hall of residence or in another students hall of residence to assess recall students who recalled seeing any of the norms materials will be asked to identify core messages from a list students will also be asked whether messages within the materials were credible and relevant and whether they felt that exposure to the materials had influenced their normative perceptions or behaviour these questions will be identical for students in control and intervention halls allowing assessments of contamination between trial arms the survey also includes a number of bespoke items from the intervention survey which informed the social norm intervention but only where these are linked to specific intervention communications hall of residence managers will be asked for their consent for researchers to visit halls to monitor the placement of campaign materials prior to group interviews an information sheet would be provided with participants offered the opportunity to ask questions prior to obtaining informed consent since part of the process evaluation requires asking different questions of intervention and control premises representatives the research team members who conduct the process evaluation will be unblinded analysis in order to assess exposure to intervention materials and contamination between trial arms percentages of students within the intervention and control groups reporting having seen each of the intervention materials i in their own hall of residence and ii in another students hall of residence will be examined among those students reporting exposure to intervention materials percentages correctly identifying the messages within them will be calculated for each trial arm percentages of students reporting each level of agreement with statements regarding the credibility relevance and perceived impacts of intervention materials will also be examined for each trial arm whilst the study is likely not sufficiently powered to detect impacts on behaviour it is likely that relatively large changes in perceived norms will be necessary to produce small changes in behaviour hence regression analyses with random terms to adjust for clustering at the hall level and fixed terms to adjust for stratification variables will examine differences between intervention and control participants in terms of normative perceptions for alcohol consumption and alcohol related consequences comparisons between trial arms will be conducted on an intentiontotreat basis secondary analyses would compare halls on the basis of researcher observations of whether or not materials were placed to inform the design of a potential large scale definitive trial with sufficient power to detect changes in behaviour intracluster correlations and standard deviations will be calculated for total number of units per week response rates will be calculated in each trial arm the percentage of students reporting willingness to provide hair samples will also be presented whilst among those students reporting that they would only do so if paid percentages reporting that each level of payment would be required would be presented discussion the need to address high levels of alcohol misuse amongst uk student populations has led to a range of possible preventive approaches including social marketing campaigns that address misperceptions of social norms however the lack of a strong evidence base for uk interventions highlights the need for an exploratory trial phase before large scale intervention implementation and the conduct of any definitive trial definitive trials require appropriate outcome measures cost effective data collection reliable randomisation processes an understanding of potential contamination across trial arms and a measure of recruitment and retention rates and intracluster correlations to help inform sample size calculations the current study provides the opportunity to generate such information within the context of an exploratory trial of a university halls based social norm marketing intervention it also provides the opportunity to test the application of the theoretical assumptions underlying the social norm approach by measuring the hypothesised pathways that are posited as leading to behaviour change these are an assessment of campaign awareness reception and changes in normative perceptions the challenges in facilitating such processes with a relatively low intensity interventions informed intervention development and the provision of the supportive environment toolkit and also led to a relatively large sample size for an exploratory trial to asses such changes in intrapersonal processes finally the study provides an important opportunity to assess intervention acceptability and implementation processes to inform optimum intervention content and delivery in any future trial authors contributions sm gm and lm were actively involved in the development and design of the study and all authors in the drafting of the manuscript sm is the principal investigator gm is co applicant and responsible for the day to day management of the study lm is co applicant and responsible for statistical oversight of the project aw is responsible for the conduct of the process evaluation all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background excessive alcohol consumption amongst university students has received increasing attention a social norms approach to reducing drinking behaviours has met with some success in the usa such an approach is based on the assumption that students perceptions of the norms of their peers are highly influential but that these perceptions are often incorrect social norms interventions therefore aim to correct these inaccurate perceptions and in turn to change behaviours however uk studies are scarce and it is increasingly recognised that social norm interventions need to be supported by socio ecological approaches that address the wider determinants of behaviour objectives to describe the research design for an exploratory trial examining the acceptability hypothesised process of change and implementation of a social norm marketing campaign designed to correct misperceptions of normative alcohol use and reduce levels of misuse implemented alongside a university wide alcohol harm reduction toolkit it also assesses the feasibility of a potential large scale effectiveness trial by providing key trial design parameters including randomisation recruitment and retention contamination data collection methods outcome measures and intracluster correlations methodsdesign the study adopts an exploratory cluster randomised controlled trial design with halls of residence as the unit of allocation and a nested mixed methods process evaluation four welsh uk universities participated in the study with residence hall managers consenting to implementation of the trial in 50 university owned campus based halls of residence consenting halls were randomised to either a phased multi channel social norm marketing campaign addressing normative discrepancies n 25 intervention or normal practice n 25 control the primary outcome is alcohol consumption units per week measured using the daily drinking questionnaire secondary outcomes assess frequency of alcohol consumption higher risk drinking alcohol related problems and change in perceptions of alcoholrelated descriptive and injunctive norms data will be collected for all 50 halls at 4 months follow up through a crosssectional on line and postal survey of approximately 4000 first year students the process evaluation will explore the acceptability and implementation of the social norms intervention and toolkit and hypothesised process of change including awareness receptivity and normative changes discussion exploratory trials such as this are essential to inform future definitive trials by providing crucial methodological parameters and guidance on designing and implementing optimum interventions

background prior literature has widely documented that there is a significant association between the propensity of physicians to use evidencebased medicine in their practice and the structural characteristics of their professional networks 12 in particular this stream of research has shown that the network characteristics of professional relationships among clinicians are important predictors in explaining their different orientation towards ebm 2 3 4 although ebm has been widely considered as an individual attitude its actual impact within organizations strongly relies on its pervasiveness and widespread diffusion at the organizational level 5 if physicians do practice ebm individually the risk is that barriers to the effective implementation of innovative clinical solutions are not translated from the bench to the bed of the patient 67 these difficulties are often due to social constraints and barriers which some elitists may establish against other nonelitarian members within organizations 8 as well as the resistance of other clinicians who have a different behavioral orientation 910 despite its general importance this topic has been seldom analyzed on empirical grounds in healthcare organizations the aim of the present paper is to fill this gap by exploring and testing whether physicians selfreported frequency of ebm adoption is related to the network position they hold in the overall web of collaborative relationships established within healthcare organizations where they routinely visit and treat their patients data regarding a community of hospital physicians staffed in one of the biggest italian healthcare organizations were collected and used in the present study social network analysis was firstly performed to identify structurally important physicians in the network specifically we derived a coreperiphery structure of the overall interphysician network distinguishing the dense cohesive core of the professional network from the sparse unconnected periphery then a new class of network centrality indicators overall called hubs and authorities centrality were employed to capture the structural prominence that physicians exhibited in the network finally we explored whether their selfreported frequency of ebm adoption predicted the degree of coreness and structural importance that individual doctors assume within the observed network social networks research has provided ample evidence that individuals attitudes and other personal characteristics influence the shape of their social networks as well as the position they assume in the overall web of relationships 11 12 13 on the basis of previous work developed in this field 14 we assume that the propensity towards ebm is a relatively stable physician individual characteristic which in turn influences hisher network position within organizations we hypothesize that there is an association between the physicians propensity to use ebm and their degree of coreness within organizations taking other relevant individual and organizational characteristics into consideration methods research setting and data collection the present observational study was conducted using a questionnaire survey of 329 physicians employed in six hospitals belonging to one of the largest italian local health authorities in italy lhas aim to promote and protect the health of all resident citizens of a specific territory the italian national health service is currently comprised of 145 lhas based on considerations of efficiency and costeffectiveness each lha may provide direct care through its own facilities or may commission the services to providers accredited by the system such as independent public and private bodies the surveyed lha serves approximately 800000 individuals residing in 50 municipalities the lha employs around 8400 people including technical staff nurses and physicians and more than 80000 hospitalizations occur annually hospital activities are carried out according to a matrix organizational model although hospital activities are carried out in six hospital facilities these hospital services are provided by three clinical directorates which may be considered as the health sector equivalent of strategic business units 15 clinical directorates are managerially inspired and defined groupings of clinical specialties and support services created specifically for the purposes of resource management control and accountability they are intermediate organizational establishments through which defined parts of larger hospitals health services are managed the directorates were introduced in the italian healthcare organizations in the 1990s with the aim of reorienting activities toward healthcare processes 15 data were collected using a questionnaire which was administered from february to november 2007 participation was voluntary and respondents were assured that their responses would be confidential and used for research purposes only because our study contains no experimental research and given that any information concerning patients was collected in accordance with italian law ethics approval was not necessary however all physicians provided informed consent for the survey the questionnaire consisted of three sections which contained a total of 17 questions the first section collected attributive data on clinicians such as age gender hospital tenure prior experience in the nhs and managerial role the second section was designed to collect data on advice network relationships among clinicians according to burts approach 16 we used an egocentric socialnetwork survey instrument to derive a list of people with whom the respondent had ties with each physician was asked to name colleagues within and outside their hospital organization with whom they interacted with through relationships based on the exchange of advice and responses were combined in a summary network each respondent was asked to characterize tie strength with each nominated peer using a fivepoint scale the third section of the questionnaire collected information about clinicians attitudes towards ebm it included questions about respondents perceptions of the availability of information and the possibility of accessing scientific evidence through corporate informationtechnology support responses to the questionnaire were requested within 3 months two quarterly recalls were sent to the physicians via email and a final recall asked for a response within 1 month after ten months the questionnaire was activated and made available online almost 90 of the total population completed the questionnaire variables and measures dependent variable social network analysis was used to derive the position of individual physicians within the surveyed professional network using survey relational data an adjacency matrix containing information on the interpersonal collaborative ties among clinicians was created 17 each rowcolumn listed physicians surveyed and intersecting cells represented the frequency of interaction between pairs of individuals after data preparation we used the continuous coreperiphery algorithm developed by borgatti and everett 18 to compute the degree of coreness of each surveyed physician as borgatti and everett clarify the core periphery model consists of two classes of nodes namely a cohesive subgraph of the core in which actors are connected to each other in some maximal sense and a class of actors that are more loosely connected to the cohesive subgraph but lack any maximal cohesion with the core 18378 core periphery algorithms jointly consider two kinds of structural properties of network nodes first the level of centrality that a given actor assumes within the network is considered at the same time the algorithms take into account the general level of interconnectedness it exhibits with other network nodes a network coreness score was computed and then assigned to each sampled physician a hubs and authorities analysis was conducted to complement the coreperiphery analysis described above hubs and authorities analysis represents a natural generalization of the eigenvector centrality analysis which can effectively identify the structural importance of individual actors in social networks 1920 a set of algorithms is defined to compute two distinct and heavily interwoven measures called hub and authority which reflect the prominence of each actor based on the structural characteristics of hisher network ties an actor can be defined as highly hub central whether heshe points ie heshe has many outgoing ties to many good authorities high authority actors are those who receive showing many incoming ties from many good hubs kleinberg clarifies 19 that t he authority score of a vertex is proportional to the sum of the hub scores of the vertices on the incoming ties and the hub score is proportional to the authority scores of the vertices on the outgoing ties overall clinicians experiencing high network authority scores can be commonly regarded as important actors since they are both relevant and popular within the network the ucinet 6392 software package was used in the present study to perform the analysis of the surveyed professional network 21 independent variable as in previous research physicians attitudes towards ebm were investigated by asking how often in the past year they had used scientific evidence published in peerreviewed biomedical journals to aid their medical practice 2142223 the survey questionnaire specifically asked individuals to answer how often did you use scientific evidence published in peerreviewed biomedical journals in your medical practice over the last year responses were rated on a 4point likertscale structured as follows never rarely sometimes and oftenvery often control variables a number of other demographic and workprofile variables that might affect the position that physicians occupy within the organizational network were considered and included in the regression models some attributive characteristics of each physician were included such as age gender and years of prior experience within the inhs and within the lha a dummy variable that considered the managerial responsibility of each physician was assigned a value of 1 if the physician played a managerial role within the hospital system or 0 otherwise given that the geographical distance for other colleagues likely affects the possibility of interaction between them and thus the position that an individual occupies within the network a variable named geographical proximity was computed as the reciprocal of the average geographical distance of each sampled physician from their organizational colleagues finally a set of dummy variables that considers physicians affiliation to the various lha hospitals and directorates was entered into the model results the overall sample is made up of 297 physicians table 1 shows the main characteristics of sampled individuals they are on average 47 years old and are mostly men the number of years they have accumulated in the inhs is on average 1601 years of experience that have been accumulated within the organization is instead 1095 only 51 physicians are clinical managers as for ebm adoption the majority reported adopting ebm frequently followed by physicians declaring to adopt ebm very frequently occasionally and never overall almost 86 of sampled physicians reported to adopt ebm frequently or very frequently figure 1 illustrates the network of collaborative relationships among sampled physicians the circle represents physician and the link represents an existing collaborative tie among node pairs physicians locations in figure 1 were determined using a springembedding heuristic multidimensional scaling algorithm with proximity indicating the extent to which two clinicians were connected directly and indirectly through mutual colleagues 21 table 2 shows the pairwise correlations among variables the inspection of coefficients reveals a strong and positive association between age tenure in the inhs and organizational tenure tenure in the inhs is in turn positively associated to the variable making distinction of whether the clinician has a managerial role or not network coreness and network authority variables showed to be moderately associated with both the propensity to adopt ebm and geographical proximity of physicians albeit with a different sign tables 3 and4 show the ols regression results stata 10 was used to perform the regression analysis table 3 in particular presents three different models that we built to explore the clinicians coreness within the professional network model m1 contains only the ebm adoption variable and it should be considered as a null model against which the explanatory power of the subsequent models can be compared to model m2 includes only control variables model m3 is the full model incorporating all explanatory variables model m1 in table 3 shows that there is a significant association between the ebm variable and the network position that physicians hold in their professional network in particular it was found that a negative association exists between the physicians attitudes towards ebm and their degree of coreness the regression results also documented that among all of the structural and characteristic variables included the coreness of individual physicians in their professional network was associated with managerial role geographical proximity and the variables reflecting the clinicians affiliation to hospital structures and directorates in particular managerial role and geographical proximity were positively associated with the coreness of professionals within the organization physicians in department 2 were more likely to exhibit a higher coreness than those in department 1 which is the baseline category of the model physicians in hospital facilities 2 3 4 5 and 6 exhibited a lower coreness score than those working in hospital 1 compared to the variables of model m1 model m2 includes the measure characterizing the physicians attitudes towards ebm in clinical practice this variable showed a significant negative association with the dependent variable documenting that there is a negative association between the propensity to use ebm and the coreness that physicians exhibit in the overall professional network all significant control variables in model m1 continued to maintain significance in model m2 finally it is important to note that the inclusion of the ebm adoption variable increased the overall fit of model m3 over model m2 table 4 presents all models exploring the association between the ebm adoption variable and the network authority variable our model building follows similarly to what previously presented a stepwise approach according to this logic model m1 contains only the ebm adoption variable model m2 includes only control variables and model m3 is the full model that incorporates all explanatory variables models m1 and m3 in table 4 document that a negative and significant association exists between the ebm adoption variable and the structural importance that physicians hold in the collaboration network the inspection of parameters corresponding to control variables overall confirms our previous results documenting a significant association between the network centrality of clinicians and a number of other contingencies such as their spatial proximity from colleagues the managerial position they eventually occupy in the organization and their belonging to specific hospitals and departmental arrangements discussion ebm represents one of the most important paradigms in modern medicine 24 25 26 clinicians and healthcare professionals in general are requested to increasingly adopt and integrate the latest available medical knowledge produced in their clinical practice 27 in this study we explored how the propensity towards ebm is associated with the position that professionals occupy in the overall network of collaborative ties they create within healthcare organizations our findings documented that there is a significant negative association between the physicians propensity to use ebm and the coreness they exhibit in their organization our analysis also indicated that the core is formed by physicians having a significantly lower propensity towards ebm than their peers located in the peripheral part of the network supplementary analyses were performed to capture closely the structural importance of physicians in the professional network through the use of network centrality indicators our findings again provided evidence for a negative association between ebm adoption and the network prominence of individual clinicians although the homophily of physicians in terms of ebm adoption has been documented elsewhere 23 in this study we show that higher ebm adoption can cause the isolation of such groups of professionals within organizations there is the potential risk that professionals having this kind of behavior can be viewed as elitists who may behave in contrast with the practices routinely adopted within hospitals as prior studies have shown 28 innovators within healthcare organizations often face hard times in changing the way consolidated practices are used daily in particular those who are located in the center of the network are less exposed to novelty and innovative behavior since their higher interconnectedness with homophilous pairs likely increases the risk to be influenced from colleagues 3 our findings are also consistent with extant research demonstrating that the acquisition of new knowledge by physicians often occurs more likely through personal relations than through explicit guidelines and clinical protocols 2 gabbay and le may 29 have shown that physicians often use mindlines instead of guidelines because of their tendency to discuss clinical matters with colleagues instead of relying on documentation such as articles metaanalysis and cochrane library in addition the superior propensity towards ebm of clinicians forming the periphery might reduce their risk of becoming overembedded our findings have a number of implications first hospital executives are encouraged to identify groups of professionals that exhibit potentially virtuous attitudes and behaviors within their organizations social network analysis tools and techniques appear useful in this vein they are in addition encouraged to foster collaboration across groups characterized by different propensities to use ebm in daily practices the adoption of new organizational arrangements processes and informal occasions of meeting would all be useful means to achieve this objective for example increasing collaboration might be achieved through the internal restructuring of hospital organizations the adoption of specific types of clinical directorates or interdisciplinary and interprofessional groups is an example in this direction 1530 new internal processes have to do with both organizational and professional streams of activities organizational processes for example concern the definition of objectives such us budget quality standards and appropriateness which may be targeted by administrators in order to encourage collaboration across heterogeneous groups finally executives have the possibility to support the inclusion of medical leaders within organizations so that their role might be leveraged to persuade other professionals to collaborate more with ebm users 8 policy implications are also strong health systems around the world are urged to ensure coordination and integration amongst providers by fostering the collaboration of healthcare professionals belonging to different organizations policymakers may want to encourage healthcare administrators to implement the above mentioned actions in addition in this context interorganizational cooperation may be better achieved by identifying ebm users in organizations and then leveraging the higher tendency to cooperate by the virtue of their homophily 23 these initiatives might be for instance headed to foster a better continuity of care across organizations through the formation of interorganizational groups or the definition of innovative clinical pathways our findings should be interpreted in light of several limitations first the degree of ebm adoption was selfreported in the present study although this is not an objective approach to studying physicians orientation to ebm our approach seems to be consistent with extant research on this topic 25 the type of study design poses another limitation given that all data were gathered at the same time we cannot ascertain whether the collaboration of physicians with colleagues is an antecedent or consequence of ebm adoption even though the crosssectional design adopted in this research prohibits us to determine causality it provides however that a causal link exists between ebm utilization and social collaborative relationships we encourage future longitudinal studies to disentangle the effect of physicians attitudes towards ebm and their propensity to establish collaborative ties in healthcare organizations conclusions our study documents that the overall network structure is made up of a dense cohesive core of physicians and a periphery made up of less connected clinicians the social structure of this model underlies a group tightly connected physicians who interact strongly in order to exchange relevant knowledge and a large number of less cohesive clinicians who are more likely to be connected amongst themselves than to members of the core part of the network this result might be interpreted as a marginalization of physicians who are more prone to use ebm in their clinical practice this social structure may result in a fragmented organization in which different habits and characteristics of groups of physicians likely increase the risk of conflicts and barriers for integration within hospital boundaries 3132 social network analysis tools and techniques should be increasingly adopted by policymakers and administrators in order to support integration and coordination of clinical activities in complex social systems such as healthcare organizations competing interests the authors declare that they have no competing interests in the present study

background extant research suggests that there is a strong social component to evidencebased medicine ebm adoption since professional networks amongst physicians are strongly associated with their attitudes towards ebm despite this evidence it is still unknown whether individual attitudes to use scientific evidence in clinical decisionmaking influence the position that physicians hold in their professional network this paper explores how physicians attitudes towards ebm is related to the network position they occupy within healthcare organizations methods data pertain to a sample of italian physicians whose professional network relationships demographics and workprofile characteristics were collected a social network analysis was performed to capture the structural importance of physicians in the collaboration network by the means of a coreperiphery analysis and the computation of network centrality indicators then regression analysis was used to test the association between the network position of individual clinicians and their attitudes towards ebm results findings documented that the overall network structure is made up of a dense cohesive core of physicians and of less connected clinicians who occupy the periphery a negative association between the physicians attitudes towards ebm and the coreness they exhibited in the professional network was also found network centrality indicators confirmed these results documenting a negative association between physicians propensity to use ebm and their structural importance in the professional network conclusions attitudes that physicians show towards ebm are related to the part core or periphery of the professional networks to which they belong as well as to their structural importance by identifying virtuous attitudes and behaviors of professionals within their organizations policymakers and executives may avoid marginalization and stimulate integration and continuity of care both within and across the boundaries of healthcare providers

introduction faced with the fact of religious pluralism states options have ranged from persecution or rejection to acceptance and protection to disinterest something similar happens with the definition of secularism a negative concept for those who interpret it as a rejection of the religion in the public domain a positive one for those who understand it as a space for the development of more humane societies in any case even those who understand it positively have not reached an agreement as to which are the most appropriate ways of putting it into practice in this work starting from a positive conception of secularism in its political meaning as a sphere of possibility for peaceful and fruitful coexistence between different options we have focused on one of these need to put into practice affairs the management of death more specifically burials according to the islamic practices in presentday spain spanish society has undergone a profound process of secularization in recent decades particularly after the restoration of democracy in 1978 it has experienced a strong change in its religious beliefs according to a wingallup international survey spain is one of the european countries after sweden and the czech republic with the highest percentage of adults who declare themselves atheist or nonreligious on the other hand a macrosurvey carried out in 2021 by the statista global consumer survey maintains that 59 of those surveyed in spain state that they adhere to a creed a value identical to that registered in other european countries such as austria switzerland germany and denmark recent surveys conducted by the centro de investigaciones sociológicas show that approximately 40 of spaniards declare themselves agnostic atheist or nonbelievers the constitución española guarantees the ideological religious and worship freedom of individuals and communities declares the nonconfessional nature of the state and sets that the state should promote relations of cooperation with the catholic church and other confessions in order to develop the constitution the state has established cooperation agreements with religious denominations considered as notoriously rooted in the spanish society islam judaism and evangelical christianity these agreements contain references to worship centres schools and cemeteries among others even so from time to time and mainly among muslims issues relating specifically to cemeteries appear in the news whether they be reporting positively or complaining about the situation of muslim burials however a review of the jurisprudence of the high courts of the autonomous communities does not reflect any problems in this regard death is an inevitable fact to be faced not only by individuals but by societies no society secular or whatever can escape from it and in fact funerary rites and practices have more to do with social contexts than with the deceased themself the consideration of on the one hand the importance of these funerary rites and practices for any society and on the other the apparent contradiction among information about muslim burials in spain has led us to the questions that guides this article how is the cooperation agreement between the state and the muslim communities being fulfilled in practice in addition what difficulties are encountered and what answers are given by both sides the issues related to funerary practices are multifaceted with emotional social political economic and ecological components that in each case may be more or less relevant however as we cannot cover them all we have focused here on the anthropological and normative aspects regarding the methodology followed in this article it is important to clarify that we have used secondary sources among the analysed documents there is sociological and historical research and reports about muslims in spain funerary enterprises reports muslim communities reports and burial laws both from the state and from the autonomous communities this article first presents a brief theoretical framework on the concept of secularism and associated with it the concept of spatial justice added to those is an anthropological approach to the social and personal value of funerary practices a second part presents an overview of muslims in spain this is followed by a description of current muslim funerary practices with a brief look at their history after reviewing the spanish regulations on cemeteries and burials this article ends with some discussions and conclusions secularism and funerary practices secularism as berlinerblau points out there is no clear agreement on what is meant by the term secularism among the multiple definitions in this article we stand with those who interpret it as a system for articulating religious plurality in a neutral state that guarantees freedom of worship to its citizens speaking in the same positive sense habermas for whom secular entails a reasonable response to the need for peaceful coexistence in plural societies and which in his opinion has allowed religious minorities to move from mere tolerance to the recognition of rights similarly the aforementioned berlinerblau points out the following as a basic definition political secularism refers to legally binding actions of the secular state that seek to regulate the relationship between itself and religious citizens and between religious citizens themselves in his work life world politics and religion habermas devotes the last chapter to religion in the public sphere of postsecular society in it he stresses that immigration provokes in the receiving societies the challenge of a pluralism of ways of life which goes beyond the challenge of a pluralism of faith currents in other words the problems of coexistence between people of different religions are exacerbated by being associated with problems for the social integration of people with different cultures in the context of this discussion habermas poses the following question how should we understand ourselves as members of a postsecular society and what should we expect from each other in order to ensure in our states a civil treatment of citizens towards each other even under the conditions of cultural and ideological pluralism habermas proposal has two aspects on the one hand he proposes a process of reflection and permanent democratic learning in which citizens from different positions translate justify and debate their proposals on the other hand he stresses that the success of these processes depends on the acceptance of common values and that no one position should claim to be the sole guide to the world of life applied to religions this means that no religion can claim to determine all aspects of peoples lives and of society without going into definitions charles taylor describes the secular social environment as consisting of among other things in the move from a society in which faith in god was unquestioned and indeed far from problematic to a society in which such faith is regarded as one option among others and often not the easiest to adopt p 22 in other words religious belief becomes just another belief which leads to the question of whether or not now that religion is no longer the only social force able to challenge the state should not religion then be allowed to follow the same rules as other members of civil society when they participate in the public sphere the question obviously deserves a moments pause because the question of plurality and how to respond to it is not something to be taken lightly indeed some authors have pointed out some problems that can arise from the uncritical assumption of the goodness of plurality in his short article five confusions about the moral relevance of cultural diversity ernesto garzón valdes after justifying why he considers it a mistake to confuse tolerance with moral relativism and cultural diversity with moral enrichment argues for the practice of an active tolerance that has no qualms about rejecting the intolerable he insists on the importance of democracy in respecting what he calls the preserve of primary rights that escape any majority decision he adds that the justification of the limits of tolerance must be debated and argued with universalisable reasons excluding when designing social institutions the appeal to nontransferable personal convictions such as those invoked by religious or ethnic fundamentalists plurality only has value if it is able to respect the rights of all people and guarantee them the possibility of satisfying their basic needs in the same critical vein giacomo marramao notes that western democratic societies today are confronted with the claim to citizenship of culturally differentiated individuals or groups who while instrumentally demanding recognition of their rights refuse to grant universal legitimacy to democratic formalism in order to give an adequate response to this question marramao highlights three points first that the ethnocentric component of western universalism which has fuelled the politics of difference that challenge democratic values must be assumed secondly he understands that we must overcome the axiom of the incommensurability of cultures include the moment of symbolic interaction between cultural contexts and thirdly defend the value of democracy as a common place of uprootedness if the definitions and positions on secularity are many the way in which these definitions are put into practice is no less so berlinerblau considers several basic models of secularity or as he prefers to call it political secularism the three main models that berlinerblau mentions are the separationist framework the laïcité and the accommodationist framework against this doctrinal backdrop bhargava proposes shifting the focus from doctrines to the normative practices of states once we do this we will begin to see secularism differently as a critical perspective not against religion but against religious homogenization and institutionalized religious domination analysis of secular practices in different states reveals on the one hand that there are multiple models of secularism in democratic and nondemocratic states as well as in some countries with large muslim populations such as india senegal and indonesia and on the other hand it highlights the importance of setting limits on what can be accepted for example the state must be sensitive to the moral integrity of religions liberal and illiberal but it cannot tolerate any of the four forms of oppression interreligious intrareligious domination of religious by secular and domination of secular by religious and neither should religions the state must also accept that human beings feel connected to transcendent entities including god and that this must be visible in individual beliefs as well as in social practices but a secular state has its own secular ends bader further suggests that the concept of secularism should be dropped from our constitutional language as it is not only a complex polysemic and contested concept but also a fuzzy chamaleonic and highly misleading concept moreover and more importantly this author suggests that the principle of constitutional secularism hides from view the tensions among secularism liberal constitutionalism and democracy what really matters is not if the state is secular or not but whether it is decent andor liberaldemocratic to conclude in this article and very close to berlinerblaus general definition even if we are not discussing here any of the definitions we assume a positive conception of secularism understood as a set of rules that establish a playing field in which citizens of different beliefs religious or not can coexist and develop peacefully and in solidarity likewise we assume that this playing field must be established taking into account that the human being is not only an emotional rational or economic being but also a being that inhabits and interacts in spaces in relation to this aspect we present the following epigraph spatial justice in recent decades a concept related to space and urban design has become increasingly important spatial justice this concept can be understood from henry lefebvres theory of spaces and edward w sojas spatial justice proposal the starting point of these authors is that space is not a mere external environment or container a neutral scenario but a social product the fruit of certain historical and present relations of production that are materialised in a certain spatioterritorial form from this perspective human life is temporal social and spatial simultaneously and interactively and is therefore always engaged in a sociospatial dialectic soja reformulates lefevres approach by incorporating the concept of spatial justice this concept posits how space is involved in generating and sustaining different processes of inequality injustice exploitation racism sexism and so on the spaces that are shared reflect the type of society that is being created soja classifies the spaces of injustice into exogenous and endogenous geographies the former is produced by impositions of hierarchical power this would be the case for example with apartheid the second derive from decisions related to the location of services infrastructure projects and their consequences on spatial distribution evidenced in for example the inequitable distribution of basic urban services such as public transport clinics and schools pp 3166 spatial thinking thus links the quest for spatial justice with the pressures and struggle over what lefebvre called the right to the city however these authors do not mention cemeteries in any case the right to the city was first defined in 2005 by the world charter for the right to the city as the equitable use of cities within the principles of sustainability democracy equity and social justice its first article assesses that all persons have the right to the city free of discrimination based on gender age health status income nationality ethnicity migratory condition or political religious or sexual orientation the european union is also increasingly concerned about making this concept a reality based on the criteria of spatiality integration and inclusion in order to contribute to better territorial cohesion from this perspective spatial justice can also be circumscribed to the spaces designed by the living for the dead cemeteries cemeteries should also be inclusive places that reflect the same inclusiveness sought and projected for the spaces of the living in a city designed under the concept of spatial justice cemeteries should also be places where any citizen can feel that his or her mortal remains have been duly received without any discrimination in the following section we develop some ideas that in our opinion justify a secular state paying attention to the funerary practices performed by any of its citizens funerary practices the wide variety of mortuary customs and rituals collected by the extensive ethnographic literature shows the importance of death for all human beings beyond the bodys disposal the meaning of these rites can be varied transcendencesurvival regeneration of life and reaffirmation of the social order as well as the relationship between generations and legitimation of authority or a prolonged dialogue about the notion of personhood robert kastenbaum defined the death system as the interpersonal sociocultural and symbolic network through which an individuals relationship to mortality is mediated by his or her society in preindustrial societies death had a clearly social communal dimension the death of a member of the community disrupted social organisation and highlighted the risks to the survival of the community requiring a response that reorganised society and averted the danger such behaviour was widespread well into the 19th century and even into the early decades of the 20th century however modern instrumentality has deconstructed mortality stripping death of meaning and seeing it as a useless leftover of life and as the other of modern life philippe ariès called inverted death or forbidden death the characteristic model of 20th century western societies death once so present is going to fade away and disappear the progressive process of individualisation together with the medicalisation of death consolidated the social indifference to the loss of one of the members of the group and the perception that death was more a personal than a social problem medical technology became the new instrument for domesticating mortality replacing religion in this function today a large part of the population is dying in hospitals it is not usually the preferred place to die however when the dying patient has not expressed their will about where to die families generally send him to the hospital for the greater security that it offers them many times the corpse is quickly sent to a mortuary where those who want to say goodbye look at it through a glass window before it is buried or cremated the collective support provided by traditional ritual is lost and the living are left without references for gestures to relieve their grief and symbolically facilitate the deceased taking their place among the dead the recent situation of the covid19 pandemic has shown how hard it has been for many families not being able to say goodbye to their loved ones or having been able to celebrate the usual funeral rituals although funeral rites are transformed into a public celebration of a private experience adapted to the individual characteristics of the deceased or those who remember them they are far from disappearing new technologies can also influence funeral rituals and the way people deal with death thus for example more and more terminally ill people are sharing their experiences and personal process in blogs in largely secularised societies where personal belief is autonomous from denominational orthodoxy funerary practices may be distanced from religious customs even among those who claim to belong to a religion thus spain a country which until a few decades ago had a strong catholic tradition is the country in the european union that cremates its dead the most whereas the catholic church only allowed cremation from 1963 and from 1997 a funeral liturgy in the presence of cremated remains which have to be buried in fact in 2005 the average number of cremations in spain was 16 reaching 41 in 2018 and it is estimated that it will reach 60 in 2026 in short the multiplicity of funeral rites existing in todays societies whether associated with a religion or not traditional or innovative reflects the variety of communities that make them up as well as the multiplicity of meanings that people give to their lives all societies including the most secularised ones must manage the treatment of these plural practices and sensibilities surrounding death sociological data on the reality of muslims in spain spain currently displays great religious diversity as we do not have precise data because each confession estimates the number of its faithful with different criteria we must consider the following data as approximate the spanish episcopal conference estimates that there are 326 million catholics the federation of evangelical religious entities of spain considers that there are 17 million evangelical christians 900000 of whom are migrants the union of islamic communities of spain puts the number of muslims at 23 million and the federation of jewish communities of spain groups together 40000 jews with each of these accounts the spanish state has established cooperation agreements in compliance with article 163 of the constitution in this context and given that this paper focuses on islam this section presents some data on the social situation of muslims in spain beyond being a homogeneous reality the plurality of spanish muslims is manifested in relation to their origins their language and the way they live their faith on the other hand there are spaniards of spanish origin who for various reasons profess the muslim religion it is not easy to know the exact numbers of muslims in spain as the question of religion does not appear in most official surveys the reports of the centro de investigaciones sociológicas only ask whether the person is catholic or of another denominationwithout specifying which oneagnostic or atheist and the population and housing census in its last wave will not have data until 2023 the last one being from 2011 we can add the reports by metroscopia which in its fifth wave collects data from the 2011 census and those prepared by the union of islamic communities of spain on muslim citizens in spain these as of 31 december 2021 are based on data from the general state administration and ucides own registers and include as muslims the descendants up to the third generation of those who came to spain in the 1950s the two studies are hardly comparable metroscopias survey has muslim immigrants as its study universe and is an opinion survey ucides survey is based on official data about all muslims the results are logically diverse and are summarised below the metroscopia report among the results of the study three fundamental aspects stand out religiosity the desire to integrate and the positive evaluation of spanish society regarding religiosity 53 of respondents declared themselves to be practising muslims and 12 nonpractising muslims however religion ranks fourth in importance in their lives behind family and money the authors underline that they favour a secular state that does not give special treatment to any religion and their adherence to islam seems more identitarian than a defence of religious orthodoxy talking about integration 67 feel at ease in spain most speak spanish well and say they do not encounter any obstacles to the development of their religious beliefs among those who mention an obstacle most point to the shortage of mosques there is no mention of cemeteries finally they value spanish society and institutions and the treatment they generally receive from them they value equal treatment in health care equality between men and women the general standard of living and consider that muslims and christians make an effort to understand and respect each other in general they perceive little negative social reaction to the muslim religion despite the good results the authors question to what extent the data reflect reality or are mediated by what they call the influence of social desirability ie what immigrants think they are expected to answer the report of the union of islamic communities of spain produced in 2021 and much shorter this report does not collect opinions but rather data from the records of the general state administration and the union of islamic communities of spain itself the collected data refer to the muslim population in spain both immigrant and native according to different variables such as place of origin and nationality muslim population in the different autonomous communities and within them as well as by provinces as mentioned above it considers all descendants up to the third generation of those who came to spain in the 1950s to be muslims the report begins by noting that maleki and hanafi rites are the most widespread in spain for the practice of islamic worship it also gives data on the number of islamic entities in spain 52 islamic confessional federations 1819 religious communities and 21 confessional associations these figures show the internal diversity of the group although the islamic community of spain the legal entity in charge of monitoring the cooperation agreement with the spanish state does not include all of them on the question of cemeteries the two reports diverge in the metroscopia report muslims interviewed did not report any perceived lack of cemeteries while ucides report indicates that 95 per cent of communities do not have a cemetery or almacbara it is not clear which entities are meant by islamic communities whether it is each of the entities registered in the register of religious entities or those at the municipal level this distinction is important because in a municipality there may be several registered entities whereas public cemeteries exist at a municipal or supramunicipal level in short the reality of muslims in spain is more complex and plural than might be expected from the fact that the state recognises that a single entity the islamic commission of spain has the legitimacy to represent the interests of all muslims burials in islam basic funerary practices and legal considerations basic funerary beliefs and practices it is important to know what the basic funeral practices of muslims are some of them according to circumstances could somehow affect the mortuary policy of western countries in our case spain a brief review of history shows that these practices were not always the same and varied according to circumstances and cultures this suggests that as with mortuary practices in western countries muslim funeral practices may also undergo changes the quran is not very explicit about how muslim funerals should be conducted but it gives indications of the custom of burial in direct contact with the earth further information is provided by the sunna the body of muhammads sayings and deeds and his way of proceeding as attested by the ashab his contemporaries and companions from the quran and the sunna emerge a series of funerary guidelines for the muslim world which are summarised below it is essential that the body is washed and buried as quickly as possible preferably on the day of death but no earlier than eight hours and no later than twentyfour hours the corpse must be respected because it is to be returned on the day of resurrection so embalming and autopsy are not recommended unless strictly necessary and cremation is prohibited the corpse will be washed by men if it is a male and by women if it is a female it is then wrapped from head to foot in white linen in three pieces if male and five pieces if female the corpse will be placed on a flat board in a slightly foreshortened position with the eyes facing mecca the arms outstretched at the sides of the body and the feet pointing south the characteristics of muslim cemeteries are austerity and uniformity the deceased are buried in absolute anonymity the acquired social status disappears in order to emphasise the religious sense of the eschatological afterlife consistently the style of tomb construction is characterised by simplicity and economy of cost the deceased should be buried in the locality in which they liveddied the burial consists of a hole in the ground that completely conceals the corpse all muslims rich or poor are buried following the same procedure it is not permitted to bury the deceased in the coffin unless there is a requirement that must be met in a particular area or country shared graves are only permitted in times of war or epidemic if there are multiple graves the muslim graves must be separate from those of nonmuslims however historical documents and some current studies show that burial customs and forms of burial while maintaining the position facing mecca and with the body in the ground have varied over time as well as according to social groups and territories in the case of spain historical texts especially those of al tafri and yça de segovia reflect customs that differ from those of today it states that there is no established rule and that whoever knows best should bathe the dead that the man should bathe his wife and the woman her husband and young boys on the other hand the excavations of the islamic cemeteries in toledo and other cities of the islamic period in the iberian peninsula show that overpopulation forced communities to bury several persons together in a single tomb they show the reuse of some tombs even of the muslim rite by simply covering the ground again with earth to fulfil the precept of resting on the ground the position of the body which was originally in strict lateral decubitus also changed the tombs of the wealthiest became more conspicuous and the practice of customs originally rejected by jurists such as visits to the cemetery and mourners at funerals has been recorded even today depending on the local practices of the various countries where islam has become firmly established differences can still be found thus for example for mourning in north africa women will wear white in the middle east they wear black and in turkey they will choose subdued colours generally speaking a large proportion of middleaged muslims living in europe maintain traditional funeral practices and beliefs about the afterlife pp 5859 even so today there is a growing individualisation in the religiosity of muslim communities this development entails redefining rituals that become more an identity question than a strictly religious one and act as active negotiation mechanisms with respect to european societies as in the spanish case analysed here on the other hand as we will see below the muslim legal tradition offers examples of flexibility and adaptability to new circumstances with regard to funerary needs legal considerations the muslim principle of maslahah mursalah the term maslahah designates in islam that which is in the public interest or welfare strictly speaking maslahah means utility but in general terms maslahah denotes cause or source of something good or beneficial p 194 maslahah is the interest or benefit for which there is neither legitimate supporting evidence in the islamic sacred sources nor a claim to the contrary jurists use this concept to mean general good or public interest it is the principle by which allah is moved by considerations of utility and universal good to put the principle of maslahah mursalah into practice three conditions are required it must be a real interest to benefit people or prevent them from harm it is in the public interest of the nation as a whole or the majority not to serve personal interests or the interests of a particular group provisions based on the general interest are not expressly regulated by the quran the sunna or the consensus of the scholars in any case the maqasid shariah or principles of shariah must be respected religion life intellect lineage and property malik ibn anas is credited with being the first jurist to make decisions on this principle in spain it appears in the mentioned medieval author yçar de segovia some quranic principles capture the essence of the concept of maslahah such as those that point out that allahs message to muhammad is not intended to be a burden but to offer divine mercy to all humankind regardless of any barriers only the shafii school does not admit legal opinions based on maslahah because it holds that there can be no maslahah outside the sharia in present days this concept has become the subject of increasing interest among those jurists who have sought legal reforms to meet the needs of modern conditions in islamic society since in any case maslahah implies respecting the five principles of the sharia it might seem that there is an incompatibility between this principle and the secularised democracies of the west however these democracies from a secular and nondenominational perspective respect the same values such as the ones mentioned previously religion life intellect lineage and property this means that between contemporary muslim culture and western culture there can be found a certain degree of reasonableness in order to promote the common good this degree of reasonableness or compatibility can also be seen as shown below in relation to the question of cemeteries funeral legislation the spanish legal framework the approval of the current spanish constitution in 1978 gave birth to a dramatic change in the organization of the spanish state with freedom justice safety equality solidarity and pluralism as prime principles the constitution in its part viii referred to as the territorial organisation of the state in its chapter one settled that the state is organised territorially into municipalities provinces and autonomous communities that may be constituted all these bodies shall enjoy selfgovernment for the management or their respective interest chapter three of the same part viii assesses that in the exercise of the right to selfgovernment recognised in article 2 of the constitution bordering provinces with common historic cultural and economic characteristics island territories and provinces with historic regional status may accede to selfgovernment and form autonomous communities in accord with the provisions contained in this title and in the respective statutes articles 148 and 149 respectively fix the competences that may assume the autonomous communities and those that will hold the state exclusively as a result spain is presently territorially decentralised and formed by 17 autonomous communities each one with its statute its government and its parliament with legislative power there are also two autonomous cities where the majority of the population is muslim equally the spanish constitution of 1978 guarantees the ideological religious and worship freedom of individuals and communities declares the nonconfessional nature of the state and establishes relations of cooperation with the catholic church and other confessions the state has established cooperation agreements with some religious denominations law 261992 of 10 november approving the state cooperation agreement with the islamic commission of spain establishes that islamic communities belonging to the islamic commission of spain are recognised as having the right to the concession of plots reserved for islamic burials in municipal cemeteries as well as the right to own islamic cemeteries currently the autonomous communities are the bodies that have competence in matters related to the implementation of agreements with religious denominations within each autonomous community it is the local councils that have competence in the area of cemeteries this means that they are being obliged to guarantee that burials in their cemeteries are carried out without discrimination of religion or any other grounds of 3 november article 2b of the organic law on religious freedom this is why the territorial associations and federations islamic in this case choose to establish agreements within the autonomous community or the municipality in which they reside however the organic law on religious freedom of 1980 imposes some limits such as the protection of the rights of others in the exercise of their public freedoms and fundamental rights or the safeguarding of security and health the application of the regulation may present some difficulties these are mainly confined to three areas that of health that of availability of space in cemeteries and that of the spatial arrangement within cemeteries given that the muslim tradition advocates the separation of muslim plots from nonmuslim plots health national and regional legislation establishes that burial in a coffin is compulsory which is contrary to the traditional muslim prescription of burial in contact with the ground only in the autonomous cities of ceuta and melilla where the majority of the population is muslim did the regulations allow burial directly in the ground without a coffin lately this has been changing andalusia updated its regulation on mortuary health police in 2001 to accommodate religious specificities requiring the coffin to carry the corpse but exempting it in the burial as long as it concerns persons whose cause of death does not represent a health risk shortly before the advent of the covid19 pandemic valencia castilla y león and galicia joined this list of communities that allow coffinless burial in any case even before the pandemic muslims had already adapted to the regulations prohibiting burial without a coffin by placing soil inside the coffin to allow the corpse to be in contact with the earth this was seen as a formula of rapprochement of positions this formula became mandatory because of the covid19 pandemic which forced a drastic change in funeral practices worldwide affecting all religions which made a great effort to adapt the technical document procedure for the management of dead bodies of covid19 cases published by the spanish ministry of health on 26 may 2020 stated that any burial of a person who died from covid19 should be in a coffin in fact the president of the islamic commission of spain himself riay tatary and his wife who died of covid19 in april 2020 were buried in coffins availability according to the observatorio andalusí and union of islamic communities of spain the muslim population in spain is with all reservation around 2250000 for that population there are according to a report by the islamic commission of spain two private muslim cemeteries and thirtyfive plots for muslims in municipal cemeteries some of which have already reached their maximum capacity on the other hand the differences between autonomous communities are notable while some still lack plots for muslim burials others are increasing the number of burials most cemeteries require the person to be registered as a local dweller in order to access their services this makes it difficult to find alternatives for those who do not have space in their place of registrations cemetery the lack of burial space affects people of all faiths and is one of the biggest challenges facing spanish cemeteries today on the other hand the general tendency of all spanish autonomous administrations is not to create private confessional cemeteries with public funds in these circumstances repatriation of the body is still very common among spanish muslims although those who were born in spain generally choose to be buried in spain repatriation is also very common in other european countries for example in the netherlands the repatriation rate is approximately 90 for france the rate is 80 and for norway 4050 the reasons for repatriation are varied including funeral legislation financial constraints lack of knowledge of existing possibilities and a sense of belonging to the family and country of origin since the 1990s spanish muslim communities have devoted more effort to ensuring the repatriation of their deceased than to obtaining reserved plots after the covid19 pandemic this situation has been reversed forcing municipalities to seek urgent alternatives for the dignified burial of their muslim fellow citizens therefore the lack of burial sites is the biggest complaint voiced by muslim communities in any case in relation to the availability of space for muslim burials the situation in spain is similar to that in other european countries despite this the way in which each country deals with the issue is different depending on the agreements with the respective muslim communities in this regard the application of the abovementioned legal principle of maslahah mursalah has proven to be somewhat effective in a densely populated muslim country such as malaysia multilevel construction was permitted in 2015 through a fatwa particularly in the federal territory of kuala lumpur a fatwa was issued in 2018 recommending in both rural villages and densely populated cities the implementation of multilevel burials to maximise the use of cemeteries with the condition of preserving the sanctity and honour of the dead this example in a muslim country reinforces the idea that in countries where muslim communities are a minority the principle of maslahah mursalah could be used to solve similar problems in this sense although it is not specified that it be by application of the maslahah mursalah in some cemeteries in spain such as those in valencia and mallorca it has been decided to build muslim burials in the ground downwards one on top of the other this shows that muslim communities have made efforts to adapt to the new circumstances created by spatial problems or health problems which have forced them to modify some of their burial practices to some extent in these adaptation efforts concern for the common good beyond the religious beliefs of individuals has been fundamental spatial arrangement applying edward w sojas concept of spatial justice to funerary spaces one might wonder whether it would not also be possible to design in the near future an inclusive type of cemetery which would not show great social differences or differences based on economic ideological or religious motives one might ask to what extent the parcelling of funerary spaces helps inclusivity or underlines exclusivity in a society that upholds the principle of equality from this perspective if a society with multicultural ghettos is clearly not inclusive compared to one whose spaces are not separated but shared by members of the whole society it is logical to think that something similar might not happen with the spaces shared by the deceased or rather by the living dedicated to the deceased cemeteries that are much partialised and clearly differentiated can generate the sensation of separation between the faithful and the unfaithful ours and the others however the realisation of spatial justice can take various forms and the fact of separating plots in a cemetery on religious grounds can also be seen as an example of respect for diversity and as an attempt to integrate those firstgeneration muslims older people from muslim countries who generally opt for repatriation of corpses equally it can be seen as a way of integrating those who were forced to migrate for political reasons and asylum claims and who cannot return in any case it seems prudent to avoid severe segregation so to establish distinctions between muslim plots and the rest of the groupings the use of ornamental and vegetal elements is recommended moreover parcelling may in the medium term become meaningless if as may happen secondand thirdgeneration muslims adopt and assimilate majority practices all of this is not incompatible with those proposals that posit the desirability of certain key principles for all cemetery systems dignified disposition of the body of the deceased democratic accountability equal access to funeral services regardless of income freedom of religious expression and environmental sustainability in any case the three aspects presented although susceptible of being debated and dealt with from different angles do not seem to pose serious problems of coexistence among citizens of different creeds discussion at the beginning of this article we asked ourselves about the positive and problematic aspects of the spanish model of secularism we discuss here some issues related to this question questions that the very development of this article has raised in its authors and which remain open for future debates and work first spains experience seems to prove marramao right when he rejects the axiom of the incommensurability of cultures and proposes to highlight the meeting points between different positions however although it seems to have achieved a peaceful and respectful integration of religious plurality the model of the spanish state in its relationship with religious denominations is not easy to classify within the models pointed out by berlinerblau stepan and bhargava the spanish state itself departing from the spanish constitution and the agreements established with various confessions including muslims defines this relationship as one of cooperation perhaps it can therefore be framed within what could be called a cooperation model the very term cooperation at least in the spanish language seems more constructive and positive than accommodation to cooperate implies to work together with another or others to achieve a common goal while accommodate implies to harmonise to adjust to a norm to conform this nuance has also been pointed out in some studies critical of the goodness of the model and the widespread use of the term accommodation second the organisation of the spanish state combines hierarchical aspects with territorial decentralisation the states relationship with islamic communities thus brings into contact a complex hierarchical organisation with a multiplicity of communities that are not only not hierarchically organised but also often not even related the state establishes an agreement with a single interlocutor which may make it difficult to reflect all the sensitivities of such a plural and heterogeneous group moreover it is an agreement that is not the responsibility of the state administration to implement since competences in this area correspond to the autonomous communities and municipalities this fact can make it difficult to implement agreements in the same way throughout the country paradoxically however this organisation brings local religious communities closer to the decisionmaking centres enabling a more fluid dialogue between communities and the administration given that there are different forms of state organisation to what extent are the ways of relating to the different confessions conditioned by the centralisation or decentralisation of the state ie its territorial organisation although it seems to work in spain is decentralisation always accompanied by an improvement in statereligious community relations third spain has opted for a model of dialogue with the different religious denominations this option for dialogue and cooperation has been accompanied by a positive attitude on the part of the different religions in our case muslim communities have shown their willingness to adapt to new circumstances that have affected their burial practices this adaptation has been consistent with the legal tradition of the principle of muslaha mursalah which for the sake of the common good makes it possible to deal with new situations not contemplated in the foundational texts of islam this reinforces the conviction that there can be common ground between secular values and religious beliefs simultaneously it makes us rethink some of the criticism habermas has regarding his proposal of translation of religious questions onto secular language be the translation language secular human rights or liberaldemocracies principles could it be possible to communicate among those that are different in the absence of a minimal common language in the language of garzón valdés and marramao would communication be possible without an untouchable common place of the rootless fourth in spite of the above one of the aspects that we consider potentially problematic is the fact that the only subject of the right to burial according to the muslim rite are the islamic communities integrated in the islamic commission of spain this could pose problems for muslims belonging to a community that is not part of the commission although it is not publicly stated it would not be unreasonable to think that the internal plurality existing within muslim groups could generate some conflicts and not only within communities but even concerning individuals who might wish to break with their religious tradition or simply change their burial practices without renouncing their faith the need to respect the principles values and objectives of a secular society leads us to point out that any muslim should be able to choose the way he or she wishes to be treated when dying fifth the agreements established by the spanish state which are not established in other european countries in the region despite providing guarantees may raise doubts or objections as to the possibility of their generalisation and therefore their sustainability in that sense for example should agreements be made with all religious denominations or only with the most representative or established ones should the agreements be equal or is it better not to make any agreements at all on the other hand and continuing in the field of limits can the right that is recognised for a religious community be extended to an individual who is not part of it for example if muslims are allowed to be buried without a coffin should any citizen not have the same right regardless of their beliefs sixth in addressing the diversity of funerary rituals that affect the management of shared public spaces this article has underlined the importance of what authors such as lefebvre and soja have called spatial justice given the emotional and identity value that funeral rites have for the living we understand that this concept is also important when rethinking the public space designed for the dead if the shared space of the living must be fair and inclusive should the shared space of the dead not be fair and inclusive as well conclusions as a first and general conclusion it seems that there is not any major incompatibility between the muslim funerary practices and the spanish law neither between those practices or the spanish society on the contrary despite the difficulties in its implementation due to the heterogeneity of the muslim communities the spanish model to manage the religious phenomenon which calls itself cooperation shows that aside from the law the attitude of the participating groups matters it also shows that practiced as dialogue secularism there can be an opportunity for the integration of religious diversity not a system of confrontation between the state and cultural or religious groups regarding the funerary rites the implementation of the spanish states agreement with muslim communities has encountered difficulties of various kinds mainly those related to health and available space however none of these has led to serious problems of social coexistence part of these difficulties can be understood in the context of a wider issue of burial space which is widespread throughout the country and for all persons and denominations muslim communities have shown a capacity to adapt to these difficulties moreover from its historical legal tradition we highlight the principle of muslaha mursalah which has allowed muslim communities throughout history to adapt to new situations not specifically envisaged in the quran or the sunna while respecting the fundamental principles of islam this legislative adaptability in pursuit of the common good has also been effective in its treatment of certain funerary practices this shows that when the secular framework of the state is open neutrally positive and religious communities show adaptability in pursuit of the common good integration and coexistence are possible data availability statement not applicable

death is not only a universal biological fact for the individual it is the event horizon this fact has important symbolic meanings and complex social consequences any society secular or not must manage this reality what response is given to the question of religious phenomenon in general and to funerary practices in particular in a secular society in which individuals with different religious sensibilities coexist this article aims to analyse the response given by the spanish state to the questions raised regarding burials by muslim communities the most widespread minority group in spain as a whole this response which would be framed within what could be called a cooperation model has encountered some difficulties as a result of the territorial organisation of the spanish state despite this the willingness to cooperate on the part of both the administrations that make up the state and the islamic communities has made a situation of stable coexistence possible

themselves moving back home in the us alone 22 million adults between the ages of 18 and 25 moved back in with either a parent or grandparent through march and april 4 the effects of this major disruption to the spring semester were reflected in many social media posts online forums and news outlets one especially telling article featured in the new york times titled im in high school again virus sends college students home to parents and their rules documented the challenge of adjusting not only to online classes but also to the unexpected and abrupt transition to living back home 5 due to the pandemic the conclusion of the spring 2020 semester was in stark contrast to previous years during a traditional academic year the conclusion of the spring semester is associated with enhanced positive mood states 6 as well as a significant increase in alcohol consumption 7 this is consistent with research demonstrating increased alcohol consumption by college students during positive mood states and periods of celebration 89 however because of the pandemic what happens when the party moves home the effect of the covid19 pandemic on us college student alcohol consumption as a function of legal drinking status using longitudinal data many end of semester celebratory events were either cancelled or moved online given the widespread impact of the pandemic on the spring semester it is yet unclear how the pandemic related changes may have impacted college student alcohol consumption research on the impact of the pandemic on alcohol consumption has produced conflicting reports while product research has shown an increase in alcohol sales 10 there is also data showing a higher number of respondents reporting either no change or a decrease in consumption 11 further still research has found an increase in alcohol consumption by commuter college students the college environment has been notoriously associated with a culture that endorses alcohol consumption research conducted prior to the pandemic has found that greater exposure to college environmental factors correlates with increased drinking frequency 13 the impact of the college environment on increased alcohol consumption is further supported by data showing that college students tend to consume more alcohol than their noncollege attending peers 14 students who were living in dorms near college downtown areas and other campus related accommodations for the spring 2020 semester may have had to severely adjust their drinking habits when they suddenly found themselves back home it is worth noting that research has found an impact of legal drinking status on alcohol consumption using college student samples students above the legal drinking age demonstrate patterns of drinking that are distinct from their underage peers some research has demonstrated that younger students report more frequent alcohol consumption compared to older students 15 however this pattern of drinking may be dependent on a number of different factors for example students above the age of 21 have been shown to be more likely to engage in heavy alcohol consumption before going to and while at bars 15 this indicates that students over the age of 21 who were living on campus or near downtown bar areas may be especially impacted by pandemicrelated closures specifically they have lost access to preferred establishments due to bar closures andor having to relocate because of the complex relationship between legal drinking status drinking settings and exposure to college environmental factors the impact of pandemicrelated changes on college students alcohol consumption is a topic worthy of investigation this is especially the case as many health experts anticipate additional waves of the virus 16 and the effects may continue into the academic year the current study sought to investigate the impact of the covid19 pandemic on the alcohol consumption habits of college students as a function of legal drinking age the current study utilized longitudinal data from a large land grant university located in the northeast us to compare alcohol consumption data from past spring cohorts to actively enrolled spring 2020 students across two time points analyses were conducted using students who reported living either oncampus or near the downtown area at the beginning of the semester methods design data for this longitudinal cohort study were collected at a large northeastern us university during the spring 2019 and 2020 semesters via an online survey as part of a larger ongoing research project examining college student health behaviors and outcomes baseline data for the independent cohorts were collected at the start of the semester after the adddrop deadline and followup data were collected prior to the end of semester exams data collected in 2019 and 2020 cohorts were considered to be collected during normal and covid19 circumstances respectively covid19 cohort participants experienced a shift to online instruction after penn state issued a university wide shut down immediately following 2020 spring break in midmarch the pennsylvania state university institutional review board approved this study participants and procedures undergraduates enrolled in general health and wellness classes were recruited to complete the baseline survey data were password protected and only accessible to research team members an informed consent statement was presented to students upon opening the survey link cookies were used to prevent multiple submissions measures demographic characteristics participants in both cohorts selfreported their age gender raceethnicity sexual orientation year of study and living situation at baseline the spring 2020 covid19 cohort reported their living situation at followup too however this measurement focused on specifying the type of housing they resided in as well as the zip code alcohol consumption alcohol consumption was assessed using the daily drinking questionnaire 17 the ddq assesses the quantity and frequency of alcohol use by asking students to estimate the typical number of drinks consumed on each day of the week averaged over the previous three months baseline ddqs for both cohorts were framed for 3 months while the 2019 and 2020 followup ddqs were framed for 3 months and 1 month respectively the 2020 framing of the ddq was altered to exclusively encompass the period postpandemic and closure of the university ddq was summed to compute a variable indicative of typical total weekly alcohol consumption which was used as the dependent variable in analyses statistical analyses analyses were conducted using spss version 260 data were analyzed using a 2 × 2 × 2 mixed model anova with cohort group and age group as betweensubjects factors and time as a withinsubjects factor the main model was analyzed using only students reporting living either oncampus or in the downtown area at time 1 an alternative model was analyzed using only offcampus students to confirm the unique effect on students living near or oncampus results participant characteristics the majority of participants were women nonhispanic white and heterosexual participant characteristics are displayed in table 1 and attrition rates are displayed in table 2 main model there was a significant 2 × 2 × 2 interaction f 14198 p 001 η 2 0059 there was a significant main effect for all three factors as well as a significant twoway interaction between time and cohort at the onset of a typical spring semester students over the age of 21 consumed more alcohol than their underage peers with the discrepancy increasing slightly at the end of the semester at the onset of the spring 2020 semester students over the legal age consumed more alcohol compared to students under 21 however by the conclusion of the semester there was a marked decrease in the discrepancy between the two age groups this change was largely driven by a drastic drop in consumption by students of legal drinking age it should be noted when gender was included as an additional factor the overall model was not significant f 046 p 50 there was not a significant main effect for gender and gender did not interact with age group or cohort but did interact with time given the lack of strong statistical support that gender played an important role in the relationships of interest it was excluded from main model it should be noted that within the factorial anova model that included gender the threeway interaction of cohort age and time remained significant model assessing offcampus students in order to fully investigate the impact of living situation the model was computed using only students who reported living off campus outside of the downtown area the model was nonsignificant f 0487 p 488 providing further support for the enhanced impact of the pandemic on students living oncampus or near campus within the downtown area discussion the current study investigated the impact of the global pandemic on alcohol consumption as a function of legal drinking status longitudinal data were used to compare spring 2020 students to spring 2019 students with data collected at the beginning and end of the semester analyses specifically focused on students who reported living oncampus or near campus in the downtown area results found a significant threeway interaction between all factors during the prepandemic spring semester students over 21 years consumed more alcohol than their underage counterparts with the difference between the groups increasing slightly by the end of the semester the start of the spring 2020 semester was similar with students over the age of 21 consuming more alcohol than underage students however by the end of the spring 2020 semester the alcohol consumption of students over the age of 21 dropped to a level that was similar to their underage peers there are several potential explanations for this pattern of results one is that students lost access to their preferred drinking establishments during march and april 2020 43 state governors including the governor issued stayathome orders which included the shutdown of nonessential businesses in this case bars and restaurants 18 it is common for large universities like the one of the current study to have downtown areas with bars that are frequented by students previous research has found that students tend to consume heavily at these establishments especially students over the legal drinking age 15 therefore the loss of access to these traditional consummatory settings may have played a role in the change of alcohol consumption behavior students over the legal drinking age could have purchased alcohol to maintain prepandemic consumption habits however given the marked decrease in reported consumption it appears that this was not the case this leads to a second potential explanation change in living situation almost all oncampus students had to vacate university affiliated housing with national data suggesting that millions of students moved back in with parents or grandparents as a result 4 many students may have found that their college level drinking habits were not endorsed within their family homes and adjusted accordingly there are also additional explanations outside of the scope of the current study such as decrease in peer pressure 19 change in caloric intake and physical activity 20 and loss of financial opportunities 21 these and others should be explored in future research it is worth noting that a potential implication of this effect is that living with family and away from collegiate drinking establishments during the academic year may serve as a protective factor against overconsumption this may be an unanticipated benefit of the current global pandemic and is in line with previous research that has identified living at home as a protective factor against dangerous alcohol related behaviors 22 additional research has found that college students living in their familial home report a greater influence of their parents beliefs impacting their decisions in general 23 research has also found that the protective effects of parental involvement extend to many riskrelated behaviors associated with the collegiate environment 24 further support of the protective effects of parental involvement can be found in research demonstrating that these effects begin before the transition to college and may persist even if the child leaves home for college 25 identifying protective factors against harmful drinking in college student populations is especially important given that college students are a highrisk demographic for dangerous over consumptive behaviors 26 however in continuing to look toward the future researchers and college administrators should closely monitor student alcohol consumption behaviors when full student bodies are welcomed back to campus and downtown drinking establishments resume business although the current study did find a decrease in alcohol consumption among legal drinkers compared to past spring semesters recent research has found an increase in alcohol consumption among commuter college students 12 this may be due to demographic differences between campuses in particular student living situations students living in campus affiliated accommodation or near college campuses tend to consume more alcohol compared to commuter students 27 it appears as though alcohol consumption increased for students who were not required to relocate 12 while students living in campusaffiliated accommodation had to adjust their drinking habits upon moving back home a limitation of the current study is that current living situation was only measured at the first time point although at followup the covid cohort was asked to report on their housing type this would allow for additional investigation into the impact of living situation changes throughout the academic year on alcohol consumption an additional limitation that warrants discussion is in reference to the influence of gender within the current study longstanding research spanning across cultures has consistently demonstrated gender differences in alcohol consumption with men reporting higher drinking frequencies and quantities compared to women 29 however the current study did not find statistical evidence for an impact of gender on the interaction between cohort time and age one potential explanation for this pattern of results is that the current study did not have enough statistical power to detect the effect within the fourfactor model another explanation could be that the overwhelming impact of covid19 on alcohol consumption may have had such a severe impact on both men and women that existing gender differences were no longer apparent future research to explore further into the impact of covid19 on alcohol consumption habits of male versus female college students related to this limitation are the patterns noted in attrition rates the attrition rate for men was higher than that of women within the spring 2020 cohort furthermore it should be noted that these attrition rates were lower compared to the attrition rates for men and women for the spring 2019 cohort the lower attrition rate among the covid group may be due to students having more time to complete the followup survey due to changes in academic employment and leisure activities as a result of the pandemic however differences in attrition rates based on age were negligible within each cohort attrition represents one of the major concerns in conducting longitudinal studies as it can potentially impact the generalizability of the study although there are slight differences reported by gender and cohort it is common for attrition rates between 30 and 70 to be reported in longitudinal studies 30 however results should still be interpreted with caution as the differences in attrition rates may imply a bias in relation to gender and cohort additional research is needed to further assess attrition in the time of covid19 related data collection in conclusion the findings suggest that the effect of the pandemic on us college students alcohol consumption may depend on a number of factors including legal drinking status and living situation as the covid19 pandemic continues to unfold researchers should continue to monitor the impact it has on college students this is especially the case with the varied approaches to course delivery and anticipated future waves of the virus 16 data availability deidentified data from this study are not available in a public archive deidentified data from this study will be made available by emailing the corresponding author analytic code availability there is no analytic code associated with this study materials availability materials used to conduct the study are not publicly available transparency statement study registration the study was not formally registered analytic plan preregistration the analysis plan was not formally preregistered

colleges local public servants and health officials should closely monitor student alcohol consumption as traditional establishments and campuses change policies due to the pandemic eg closing and reopening

background the purpose of informed consent is to protect patients autonomy in the west under the principle of informed consent doctors are required to provide patients with adequate information and respect their decisions 12 the patients family members may take part in the treatment process however on the doctors side the patients autonomy and rights are always the primary consideration they will not disclose a patients condition to family members without the patients consent it is even less likely for doctors to bypass patients and prioritize informing the family members of their condition only in special circumstances such as when a patient loses the ability to make decisions will the doctors then inform the family members and act on their decisions 34 in china however it is customary for doctors to inform both the patient and their families of the patients condition even if the patient is capable of making decisions this usually happens when the family members accompany the patient or when the patients condition is complex and severe 56 in some special cases doctors will even give priority to informing family members of the condition and letting them communicate with the patient 78 in other cases family members believe that disclosing the true condition will cause significant psychological harm to the patient and they may request that doctors cooperate with the family in deceiving the patient most of the time chinese doctors will accede to the familys request 9 10 11 some scholars claim that family members play such an important role in contemporary chinese medical practice because of the influence of the traditional confucian culture 12 13 14 confucian culture tends to view the family as the basic unit of society as opposed to the current western society which views the individual as the basic unit of society major decisions regarding personal wellbeing are often made collectively by family members this familyoriented ideology has shaped a unique doctorfamilypatient model of the physicianpatient relationship in which physicians are no longer dealing solely with the patient but also with the patients family countries and regions influenced by confucian cultures such as japan south korea and hong kong also have similar situations where family members participate in medical decisionmaking 15 16 17 18 additionally scholars have analyzed this physicianpatient relationship model from an economic medical insurance policy and educational perspective to explain its realistic basis 519 research on this doctorfamilypatient model of the physicianpatient relationship has primarily focused on three areas investigating the attitudes and reactions of patients and their families toward family involvement in informed consent and medical decisionmaking 101920 analyzing the underlying reasons for this model 5121921 and evaluating the advantages and disadvantages of this model 22 23 24 25 however existing research lacks empirical studies on the physician population this appears to neglect the views of physicians on this doctorpatient relationship model and the potential challenges it may pose for them on the one hand chinese physicians are educated and trained to protect the patients privacy fulfill their duty of informed consent and respect the patients autonomy with such requirements reflected in relevant laws 2627 on the other hand in china physicians appear to comprehend and accept the model of the physicianpatient relationship in which the family members play an important role in informed consent this implies that chinese physicians may encounter ethical dilemmas when conducting informed consent as mentioned above in some cases family members may request that physicians conceal the patients condition from the patient although doctors are allowed to inform family members rather than patients of their conditions in some special situations 2627 there is no explicit provision of law that doctors can deliberately conceal the patients condition from the patient based on the request of the family members therefore what should a doctor do when the family members demands conflict with the patients right to be fully informed in addition when a patient explicitly states that they do not want their family members to be involved how should a doctor decide between the patients privacy and the family members requests for the patients information and when a family members decision does not seem to fit the patients best interests what should a doctor do these ethical dilemmas and the challenges they cause for physicians will be the focus of our research as mentioned above chinese physicians are required to conduct informed consent to respect the patients autonomy however such requirements emerged gradually at the turn of the 21st century under relevant legal and ethical principles at the legal level the provision of informed consent in surgical procedures was first included in the medical practitioners law of the peoples republic of china in 1998 28 in terms of medical ethics education mainstream textbooks gradually began to include informed consent as an ethical principle in the early 21st century medical ethics education is compulsory course in all medical universities in china and the course is usually scheduled for undergraduate medical students in their junior or senior year thus the moral distress felt by doctors who received medical education and entered clinical work after 2000 ie those in the under 35 age group may be more pronounced than that felt by senior doctors at the same time these young doctors will become the backbone of the medical field in a decade or two which means that their attitudes toward the doctorfamilypatient relationship model will reflect the attitude of chinas medical community toward this model in the next few decades as well as their responses to the corresponding ethical dilemmas therefore our study targets young doctors to investigate their attitudes and reactions to the above ethical dilemmas and the reasons behind their responses to them this study is the first largescale study of doctors attitudes and reactions to the doctorfamilypatient model of the physicianpatient relationship in china in the past decade and the first to be conducted among young doctors under the age of 35 china has multiple distinct medical education pathways that can last from 5 to 11 years 29 the normal age for the students who start a 5year bachelor of medicine degree is 18 after mb program they are qualified for the medical licensing examination and further pursuing a 3year master of medicine degree in fact most medical students are able to obtain their medical license at the age of 23 before starting the mm program the mm program usually include a 3year general training which is required for physicians to be solely responsible for the patients in our study all participants have completed their mb program and hence most of them have obtained the license however not all participants can independently manage patients considering that some of them are in their mm level even for these participants they have played assistant role under supervision of highhierarchy physicians in the physicianpatient communication thus all participants would have already experienced such model of physicianpatient relationship methods study design this study was conducted from june 11 2022 to september 20 2022 data were collected through an online survey using a snowball sampling method the target population is doctors of all grades with clinical experience in various departments from 3 a hospitals the highest normal level hospitals in the chinese healthcare system questionnaires the questionnaire was developed by consulting several literature including the theoretical discussions of the doctorfamilypatient model of physicianpatient relationship and some qualitative studies 5141930 in addition a couple of young physicians were interviewed as the prestudy the interview also contributed to the content of questionnaire the questionnaire consisted of 31 multiplechoice questions and took approximately 10 min to complete the questions covered four major parts the participants basic information the fulfillment of the obligation to fully inform who will be informed ethical dilemmas in decisionmaking and 10 questions related to the content of this article the results of these 10 questions are included in this paper other questions will be presented and discussed in a subsequent article the requirements of fully informing and the reaction to patients decisions a questionnaire study on chinese doctors 1 ethical considerations participants identifiable personal information was withheld from the questionnaire results data the first page of the questionnaire stated the purpose of the study its use and the contact information of the person in charge informed consent was obtained from all participants the study was also approved by the ethics committee of nankai university data analysis data were imported into ibm spss version 25 for statistical analysis descriptive statistics were performed for each variable separately by the respondent cross tabulation and pearsons chisquared test were used to analyze the differences between types of patients for categorical variables and a pvalue 005 was considered statistically significant results we obtained a total of 421 data sets of which 368 met the age requirements for this study the participants included 155 males and 213 females the minimum age was 21 years old the maximum age was 35 years old and the average age was 276 years old in terms of education level 118 participants held a bachelors degree 217 participants held a masters degree and 33 participants held a doctoral degree finally their professional titles were distributed as follows 171 participants were resident physicians 126 participants were attending physicians 70 participants were associate chief physicians and 1 participant was a chief physician our data showed that only 20 doctors stated informing the patient alone is sufficient when it comes to informing adult patients of their serious conditions 254 doctors stated that unless the patient explicitly expresses a desire for their family members to remain uninformed the family members will be informed while 35 doctors stated that even if the patient explicitly expresses a desire for their family members to remain uninformed the family 1 the article is being written members will be informed the remaining 59 doctors would inform the family members first and let them inform the patient when facing elderly patients with decisionmaking capacity the situation was significantly different only 14 doctors stated that informing the patient alone is sufficient of those surveyed 146 doctors chose to inform the patients children2 unless the patient explicitly expresses a desire for their children to remain uninformed while 100 doctors stated that even if the patient explicitly expresses a desire for their family members to remain uninformed the children will be informed of respondents 108 doctors would inform the patients children first and let them inform the patient in general many respondents who chose a or b in the first question chose c or d in the second question by contrast most respondents who chose c and d in the first question made the same selection in the second question when asked about the primary reason for ensuring that family members are informed about the medical condition of the adult but not elderly patients 144 doctors believed that major medical conditions can have an impact on the whole family so families also have the right to know 139 doctors chose informing family members to let them to discuss with patients can help patients make better decisions and 62 doctors chose avoiding medical disputes and preventing family members from holding doctors accountable on the grounds of not being informed the proportion of doctors who cited the reasons for ensuring that family members are informed about the medical condition of elderly patients is slightly different of those doctors 180 believed that informing adult children and involving them in medical decisionmaking can help patients to make better decisions 128 considered the overall impact on the patients family and 44 chose avoiding medical disputes and preventing family members from holding doctors accountable on the grounds of not being informed we further analyzed the data on doctors who chose avoiding medical disputes and preventing family members from holding doctors accountable on the grounds of not being informed we found that compared to doctors who chose other options a larger proportion of doctors who chose to inform family members even when adult but not elderly patients explicitly stated that they did not want their family members to be informed cited avoiding medical disputes and preventing family members from holding doctors accountable on the grounds of not being informed however there was no significant difference in this proportion when it came to elderly patients when family members asked doctors to conceal the patients medical condition for the best interests of patients 270 doctors chose to respect the views of the family and cooperate with them in concealing the condition from the patient while 73 doctors explicitly refused the suggestion and advised the family that this violated professional ethics in addition 21 doctors tended to make situationspecific analyses and 4 doctors would report to their superiors and follow their instructions when faced with elderly patients who have decisionmaking capacity the attitude of doctors did not significantly change of the respondents 293 doctors chose to cooperate with adult children in concealing the patients medical condition 55 doctors explicitly refused and 18 doctors based the decision on the situation while 2 doctors followed the instructions of their superiors discussion firstly chinese doctors pay extra attention to informing the patients family which may not be in the patients best interests in contrast to previous studies our study reflects for the first time the balance that doctors consider between the patients right to know and their family members right to know when faced with an adult but not elderly patient most doctors would regard the familys right to know as equally important to the patients right to know when informed of a severe medical condition onequarter of the respondents give extra weight to the familys right to know with some believing that it takes priority over the patients right to know and some even thinking that it is more important than the patients right to privacy only 54 of respondents believe that it is only necessary to ensure the patients right to know it can be seen that chinese doctors place a high priority on keeping patients families informed but not exclusively for the best interests of the patient according to the existing literature patients especially old patients would not refuse their family members to involve in their medical decision making 51932 three reasons were most mentioned familyoriented tradition in china the patients ability to understand the information and the patients economic situation generally both patients and their family members believe that this model in which the family have the patients information and take part in the patients medical decisionmaking fits the patients best interests however how physicians perceive this model is slightly covered by previous studies our study shows that only about 40 of participants primary reason for ensuring that family members are informed is for the interests of the patient about 41 is for the consideration of the overall impact on the patients family and about 18 is for selfprotection considerations although the interests of the patient and the patients family are often consistent factors other than the patients interests should not be the primary consideration for doctors as the requirement of medical professional ethics as mentioned above influenced by the familyoriented culture family members play an important role in medical activities in china which creates a socalled doctorfamilypatient model of the physicianpatient relationship however this can be morally accepted and defended because it is considered the way to maximize the patients interests in the chinese cultural context as doctors the emphasis on the familys right to know should be for promoting the patients best interests rather than for weakening the consideration of the patients interests in addition exemption considerations were particularly evident among respondents who felt that the familys right to know was more important than the patients right to privacy our data suggest that the exclusion of liability has become an important reason for doctors to value family members right to information which is contrary to their professional ethics although the subjective reasons for this phenomenon lie in the lack of professional ethics of physicians who have failed to consistently prioritize the patients interests objective factors such as tense doctorpatient relationships cannot be ignored over the past decade there have been unrelenting incidents of violence against doctors 3334 the lancet published two editorials in 2010 and 2020 calling for concern about the personal safety of chinese doctors 3536 tensions in the doctorpatient relationship have led to a decline in trust between doctors and patients and doctors have had to consider how to avoid getting themselves into potential disputes when facing patients and their families this is particularly evident in extreme cases such as when doctors delayed performing a cesarean section on a woman who died in labor without obtaining her husbands consent 37 in the case the pregnant woman was suggested by her physician to have a csection immediately however her husband insisted a natural birth and refused to sign on the informed consent form the physician didnt perform a csection on the woman as the familys informed consent was the necessary for the operation then the pregnant woman died in labor fear of complaints from the patients husbands would be the main reason that the physician delayed the operation secondly our study reveals for the first time that chinese doctors treat adult patients and elderly patients differently when it comes to informing family members our data showed that compared to adult but not elderly patients chinese physicians tend to place greater emphasis on the familys right to know with elderly patients even if they have the capacity for decisionmaking and consider it more beneficial to the patient the reasons for this difference in treatment mainly stem from two factors the emphasis on filial obligation in traditional chinese culture and the consideration of the education level of the elderly first influenced by traditional confucian culture chinese society places great importance on the obligation of children to support and care for their parents 14 adult children accompanying their parents to medical appointments is often seen as a sign of a harmonious parentchild relationship and filial piety elderly patients are also often pleased to see their children show their concern by being informed and involved in decisionmaking in such cases doctors are more likely to be convinced that their children represent the best interests of their parents and are therefore more inclined to ensure that their children are informed in the interest of their elderly patients in addition the elderly population in china has a lower level of education according to the 7th national population census of china in 2020 only 139 of the population aged 60 and above had a high school education or above 38 the level of education significantly limits the elderly patients understanding of their medical condition especially when medical terms are involved in the physicians explanation 19 in such cases ensuring that family members are informed is more beneficial for the patients decisionmaking and subsequent treatment thirdly when family members request that doctors withhold information from patients in the best interest of the patient the majority of participants choose to comply with the request although this may cause them distress the practice of benevolently withholding information from patients is not uncommon in medical history 39 however since the 1950s with the shift in the doctorpatient relationship and the emphasis on patient autonomy this practice has been criticized as paternalism and has been gradually replaced by informed consent 4041 in current medical practice the professional ethics of doctors in many countries explicitly prohibit doctors from withholding information from patients 4243 in western countries on the patients family side it is not common for them to request doctors to withhold information from patients on the doctors side it is difficult to imagine that doctors agree and comply with such requests for example anne lapine and her colleagues reported an interesting case in which the wife daughter and soninlaw of a chinese patient requested that an americanborn physician withhold information regarding a terminal diagnosis the family felt that if the patient was told he had cancer then his spirit would be broken the ethics committee invited an americanborn chinese physician as a guest consultant the consultant confirmed that it is common in chinese culture for the family to request physicians to withhold a terminal diagnosis to protect the patients feelings 44 however even in china complying with family members requests to withhold information from patients may cause distress to doctors in our prestudy the interviewees mentioned that it is also showed in existing literature 45 46 47 the familys requests put the physician in a dilemma on the one hand withholding information from patients not only violates professional ethics but also violates relevant laws the current professional ethics and laws all require doctors to fulfill their obligation to inform patients fully and respect patients autonomy 2627 although in some special cases doctors are allowed to inform family members rather than patients themselves no law or ethical rule explicitly states that doctors can withhold information from patients based on family members requests 2627 on the other hand although most doctors acquiesce to the power of family members to make decisions for patients and indicate their willingness to comply with family members requests to withhold information from patients it can be imagined that some of these doctors do so for the sake of exemption rather than the best interests of the patient for doctors who consider the best interests of the patient deciding whether to comply with family members requests to withhold information from patients is not an easy task it requires the doctor to consider the patients condition the patients mental capacity the patients rapport with the family and the impact of withholding information on subsequent treatment this is probably why some respondents stated that it depends on the specific situation limitations our study has some limitations and deficiencies first our participants were all recruited from 3 a hospitals which have a relatively high concentration of medical resources and a relatively high volume of patients however 3 a hospitals situation is limited to show the whole picture of the physicianpatient relationship models considering the proportion of 3 a hospitals is low in china future studies should also focus on hospitals or medical institutions of lower levels differences in management systems patient volume and types of doctorpatient relationships between hospitals of different levels may lead to variations in results second although snowball sampling was the most appropriate and efficient way to collect data under the covid19 prevention and control requirements in china last year it has its unavoidable disadvantages as a nonprobability sampling method such as sample selection bias limited generalizability difficult to estimate sampling error and so on third our data have been representative of young doctors as possible on the basis of publicly available data however our sample size was not large enough and factors such as age department and region were not completely balanced which may have resulted in some bias conclusions and practical implications our study is the first largescale study of young doctors attitudes and reactions to the doctorfamilypatient model of the physicianpatient relationship in china it shows the doctors balance weighing the patients right to know against the familys members right to know as well as the patients right to privacy against the familys requests for the information it also shows the doctors responses to the requests from family members to withhold information from patients and the reasons behind such responses our study reflects the potential moral distress caused by such a model in terms of practical implications it is necessary to increase clinical ethics training to promote doctors professionalism considering that some doctors are not motivated for the best interests of the patient in addition the ethical dilemmas faced by doctors cannot be ignored perhaps it could be helpful to have different rules for informed consent for different types of populations ie adult and elderly patients furthermore communication techniques such as spikes protocol 48 and cst 49 may be useful aids for doctors when communicating with patients and their families data availability the datasets used andor analysed during the current study are available from the corresponding author on reasonable request supplementary material 1 supplementary material 2 competing interests the authors declare no competing interests

background based on the principle of informed consent doctors are required to fully inform patients and respect their medical decisions in china however family members usually play a special role in the patients informed consent which creates a unique doctorfamilypatient model of the physicianpatient relationship our study targets young doctors to investigate the ethical dilemmas they may encounter in such a model as well as their attitudes to the family roles in informed consent methods a questionnaire was developed including general demographic characteristics the fulfillment of the obligation to fully inform who will be informed and the ethical dilemmas in decisionmaking we recruited a total of 421 doctors to complete this questionnaire of which 368 met the age requirements for this study cross tabulation and pearsons chisquared test were used to analyze the differences between types of patients for categorical variables and a pvalue 005 was considered statistically significantour data shows that only 20 doctors 540 stated informing the patient alone is sufficient when it comes to informing patients of their serious conditions the rest of the participants would ensure that the family was informed when facing elderly patients with decisionmaking capacity the data was statistically different 38 p 0001 the primary reason for ensuring that family members be informed differs among the participants in addition when family members asked doctors to conceal the patients medical condition for the best interests of patients 270 doctors 734 would agree and cooperate with the family a similar proportion 796 would do so when it comes to elderly patientschinese doctors pay extra attention to informing the patients family which may not be in the patients best interests 2 chinese doctors treat adult but not elderly patients and elderly patients differently when it comes to informing family members 3 when family members request that doctors withhold information from patients in the best interest of the patient the majority choose to comply with the request although this may cause them distress

introduction randomized controlled trials have long been heralded as the gold standard for measuring the effectiveness of an intervention due to their ability to reduce bias and show causeeffect relationships in this article we will briefly summarize the evidence base for the effectiveness of complex mental health interventions in prison settings while also identifying the recurrent issues we will then focus predominantly on our experience of conducting prisonbased rcts and ask the question are prison rcts of complex interventions a sisyphean task to date there has been a surprising number of systematic reviews of interventions or prisonersforensic populations these reviews have assessed the evidence base in a number of different ways for example discrete subpopulations eg adolescent offenders female offenders offense types eg violent offenses specific interventions eg psychotherapy or the impact on specific outcomes eg health outcomes violent behavior or reoffending with many having a broad inclusion of primary studies designs of relevance here are two reviews the first reviewed rcts of a range of psychological therapies for prisoners with mental health problems across 37 identified studies they found a medium effect size for psychological therapies however effects did not appear to be sustained over time where trials had used a fidelity measure these were associated with lower effect sizes the authors also undertook a qualitative analysis of the difficulties of conducting rcts in prisons the issues included • posttreatment followup high rates of release rapid turnover of prisoners and short duration of stay leading to difficulties with initial recruitment and loss to followup • institutional constraints constraints on the scheduling of sessions lockdowns high attrition rates partly due to scheduling changes and inmate infractions • small sample sizes • contamination of treatment and control conditions due to the closed communal setting of the prison • not being able to blind the participants to interventiontreatment as usual and • reliance on selfreport measures the second review examined rcts of psychological interventions delivered during incarceration but focused solely on recidivism as the outcome of 29 rcts psychological interventions were associated with reduced reoffending but after excluding smaller studies there was no significant reduction in recidivism the number of studies was not large which the authors suggested supports the evidence that there are significant challenges of doing highquality research in prisons also many of the studies had a risk of bias mainly around randomization intervention deviations and difficulties associated with masking staff and participants to the assigned intervention in this context we will now reflect on our own experiences of conducting two prisonbased rcts critical time intervention and engager both studies started with a pilot trial followed by a full rct both interventions were throughthegate interventions with baseline assessments completed in prison and then followup after release from prison the two studies are described below and in table 1 critical time intervention cti is an intensive form of mental health case management operational at times of transition between prison and community and designed for people with severe and enduring mental illness cti case managers routinely mental health nurse psychologists or social workers provided direct care where and when needed for a limited time period they began their involvement when the individual was still in prison for sentenced prisoners this started 4 weeks before release for remand prisoners or those with unpredictable dates of release intervention starts as soon as the person is known to the prison mental health team the holistic intervention involves working with the individual and their families as well as active liaison and joint working with relevant prison and community services five key areas are prioritized psychiatric treatment and medication management money management substance abuse treatment housing crisis management and lifeskills training cti is not prescriptive it responds to the needs of each individual thus looks slightly different for each person but still within the fivepriority area framework the intervention includes four phases phase 1 is conducted while the person is in prison and requires the development of a tailormade discharge package based on a comprehensive assessment of the individuals needs phases 2 and 3 focus on intensive support postrelease and then handing over primary responsibility to community services and phase 4 fully transitioned care to community services to provide longterm support the aim is that phases 24 are completed within 6 weeks of release from prison we conducted a multicentre parallelgroup randomized controlled trial across eight english prisons with followup at 6 weeks and 6 and 12 months postrelease a sample of 150 male prisoners were included with eligibility criteria of being convicted or remanded cared for by prison mental health teams diagnosed with severe mental illness and with a discharge date within 6 months of the point of recruitment of these 150 72 were randomized to the intervention and 78 were randomized to the usual release planning provided by the prison engagement with community mental health teams at 6 weeks was 53 for the intervention group compared with 27 for the control group 95 confidence interval 013 to 078 p 0012 at 6 months followup intervention participants showed continued engagement with teams compared with control participants there were no significant differences at 12 months engager the engager intervention is designed to engage individuals with common mental health problems in the development of a pathway of care for release and resettlement in the community it is a manualised personcentered intervention aiming to address mental health needs as well as to support wider issues including accommodation education social relationships and money management the intervention is delivered in prison between fourand 16weeks prerelease and for up to 20 weeks postrelease experienced support workers and a supervisor with experience of psychological therapy deliver engager the practitioner and participant develop a shared understanding of the participants needs and goals recognizing the links between emotion thinking behavior and social outcomes a plan is developed based on agreed goals and including liaison with relevant agencies and the participants social networks a mentalisationinformed approach underpins all elements of the intervention use of existing practitioner skills is also key to intervention delivery we conducted a twogroup parallel randomized superiority trial in three prisons men serving a prison sentence of 2 years or less were individually allocated 11 to either intervention or the control group the primary outcome was the clinical outcomes in routine evaluation outcome measure six months after release a total of 280 men were randomized our perspective what works intervention allocation in cti and engager was at the individual level and so our perspective here focuses on this type of design however there are several alternative designs such as cluster preference and benchmarking controlled trials we refer the reader to overall we agree with the reviews in that prison rcts are possible in both studies participant engagement was positive with high levels of consent and enthusiasm for the interventions but also being involved in the research process however the unique prison context can make standard trial procedures and standard assessments of study quality more difficult to achieve pilot trials in both our studies we undertook pilot trials for cti the focus of the pilot was very much about testing if the intervention could produce an outcome while in engager the pilot trial explicitly examined trial design and recruitment building on earlier feasibility work but importantly also had an embedded realist1 informed formative process evaluation which focused on how the intervention was working both pilot trials provided invaluable knowledge and supported the development of relationships with the recruitment sites on reflection had the cti pilot formally tested recruitment and eligibility rates then perhaps we could have better predicted the slow recruitment rates faced and negated the need to add so many other sites slow recruitment was due to a complex interplay of lengthy delays in approval and other operational delays such as change in healthcare providers which meant that men became ineligible to take part due to not being released within the study period the difference between these two pilot studies also reflects the fast pace of change we have seen in our understanding of intervention development and testing and the improved guidance on feasibility and pilot trials the uk medical research council published a framework on developing and evaluating complex interventions in 2000 it was revised in 2006 but has been very recently updated again in 2021 clear evidence of this fast pace in addition our theorical understanding of acceptability often a key outcome in feasibility and pilot trials has advanced with the work of sekhon using this framework may have added significant depth of understanding of the anticipated and experienced acceptability from the perspective of the intervention delivers and recipients blinding single double and tripleblinding are commonly used in rcts a singleblind study blinds the participant from knowing which study trial arm they have been assigned a doubleblind study blinds both the participants and researchers to allocation and tripleblinding involves blinding the participants researchers and statistician the review above highlighted that blinding was problematic blinding participants where the intervention is a psychological therapy andor person facing is difficult if not impossible in cti we were able to blind the researcher and statistician data we were able to blind the researcher to allocation as there was no facetoface contact with the participants after baseline data collection which was before participants were randomized in engager we were only able to blind the statistician in our engager pilot trial we tested and reported on our attempts to blind the researchers but researchers were unblinded very quickly due to the frequent contact the researchers had with participants participants were keen to share their experiences with the researchers andor the researchers saw the participants with the engager practitioners due to the closed confines of the prison we considered a range of workable solutions to maintain blinding such as using a articlebased selfcomplete outcome measure for participants but decided against this due to literacy problems and the likely increase in incomplete data in the main engager trial the researchers knew trial arm allocation this was a positive in that it allowed for the continued building of rapport between the researcher and participant to facilitate followup rates but may have diluted the relationship building effects of the intervention both studies could have considered adaptations to their design to allow recruitment to each arm to be staggered but this lengthens the overall study time and cost outcome measures how we measure outcomes in forensic populations is notoriously complicated and the reason why there is little agreement about which outcomes to use forensic settings and forensic populations are diverse for example settings can include police custody prison probation services in the community and secure forensic hospitals even within the same setting there is diversity for example secure forensic hospitals have different security levels and different provider organizations services may also be viewed as having diverse goals including clinical legal and public safety in addition forensic populations may have multiple and varied problems for example personality disorder mental illness learning disability substance abuse and offending behavior with many cooccurring leading to many combinations of potentially relevant outcomes to confound this further there are also different type of outcomes objective outcome measures can be viewed as outcomes such as rehospitalisation reoffending and death and are usually obtained from administrative datasets in our cti study our primary outcome was based on information collected from participants electronic health records while on the surface this would seem to avoid the limitations associated with selfreport data eg social desirability honesty introspective ability latent nature of the measures missing data it was not without shortcomings the data was only as good as the quality of the written records and at times this was poor something highlighted by other researchers we also planned to supplement this with information from uk health registries however due to accessibility issues likely data quality and an inability to join data from different registries we were unable to progress this a recent systematic review of 160 rcts accessing routinely collected heath data found only a very small proportion of uk rcts and highlighted issues with access quality and a lack of joinedup thinking between the registries and the regulatory authorities in both cti and engager we had planned to obtain offending data but faced similar issues to the health data in terms of protracted approval processes over recent years there has been an explosion of the number of subjective outcomes available there have been a number of reviews of outcome measures in forensic settings identifying a large number of questionnairebased instruments focusing mainly on risk and clinical symptoms neglecting quality of life functional outcomes and patient involvement in the most recent review a total of 435 measures were identified of the 10 most frequently used half of the instruments were primarily focused on risk only one instrument the camberwell assessment of need forensic version had adequate evidence for its development and content validity in our engager trial outcome data was primarily subjective and significant work went into deciding which outcomes to use with the aim of selecting a set of outcome measures that captured the most important areas of the engager intervention we adopted a fourstage approach involving a single round delphi survey to identify the most important outcome domains a focused review of the literature testing of these measures in the target population to assess acceptability and the psychometric viability of the measures and a consensus panel meeting to select the primary outcome measure for the trial and key secondary outcome measures in addition we actively sought the input of our peer research group throughout this process after the four stages the coreom and canfor both received the same number of votes to be the primary outcome measure we opted for the coreom as the primary outcome measure it had marginally superior psychometric properties could be administered in a highly scripted fashion that would reduce researcher bias some items were of little relevance to a prison population and there were issues with the canfor being able to demonstrate change overtime there is also some criticism of the reliability of the scoring system for the canfor we had considered using outcomes based on practitioner records however it quickly became clear that these were not recorded in a sufficiently consistent way to merit inclusion they were not undertaken at set time points were often subjective in terms of focus and suffered from missing data ultimately even going through this process of selecting the primary outcome we found problems with the coreom the before and after changes for individuals did not match the journey of rehabilitation and recovery detailed in the depth process evaluation where we found that the intervention was more effective when practitioners developed an indepth understanding of the participant it may therefore not to be sensitive enough to detect small unpredictable steps in recovery resultant from the intervention for individuals with lifelong experiences of adversity it also highlights the problems of reducing very complex interventions down to just one outcome it may be that we just do not have adequate outcomes to test such complex interventions we tried to use the psyclops questionnaire an idiographic measure designed to detect changes in person specific problems but the prison environment rendered it unworkable because once released individuals problems were almost entirely different intervention fidelity one of the reviews highlighted above showed that studies including a measure of fidelity were associated with lower effect sizes intervention fidelity like outcomes is a complex area with a lack of agreement about the appropriate indicators of fidelity and how these should be measured it is argued that any assessment of fidelity should look at the intervention designer providerand recipientlevels however it is likely that the delivery of an intervention as complex personcentered and flexible to the individual as cti or engager will be harder to evaluate than simpler one dose fits all designs in cti fidelity was assessed using an adapted version of the fidelity scale used in the critical time intervention task shifting study at eight time points over the course of the trial however a more reliable and detailed way to assess fidelity would have been for the cti manager to complete a checklist per participant against the core cti principles this would have allowed more detailed analysis of what each participant received mapped against their needs there was variation in fidelity to the intervention across the different cti managers in engager fidelity was assessed by creating an intervention delivery timeline which depicts practitioner and supervisor start and end dates instances of training sessions research teamengager supervisor supervision and periods of prison lockdown where practitioners were unable to access the prison sites to deliver the intervention practitioners and supervisors also kept records of contacts in the form of daily activity logs and recorded session case notes we recognized however that this only measures superficial aspects of fidelity and not the multiple mechanisms designed to be at play in such a complex intervention there is however little published regarding fidelity in complex behavioral interventions and there needs to be more published on fidelity results process evaluation the biggest difference between cti and engager was the complexity and depth of the qualitative components in cti we undertook a nested qualitative study at that time even this was relatively unheard of in rcts jump fiveyears and we were undertaking one of the most indepth process evaluations for complex health interventions even after the publication of the mrc guidance in 2000 and 2006 process evaluations have often been small qualitative addons to trials and of little importance to the main trial findings although more recent guidance emphasizes the importance of detailed analysis the parallel mixed method process evaluation in engager not only provided evidence of breadth and depth and from multiple perspectives about what was delivered to participants but also allowed us to focus in on how team dynamics and underlying beliefs and values affected implementation and to propose what might be done to support practitioners further to optimize delivery documenting suboptimal implementation was important for trial result interpretation and development of future practice the use of realistinformed methods allowed us to interrogate the intervention mechanisms by assessing if delivering the specified intervention components produce the hypothesized outcomes this gave us insight into how the intervention can have a sustained effect when delivered well we showed how consistent delivery across time could lead to the several mechanisms being activated often repeatedly to achieve incremental but sustainable change it also allowed us to examine more deeply what meaningful change meant for the intervention participants in ways that standard outcome measures cannot assess discussion are conducting rcts of complex interventions in prisons a sisyphean task no far from it in our experience they can be conducted are a key tool in developing evidenceinformed practice and for some interventions provide the best approach to test effectiveness but there is also a need for flexibility so that we are not unduly limited by a specific set of perspectives for us there are some key must dos pilot andor feasibility trials to help minimize risks to the main trial eg ensuring testing of recruitment and followup rates developing effective relationships with the prisons so they see the value of research a robust process evaluation is key for understanding what was delivered but more importantly how was it delivered and how it produces change how interventions work has often received little attention in prison research areas where we need to improve are our understanding how best to assess fidelity and our choice of outcome measures is this user led vs standardized measures vs bespoke or should we use a combination plus we need to work to improve access to routinely collected data other european countries such as the nordic countries are much more advanced here we also need to work with the prison system to ensure they see the value in supporting independent external research to reduce protracted approvals we must not get overly fixed on some traditional aspects of rigor alongside flexible adaptive rcts we also propose the development of rigorous methods for evaluating impact of interventions in nonrandomized studies eg prepost implementation studies beforeafter health or quality of life questionnaire data can be examined alongside processes of care economic data and depth qualitative process evaluation analyses where novel interventions are adopted as treatment as usual there is a place for robust service evaluations of routinely collected data where research ethics would not be required it was fyodor dostoyevsky who said the degree of civilization in a society is revealed by entering its prisons and therefore we continue to undertake prison research despite some of its challenges we strive to reduce health inequalities and driveup quality healthcare for a group of people who are significantly disadvantaged and vulnerable so that we can live in a more civilized society data availability statement the original contributions presented in the study are included in the article 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

randomized controlled trials rct are the gold standard for measuring the effectiveness of an intervention however they have their limitations and are especially complex in prison settings several systematic reviews have highlighted some of the issues including institutional constraints eg lockdowns followups contamination of allocation conditions and a reliance on selfreport measures in this article we reflect on our experiences and will describe two rcts people in prison are a significantly disadvantaged and vulnerable group ensuring equitable and effective interventions is key to reducing inequality and promoting positive outcomes we ask are rcts of complex interventions in prisons a sisyphean task we certainly dont think so but we propose that current accepted practice and research designs may be limiting our understanding and ability to test complex interventions in the realworld context of prisons rcts will always have their place but designs need to be flexible and adaptive with the development of other rigorous methods for evaluating impact of interventions eg nonrandomized studies including prepost implementation studies with robust research we can deliver quality evidencebased healthcare in prisons after all the degree of civilization in a society is revealed by entering its prisons

introduction alcohol consumption remains a major public health problem contributing to myriad preventable conditions and increasing the risk of violence management of adverse outcomes of alcohol is estimated to cost australia 668 billion a year 1 as such australias national alcohol strategy 20192028 aims for a 10 reduction in harmful populationlevel alcohol consumption 2 however reduction messages need to account for the fact that alcohol consumption at risky levels is socially acceptable particularly for heavy drinking subpopulations including women in midlife aged 4564 years 34 despite current australian guidelines which recommend drinking no more than two standard drinks on any day to reduce the lifetime risk of harm from alcoholrelated disease or injury and no more than four standard drinks per occasion to reduce shortterm acute harms in 2019 the heaviest drinking 10 of the australian population accounted for 541 of all alcohol consumed 5 central to this paper midlife women in particular are at a higher risk of lifetime harm than other subpopulations of australians and while men consume more alcohol than women alcohol causes more physiological harms to women because of differences in metabolism compared to men 6 patterns of alcohol consumption at this age have been trending up midlife women are thus a target group identified within the national alcohol strategy as warranting urgent intervention in the 2020s women are drinking more alcohol than previous generations of women in this stage of life and more than any other age group currently and the reasons for this lie in research which indicates consumption provides some women with a form of stressrelief 7 and selfcare 8 9 10 that is socially acceptable 1112 and can function as a tool to promote wellness sometimes within a limited range of resources and womens options diminish as they experience more social disadvantage 13 australian womens reasons for alcohol consumption are also differentiated on the basis of social class 13 14 15 of particular relevance to this study is that affluent women have more agentic relationships with alcohol whereas there is a tendency for less control over alcoholrelated decisions for women living with less privilege this prompts a question about how differences in social class translate to womens capabilities for alcohol reductionstrategies might be less readily accessible to women from lower social classes in order to reduce consumption than those for women with more resources urgent action is required to identify socially acceptable alcohol reduction options for heavy drinking midlife australian women the emerging evidence of widespread curiosity among middleaged woman about sobriety and alcohol reduction highlights a messaging tactic that may provide a new public health campaign strategy for harm reduction herein we engage with the notion of sober curiosity that is for some a socially acceptable movement challenging the idea that specific social contexts require alcohol while the reasons for midlife womens alcohol consumption are well explored there is a gap in knowledge about options like sober curiosity that might enable sustained reductions in consumption among this heavy drinking subpopulation further given the complex structural factors that may make it difficult for some midlife women to contemplate reducing alcohol consumption it is important to explore how these movements and options may vary with social class nonetheless the feasibility of reducing midlife womens alcohol consumption while the concept of sober curiosity is in the public spotlight offers new opportunities for public health in contrast to typical approaches that use instruction on limiting alcohol intake as a guiding principle the study reported here represents a paradigm shift where the normative social environment supports moderate or no intake in this paper we present our findings and explore factors that impact womens preparedness to reduce drinking including what women anticipate gaining or losing from consuming less alcohol or not drinking at all and important considerations in designing messages that reinforce sober curiosity the sober curious movement and reducing alcohol consumption the sober curious movement has developed progressively over the past decade and a half but has become highly prominent recently among social media influencers who pitch not drinking or drinking in moderation as pleasurable and beneficial part of the curiosity of the movement entails exploring the idea that social contexts generally associated with alcohol use can be enjoyable without it thus challenging social norms that position drinking as the default position in many social settings sober curiosity differs from complete abstinence the latter is supported by popular and wellknown organised periods of nondrinking such as dry july or febfast that are usually shortterm and validated through a philanthropic pursuit such as raising money for a cause sober curiosity is geared toward moderating consumption and decreasing risky drinking practices in a manner that is sustainable over the longterm encouraging an ongoing questioning of drinking alcohol and a decision to reflect on reasons for drinking relative to alcoholrelated health risks whilst a period of sober curiosity may ultimately lead to a decision to stop drinking completely the emphasis is primarily on reflectionand subsequent changerather than necessarily on complete abstinence the movement is a shift away from binary conceptualisations of normal versus problem drinking that might associate particular drinking practices with addiction and advocate full abstinence only 16 various other approaches to reduce alcohol consumption are possible including restrictions on availability for example through price control measures however with the exception of legislation policing driving under the influence of alcohol restrictions are often not implemented or enforced for political reasons and have limited feasibility 17 education measures such as public information campaigns and warning labels also vary in effectiveness 18 persuading behaviour change requires that consuming alcohol is recognised by the individual as being a problem however the vast majority of australian drinkers consider themselves responsible drinkers even though 68 of australian drinkers consume 11 or more standard drinks on a typical occasion 19 in this way the majority of people who are drinking over the recommended limits do not regard their consumption as risky or problematic which leads to alcohol reduction interventions being resisted or even unnoticed 20 efforts to reduce risks from alcohol intake often compete with the seemingly valuable aspects of drinking alcohol consumption a valuebase upon which industry capitalise 21 the sober curious movement and thus sober curiosity does not obscure or ignore womens reasons for consuming alcohol rather it encourages reflection on those reasons in our previous work we have explored how alcohol functions as a resource in womens lives and have identified that these uses of alcohol compete with public health risk messaging 14 research on sober curiosity is relatively new promoting the idea of reducing alcohol consumption through more mindful drinking is accompanied by an expanding market of alcoholfree beverages dry drinking venues or licensed bars offering alcoholfree options and increased visibility of these through their endorsement at popular leisure events sober curiosity not only represents a shift in australias culture of intoxication 22 but is also being appropriated by the alcohol industry in australia between 20162019 the proportion of exdrinkers increased from 76 to 89 23 sales of no or zero alcohol products increased by 83 in the 12 months following australias initial covid19 lockdown periods in 2020 24 since then there has been a substantial increase in the supply of alcoholfree wines beers and spirits linked to the sober curious movement globally sales of zero alcohol products are surging and are predicted to increase 24 in australia by 2024 24 there is an abundance of research on alcohol reduction from the perspectives of alcoholism and dependency also legislative or guidelinebased approaches and alcohol refusal but research on reduction toward moderate consumption as part of a global movement toward wellness which was prominent during the covid19 pandemic is a rapidly emerging area of interest 2526 research on sober curiosity is relatively new ours is the first australian study to our knowledge that reports empirical data on midlife womens sober curiosity in australia and other highincome countries it is young adults who appear to be driving alcoholfree lifestyles and drinking declines 27 28 29 for example in australia research notes a decline in drinking amongst younger people that is attributed at least in part to increasing pressure to value and prioritise healthy choices and lifestyles and be successful and productive 3031 similarly in the uk research suggests young people feel increasing pressure to hustle and achieve success in an increasingly anxious and uncertain social context leaving little time for the pursuit of pleasure or hedonism drinking alcohol may offer 32 there is also evidence that moderate drinking or not drinking is becoming increasingly socially acceptable for young people moving beyond the stigma or judgement that might traditionally be associated with alcohol refusal 3334 however women are overrepresented in programs promoting temporary periods of abstinence such as febfast or hello sunday morning 35 similarly platforms and spaces for expressions of sober curiosityincluding social media accounts contemporary quit lit and new online communities are mostly run by and used by women 36 participation in online sobriety communities fosters an inclusive space for likeminded individuals offering emotional and social support to others attempting to reduce or cease their drinking 3738 this support may be salient for women who may feel underrepresented in more traditional recovery communities 39 studies evaluating participation in these programs have shown that being newly sober provides opportunities for doing identity work 4041 such findings are echoed in other research with those new to sobriety for example research with recently sober women living in the uk suggests sobriety is an opportunity to reclaim control and agency over ones life and present a more authentic self 42 particularly for midlife women 43 within this research sober curiosity is framed as a flexible and positive lifestyle choice a decision to reduce drinking is promoted as beneficial for everyone and linked to wellness authenticity personal growth and improvements of the mind and body 34 such conceptualisations move away from medicalised language of addiction target a specific subset of the population and advocate for complete lifelong abstinence this previous research points to the desirable aspects of the expanding sober curious movement for women however against a backdrop of healthism 44 that is the increasing moral imperative to take responsibility for ones own health 3042 womens preparedness for sober curiosityand ability to engage with notions of wellness more widelycontinue to be overwhelmingly shaped by social class and this is not always considered this paper addresses this theoretical gap contextualising womens reflections on their drinking practices against the groundswell of a burgeoning wellness industry 45 materials and methods interviews were conducted with 27 australian midlife women and 2 womens advocacy groups living in adelaide melbourne and sydney in february and march 2022 by bl bl was a 39yearold woman with experience conducting qualitative interviews with midlife women on the topic of alcohol consumptionusing techniques of empathic neutrality and those akin to life histories which are suggested to increase validity by privileging womens own subjective meanings 46 sampling women who consumed alcohol but expressed interest in exploring reducing alcohol were recruited through a targeted facebook advertisement that asked are you sober curious ran for 2 weeks and was released in february 2022 this coincided with febfast and the advertisement was released while febfast was being advertised online initially 30 women were recruited but one became unable to participate after contracting sarscov2 another withdrew due to a significant life event occurring and one was lost to followup after completing the social class survey resulting in 27 participants in addition to individual interviews two interviews were conducted with representatives from advocacy groups for women to speak on behalf of women who are single mothers and who live in poverty this was because of limitations in access to women living with such experiences to explore the notion of sober curiosity as it relates to class we sampled for women with access to different levels and compositions of several forms of capitaleconomic but also social and cultural resources per bourdieus sociological model of class 47 to measure womens social class positionings we operationalised a novel sociological approach recently validated in the uk 48 and australia 49 and our previous study 1314 this approach extends beyond simple economic employment and educational markers and has contemporary relevance to the nuances of social class divisions and consumer behaviour that extend to the social and cultural dimensions that shape life chances and alcoholrelated outcomes we have provided detail about the survey tool we adapted from sheppard and biddles survey of australians social class in 2015 and shown its value for seeing social class in data on womens alcohol consumption behaviours elsewhere 8 the survey tool measures social class across three domains economic capital was measured as income property and assets social capital was measured by social contacts and occupational prestige of womens social networks and cultural capital was measured by the level of womens participation in various cultural activities to determine economic capital assets was measured by combining responses to the questions what is your annual income before tax or anything else is taken out what would you say is the approximate value of the property owned or mortgaged by you and roughly how much do you have in savings social capital was measured by totaling the number of a range of known occupations within the respondents social contacts and the average prestige of those occupations occupational prestige was assigned using the australian socioeconomic index 2006a validated index for occupational prestige for the following occupations secretary nurse teacher cleaner university lecturer artist electrician office manager solicitor farm worker chief executive software designer call centre worker and postal worker cultural capital was measured by a count of highbrow and emerging cultural activities per bourdieus description of cultural tastes respondents selected activities they had engaged in within the 12 months prior to completing the survey from a list of cultural activities including seen plays or gone to the theatre watched ballet or dance gone to the opera gone to museums or galleries listened to jazz listened to classical music and listened to rock andor indie music attended gigs played video games watched sports exercised or gone to the gym used facebook or twitter done arts and crafts socialised at home listened to rap music figure 1 shows the five social classes that resulted and have been collapsed into three classes on the basis of compositions of more or less capital for the purposes of presenting findings working middle and affluent int j environ res public health 2022 19 x for peer review 6 of 18 of consumption or relationship with alcohol selfreport data was utilised because it captures womens selfperceived levels of alcohol consumption which was fit for purpose for our study about womens perceptions of the possibilities for alcohol reduction that in turn influence their preparedness for sober curiosity our sample was mainly anglosaxon although several european migrants participated including one woman from germany and one from italy we did not purposively recruit aboriginal and torres strait islander women nor women from south asian or middle eastern ethnicities as we acknowledge the specific historical racial religious and ongoing health and social inequities that would require an intersectional study interview questions and approach the interviews were openended lasted on average 60 min and were focused on understanding the contexts that make midlife women interested in sober curiosity or willing to consider reducing alcohol consumption by exploring the factors that might enable alcohol reductions and allow women to consider reducing consumption we aimed to explore how and why womens women varied in their employment arrangements their experiences of covid19 countermeasures per statebased differences and their living arrangements some womens living arrangements changed as a result of covid19 lockdowns including relationship breakdown we recruited women who were alcohol drinkers at the time of the interview and were interested in moderating their consumption or abstainingie interested in the sober curious movement participants selfidentified as occasionallight moderate or heavy drinkersthere was some variation here as the main phenomenon of interest was the practices and processes associated with reducing or moderating alcohol consumption selfreport data was utilised because it captures womens selfperceived levels of alcohol consumption which was fit for purpose for our study about womens perceptions of the possibilities for alcohol reduction that in turn influence their preparedness for sober curiosity our sample was mainly anglosaxon although several european migrants participated including one woman from germany and one from italy we did not purposively recruit aboriginal and torres strait islander women nor women from south asian or middle eastern ethnicities as we acknowledge the specific historical racial religious and ongoing health and social inequities that would require an intersectional study interview questions and approach the interviews were openended lasted on average 60 min and were focused on understanding the contexts that make midlife women interested in sober curiosity or willing to consider reducing alcohol consumption by exploring the factors that might enable alcohol reductions and allow women to consider reducing consumption we aimed to explore how and why womens drinking practices develop why they persist and how these influences shape continuation or change in consumption patterns womens perceptions about any changes that would enable reductions and what they anticipated gaining or losing from reducing alcohol consumption were explored and also their perceptions of structural enablers and constraints on reduced intake for women like them interviews were conducted and recorded via zoom transcribed using otter ai and refined by author bl only two women did not want to conduct the interview on zoom and accordingly these interviews were conducted over the telephone and recorded via a digital recorder we did not perceive a difference in rapport or the depth of information collected by using either of the two mediums for data collection because we followed womens personal preferences all participants received a 30 shopping voucher to recompense their resources spent on participating ethics approval ethics approval was provided by flinders university human research ethics committee consent to conduct and record the interview was sought verbally and provided by all women and documented via the interview recording pseudonyms are used here to present findings data analysis data were managed using qsr nvivo version 13 data analysis software analysis followed a rigorous method of precoding conceptual and thematic categorisation and then theoretical categorisation 53 inductive coding was freehand paying attention to significant concepts nvivo 13 was then used for conceptual and thematic categorisation using a combination of inductive and deductive logic 54 an initial coding framework comprising opencoding emerging ideas from literature and media reports on sober curiosity guided coding of all transcripts authors bl and prw discussed themes to check for agreement in coding author prw read data summaries developed by bl and his expertise in social theories of risk and public health was utilised to expand theoretical interpretations and identified areas to improve explanatory rigorparticularly concerning womens motivations and intentions to reduce consumption deductively inferring social class differences interpretive discussions also took place with author en who has undertaken research on sober curiosity in the uk the coding framework was refined accordingly and applied to all transcripts nvivo 13 was used to generate matrix coding queries across social class attributes and conceptsthemes concerning sober curiosity classed patterning was identified and directed researchers to key excerpts for closer reading for example classed patterns were obvious in the coding organised under concepts such as future expectations health consciousness class identity sustainable change normalisation of drinking and across various positivenegative emotions that were described in the context of not drinking alcohol findings and discussion two overarching themes relevant to public health understandings of womens willingness and capability to reduce alcohol consumption emerged through the process of thematic categorisation and the factors that impact womens sober curiosity including womens perceptions of the possibilities available to them to not drink alcohol and the circumstances required for them to feel prepared to reduce alcohol consumption accordingly findings are organised by social class advantage and disadvantage the intent is to distinguish clearly social classbased patterns and differences in womens sober curiosity this allows us to readily identify inroads for public health approaches to alcohol reduction messaging segmented by levels of advantage and disadvantage in womens resources and their life chances affluent womens preparedness to reduce alcohol consumption desiring selfregulation through sober curiosity affluent women in our study have given sober curiosity extensive thought to the extent that several have selfimposed rules governing their consumption levels for example rosie who works in a fulltime professional role that she describes as taxing and has therefore limited her midweek drinking says i had all of these rules about alcohol and for the most part very successfully and certainly peoples perception would have been that i was very successful in controlling my alcohol consumption but what i actually felt was that all of these rules meant that alcohol was looming large in my life in a way that just didnt make any sense to me like all of the rules actually meant that i was thinking about alcohol all the time affluent womens preparedness to reduce alcohol consumption seems to stem from a desire to selfregulate as part of a perceived need for selfcontrol and health consciousness women in our studyrefer to desirable levels of consumption using the drinking occasion or setting as a barometer for gauging what is too much for example gloria comments on her impetus to reduce consumption as a realisation im above my weekly target and that its not even special occasion type of drinking her sober curiosity is an effort to eliminate midweek drinking sonia expresses dismay at being successful in life but unsuccessful at reducing alcohol consumption i suppose one of the things that i find really interesting about being a person who has an alcohol problem is that i am a kind of a high achiever at a ridiculous rate so i find it really hard that this is the one thing i cant solve and says i suppose it just frustrates me i think the best me probably would be better without alcohol or to be able to manage it in a more appropriate manner sonia explains she is not the only one she elaborates that her girlfriends are exactly the same as her in terms of their alcohol consumption patterns and perceptions of alcoholrelated risks and remarked upon the strong strings the alcohol has over them all adding she has selfdetermination in most ways except that one sober curiosity appears to be inhibited by the perceived utility of alcohol consumption for some it serves as emotional selfmanagement facilitating winding down and managing the strains on their time for example penny explains its drinking just about the fluidity of the moment and able to move with it affluent women in our study mostly occupy fulltime paid work roles in professional careers and some describe being at the peak of my career they said they feel their work is demanding and rewarding and it is integral in their personal and social class identity affluent women use words like hectic exhausted and achievement frequently and often in unison and as they rationalize alcohol consumption or as penny says explain how it takes the edge off when youve been on the rails all week for gloria sober curiosity competes with the value of alcohol and the ritualistic aspects of a drink when switching off between work and home and creating headspace from work or demarcating relaxation time she remarks that sober curiosity would be possible if she switched the narrative slightly to be away from the default position of the glass of wine to an alternative beneath the seemingly simple desire for selfregulation it seems gloria and affluent women like her are cognisant of more complex social expectations regarding respectable alcoholrelated behaviours she describes feeling negative emotions when expectations are unfulfilled myself and probably quite a lot of my friends who are very competent educated high functioning people that kind of shame does factor in i feel really ashamed that i cant get more on top of my drinking because i feel like im pretty on top of most things in my life but i do have this sense of shame and thats the one thing i just cant seem to really get on top of i feel a lot of shame about it which is interesting it gives me far more than it takes so its really hard to and its all ive thought about doing drinking part of this shame would be relieved through alcohol reduction which most of the affluent women explain feeling it would allow them better interactions and relationships with other people several of the affluent women who are mothers such as bronwyn describe complexities with parenting teenagers or young adult children and concerns about increasingly anxious young people and that reducing alcohol would allow for good role modeling to their older children and relief from the burden of worry about their older children however they also describe feeling peer pressure to drink when away on holiday with girlfriends which as bronwyn explains leads to excessive consumption and as gloria comments leads to moments of feeling regretful i crossed the line our analysis suggests reducing alcohol offered women a chance to cope with shame that they had failed in proper selfmanagement at work or in their role as a mother in some instances the shame seemed to manifest in women trying to manage the contradictions and tensions that too much alcohol consumption has with their identity as a good mother 5556 for example bronwyn comments i wouldnt tell most of my friends how much i actually drink whereas elizabeth describes a tolerance not necessarily encouragement to drink excessively amongst her friends we drink a lot and its very accepted both instances point to the possibility for alcohol reduction for affluent women the general need for selfpreservation was part of the value of drinking alcohol in the first place as ellen explains when she considers what she would lose if she reduced alcohol you would lose the ability to hide and push things back the ability to be able to shut myself down and relax affluent women also spoke of feeling that their struggles were invisible elizabeth explains we need recognition and to be recognised referring to a lack of recognition for her achievement of juggling multiple competing family responsibilities and career success in a role where gender bias exists the role of alcohol as a standin acknowledgment did not give women visibility but fulfilled their need to cope and this is evident in sonias comment its also because theyre insanely busy but then there is the sort of high functioning anxiety that comes with that busyness and that giving to everyone and i have a lot of girlfriends who are about my age so in their 60s were not really terribly alone in the sense that a lot of people who are drinking about a bottle of wine a day who really shouldnt be theyre intelligent capable and wonderful women who for whatever reason have been selfmedicating by drinking alcohol in such instances affluent women like ellen describe a flipside of reducing alcohol would be adding to her existing mental load it would cause unnecessary strain to completely abstain which requires management and would induce more stress contemplating reducing alcohol clearly can feel like a lot of work for affluent women when managing the mental load in their lives which is one of the reasons they gave for consuming alcohol in the first instance for some affluent women the benefit of alcohol is felt so acutely it is perhaps impossible to see drinking as a problem such as penny who says the motivation hasnt been strong enough to lean that way and i dont see alcohol as a problem the general sense was that giving up alcohol would need to result in a tangible noticeable and worthwhile outcome for women bronwyn remarks that the benefits of alcohol reduction would have to be really dramatic in order to make the strain required to abstain worth it affluent women perceive the idea of going without alcohol and completely abstaining confronting and sober curiosity appeals because they could retain a sense of agency and control and this seems to feel gentler you dont have to give up all together you can try and cut back affluent women want assistance to achieve sustainable longterm change and a good quality of life as long as possible others feel dissonance with the religious and philosophical stance of programs like aa or simply they cannot see themselves as represented within or suited to the program a peersupport type network emulating current programs that have been successful for other population groups but purposed for midlife women is possibly suitable sonia suggests i wonder whether something like the name of alcohol sobriety program but geared toward women in midlife and their reasons for consumption the supportive platform like that might be a way forward because from the women i speak to they are looking on social media and i know i wasnt sure i do are you on instagram everything almost everything theyve got is on social media it could be a very effective platform for us bronwyns narrative shows agreement with sonia and she recommends adaptations to the goals of the program to suit affluent midlife womens lived experiences i talk about this a lot with my friends a bunch of extremely busy educated women with sort of still crazy lives we talk about it quite a lot quite a lot of my friends are in the same situation they realise theyre probably drinking too much dependent on alcohol use it as a bit of a coping mechanism in life i think sometimes then when you go down the mentions alcohol sobriety program i just actually got so sick of reading these stories of women who say how their whole lives are transformed when they stopped drinking i just stopped reading the articles halfway through because im like no thats not me i dont want to totally stop drinking and alcohol isnt destroying my life but i am probably drinking too much alcohol i like this idea sober curiosity more around actually being curious and thinking about maybe reducing moderating being very mindful that youre drinking but not saying my goal is to never drink again most affluent women in our sample felt it would be appealing and desirable to go somewhere you can be a part of the normal warranting the assimilation and normalisation of reduced consumption within womens social and leisure spaces middleclass womens preparedness to reduce alcohol sober curiosity as civility and respectability within our data sober curiosity seems the most possible for middleclass women for a multitude of reasons reasons include womens concerns with the sustainability of drinking patterns they had established during covid19 lockdowns and a realisation that the stresses that lead to drinking alcohol in order to cope have not gone away because covid19 continues to impact their lives covid is going on for so long that its drinking a lot is not sustainable sober curiosity arose through experiences that resulted in feeling like alcohol takes more than it gives alcohol as giving is fiction and feeling boredom with daily living and looking for a personal challenge the drinking has become mundane not drinking is a new challenge some women link sober curiosity to the lifecourse and feeling ready for a new phase of life evident in statements such as i am developing an awareness of my own mortality and descriptions of nondrinking as identity work that people are experimenting with the middleclass was the only social class group where women mention the lifecourse from a physiological perspective and womens sober curiosity is encouraged when they felt reduced inflammation or hormonal disregulation by not drinking alcohol the menopausal symptoms are better without alcohol and menopause and alcohol is a really bloody hard combination civility and notions of respectability are key themes that emerged through our analysis of middleclass womens preparedness for alcohol reduction compared to affluent and workingclass women middleclass women speak about sober curiosity with undertones reminiscent of neoliberalism particularly prominent in their individual responsibilisation for drinking to excess and therefore for making reductions several middleclass womens narratives suggested reducing alcohol is a sign of personal strength and resilience for example alison says having a drink is nice to do when youre pretty wound up and weak and heather expresses feeling more disciplined and structured and that moderate drinking is a standard i want to set even where social influences and cultural acceptability of alcohol consumption are acknowledged middleclass women link limitations in the possibility of sober curiosity to personal motivation for example when asked about the factors that make reducing alcohol possible kelly responds tough to know i mean some of it is socialising i know that because ive got friends who drink family theyll drink so some of that will be that so who you are socialising with what youre doing so thatll be fun you know some friends particularly probably family somewhat cause ill just be drinking i think ill just have one more and im enjoying that taste and then you dont stop so theyre probably the main things almost feels like willpower really some middleclass womens logic for sober curiosity represents dutiful ideals and in several instances censure of irresponsible behaviour for example alison feels herself personally responsible for breaking the chink in the chain of alcohol and to establish new patterns for ourselves when she comments on australias heavy drinking culture alison says she feels affronted by the culture and participating in that she explains that this influences her preparedness to reduce alcohol consumption concerningly angie describes this personal responsibilisation for reductions as laborious and she feels it results in women sneaking alcohol and then justifying it as a valid rewardshe describes feelings of guilt and sadness surrounding her failure to moderate alcohol ruth explains her sober curiosity in the context of explaining the social popularity of heavy drinking amongst her peer network she is willing to be going against the grain she is familiar with the alcohol guidelines for moderate consumption in order to reduce health risk and remarks thats what i will stick to adding that im not afraid not to be cool she connects this to personal strength and remarks im strong enough to reduce alcohol her preparedness for sober curiosity seems motivated by personal responsibility to reduce drinking and she uses words such as destroy and sabotage to describe drinking to excess and wants to avoid those negative experiences for and by herself ruth does acknowledge that mental health options are unavailable or underutilised by women she knows and that alcohols role as selfcare or selfmedication makes sober curiosity less possible for them the women that are kind of using it as their medicine of choice rather than getting mental health plans or whatever they will fight you tooth and nail no no nothing wrong with me you know like no no they will not take mental health medication or seek the help or maybe its too hard to get the help so they get out now just go get a drink alcohol works thats like a chemist for them alison explains that for her sober curiosity is possible because of a social network that allows it for other middleclass women such as pamela reductions are only possible by flying under the radar and not making a scene of it among her social network she feels people hassle nondrinkers because they want their own drinking normalised certainly middleclass women observe heavydrinking norms among women like them for example mandy comments on the culture of drinking among mums that she feel glamourise alcohol joanne comments that it was difficult for her to feel part of her social network without drinking i often think afterwards i didnt have the same feeling of having been fulsomely in the social situation when ive been not drinking i have found that it hasnt felt the same kind of authentic socialising alison feels that focusing on alcohol would expose a personal failing of not coping potentially conveying to others that you are not an authentic midlife woman and mother who fits the right stereotype while on a similar theme of acceptability and expectations nancy remarks my partner is resentful if i dont drink because drinking is something she feels they do together that he thought symbolises to her partner that she is relaxed it seems alcohol reduction and interest in sober curiosity would each be more possible for middleclass women if their use of alcohol as a standin for absent support was taken seriously rather than joked about within a socially accepted culture of drinking which women express plays down the seriousness of their emotions and their emotional needs in relation to alcohol nancy says she is seeking options that are wholly relaxing not just momentaryalcohol is very momentary and there is an absence of alternatives raven describes feeling she is living in an invisible age in terms of appropriate support she feels there is suitable and purposeful mental health services for young people and there is a group chat in mental health prevention forums that would be good for midlife women so she wouldnt feel so alone alongside this alcohol is so readily available she says it can easily get into the house and she spoke about having used alcohol home delivery services raven feels it relieves some of the burden of her caring role when she couldnt leave her parents and describes feeling hypervigilant and says she was drinking in order to cope with the feelings of constant burden from caring our findings also suggest middleclass women have the affordances of resources to participate in periods of intermittent sobriety or fasts middleclass woman nancy feels this offers a defined period of time where no one questions alcohol abstinence and the philanthropic pursuit attached to fasts is considered a noble thing workingclass womens preparedness to reduce alcohol consumption complexities and impossibilities for sober curiosity many workingclass women in our sample describe feeling scared of what life without alcohol would be like quite a distinct difference from the narratives we heard from more affluent women who describe reduction as difficult to achieve but not impossible for workingclass women reducing alcohol seems particularly complicated and our analysis reveals the breadth of the value of drinking for such women that extends from and also beyond the intoxication of the drinking occasion into recovering the day after when we consider working class womens preparedness for sober curiosity we realise the deep layers of oppression that need to be peeled away before alcohol reduction can become a possibility particularly for women living with considerable disadvantage let alone something they feel prepared to do for example barbara describes feeling a deep seated loneliness and explains she lives alone in a caravan park where she is unable to house a pet for company the possibility for reducing consumption hinges on her finding happiness and confidence outside of alcohol i just want happiness and to be able to just go and do things and not need a drink to make me happy and outgoing alcohol consumption for each of the workingclass women seems a key form of enjoyment as celeste remarks alcohol is an only form of fun or interest something to look forward to and adds we dont get many other opportunities to feel carefree sober curiosity would reduce workingclass womens chances for reprieve from their hard lives and would require a presence when the desire and need is absence or distance from the difficulties of life such as barbara im drinking just to take me away from everything and im drinking to numb negative thinking and horrible stuff this poses a crucial barrier to preparedness and stifles workingclass womens possibilities for sober curiosity the workingclass women in our sampledescribe worrying about feeling exposed by having nothing to do and this worry manifests in alcohol consumption as barbara explains i get lonely and i get bored i lost a job back a year and a bit ago because i turned up at work smelling of alcohol and i have had more jobs since i drink alcohol like water and i was getting to the stage where i was drinking to combat the after effects of drinking that has been hair of the dog for my hangover the possibility for sober curiosity seems nonexistent in this continual and necessary engagement with alcohol recovering from the night of drinking and nursing a hangover seems to give some workingclass women something to do something to manage in the absence of another plausible way to occupy timecertainly the hangover is a valid if not sometimes revered experience in australias alcohol saturated society perhaps more valid than having nothing to do as mary explains at least you have a hangover perhaps a hangover offers workingclass women a distraction from the bleakness of life and its daily grinds certainly helen expresses concern about her own self and women like her what would life look like if we werent hungover mary explains i worry about what i would do with my time if i didnt have a hangover as an excuse and the alcohol numbs and the hangover provides a distraction having a hangover is spoken about in ways we interpreted as a productive means of demonstrating agency and regaining control actively engaging in disentangling yourself from real life it seems that an extension of the numbing effect of inebriation is the dull headedness of the hangover and both are coping strategies it follows that limits in possibility for sober curiosity among workingclass women were limits in their preparedness for alcohol reductions unlike affluent women who could identify avenues for support for more moderate drinking albeit not directed at their agegroup workingclass women cannot conjure up such support as celeste explains i think thats one of the things is you get scared about doing this because you think i dont want to give up alcohol for the rest of my life and i think its an eitheroreither you drink or you give up completely thats where i want to find that medium where do you talk to likeminded people who actually want to achieve that is there a group that you can actually say this is what i want to achieve the alcohol reduction programs that affluent women feel could be tailored to them cost money and this precluded participation among less wellresourced women we need to make free the ones that sell you stuff and say the perk is reducing your money spent on alcohol some of the workingclass women we interview describe feeling surveilled once they had searched for internet sources of alcohol reduction support and prefer the idea of phone consultations celeste says i dont think ive necessarily found something that is just about trying to change my drinking a little bit what i find interesting is obviously everythings monitored so you might search for that reducing alcohol and then all of a sudden im getting all these adverts for basically how to deal with being an alcoholic and its like no no im not saying im an alcoholic i certainly have a relationship with alcohol i dont need all that selfhelp stuff so ive not quite found anything yet thats supportive of women without it being weve all got a problem here sort of thing an advocate speaking on behalf of women in poverty delineated the layers of complexity experienced by workingclass women living on very low incomes for accessing suitable support for mental wellness in order to feel prepared to reduce alcohol consumption to get counselling depending upon your age you might need to go to a doctor and have a mental health plan and then you have x amount of sessions and its never free its just at a reduced cost then if you know of some community services you need to actually do a whole lot of introductory work before you can even access that service so its a lot of cost and emotional work and a willingness to put yourself out there before you can find any sort of level of support she also sheds light on the limitations for social participation and the need for peer support opportunities that acknowledge the limitations workingclass women face the ability to share with your peers when youre engaged in a professional network or you have a nice social network you can bounce around whats happening to your life in a trusted supportive space with like others but if youre isolated or youre trying to pretend in a group you start to isolate yourself away she added theres a whole lot of reasons why isolation based on money is a real factor and that we need to create a way for people women to speak and make sure that there are different sorts of support networks for them another advocate reminds us that workingclass women are also often single parents and this means if they spend time engaged in selfcare their full time position as domestic labourer and carer needs to be backfilled having a drink of alcohol as a standin support requires no engagement in any of these resource intensive and emotionally intensive processes and so this needs to be factored into reduction possibilities for workingclass women the timing of delivery of risk reduction messaging is also crucial in the current economic climate australian women on low incomes are dealing with inflation in the costs of living and interest rates increasing if they have borrowed money as one of the womens advocates remarks why the hell would you give up drinking now classsegmented approaches to alcohol reduction for women social class differentiated the factors that influenced womens preparedness for sober curiosity and most critically were the contextual and social class frames for their drinking more affluent and middleclass women discussed a desire for selfregulation and proof of willpower as motivations for sober curiosity most often this individual goal was nestled within a deeper social context comprising gendered social norms where they felt personal responsibility to control the direction of their lives even when circumstances were outside of their control our analysis suggests drinking alcohol is a means of managing social expectations or for coping for which women internalised responsibility and therefore felt drinking was something they felt they should personally manage for example women with more advantage felt that alcohol consumption rather than moderate or nondrinking options is normalised in their social contexts and are practices from which they had positive experiences and gained social and cultural capital for women with less advantage who consumed alcohol to manage difficult lives and negative emotions where alcohol consumption was less embroiled in socialisation and more so part of daily coping preparedness for sober curiosity was particularly limited extrapolating from our findings below are options for alcohol reduction targeting the social and cultural contexts of consumption that is the things that lead midlife women to drink or feel prepared to reduce drinking rather than womens individual drinking routines or habits segmented by levels of disadvantage options draw attention to and extend from the social factors and contexts that shape womens possibilities for sober curiosity and most arise from midlife womens own ideas put forward during the interviews drinking culture and social expectations the social settings women occupy that typically feature alcohol contain various avenues for supporting sober curiosity affluent and middleclass women who recognised aspects of social acceptability and socialisation in their social class responses to alcohol reduction possibilities noticed a general absence of nonalcohol options in settings where consuming alcohol is normalised an obvious avenue for change is creating womens social events or themed activities that do not involve alcohol current available options are often alcohol themed or sponsored by the alcohol industry or partnered with alcohol products increasing the visibility of these events and alternatives to alcohol in media marketing to women would support preparedness through demonstrating the social acceptability of sober curiosity for midlife women this would directly respond to women who noticed a general absence of modelling of midlife women nondrinkers and commented that sober curious social media influencers who are in the same phase of life would be helpful to normalise nondrinking among midlife women increasing support common to all the women in our studywas an absence of support for mental wellbeing but for different reasons on the basis of social class for affluent and middleclass women feelings of stigma and shame exacerbated mental instability and conflicted their feelings around admitting they were not coping with the struggles of multiple demands and this reduced preparedness for alcohol reduction our findings suggest that for affluent women improving the availability of accessible support services such as an online forum and tailoring them to be sites where women can debrief with other women and seek solace our findings differ from previous research 20 in revealing that some affluent women do see their alcohol consumption as a problem and this allows an openness to sober curiosity according to the affluent women in our study traditional sobriety programs designed to assist problem drinking require a complete overhaul and felt that the sober curious movement is a softer and more appropriate option it would increase their feelings of social engagement and connectedness allowing them to have open dialogue with other women about struggles that result in alcohol consumption in turn increase their preparedness for alcohol reduction for middleclass women making mental health care more available and accessible and particularly reducing the mental load caused by encouraging women to consider their drinking through campaigns that responsibilise women is critical because we know that while the normalisation of heavy consumption and women hiding consumption levels beneath dark comedy like termagants continues to occur and perhaps this is why women talk about the tensions they feel between drinking in order to be social and reducing alcohol consumption in order to manage health risks for middleclass women social media has a usevalue for sober curiosity and could feature influencers as peers who are reducing alcohol and are in the middle phase of life for less privileged women suitable support groups where women are not tasked with quitting in the absence of other structural or emotional supports might be helpful interventions should be designed to reduce feelings of surveillance and be mindful not to exclude women because they are unable to invest in themselves women on low incomes may be resourcepoor in particular ways that make stopping or even reducing drinking feel difficult to imagine or contemplate in formulating reduction options consideration of the resources required is warranted they need participation which requires trust safety literacy and confidence to explain what they are feeling and needing and to feel heard and supported women feeling shame about failing to embody the proper level of constraint and selfcontrol over their alcohol consumption is exacerbated for working class women by the shame that seemed to result from their stigmatised social class position limitations and areas for research extension we cannot be sure about how differences in womens life circumstances alongside their social class might increase their preparedness for sober curiosity several women spoke about distancing themselves from parental heavy alcohol intake and one woman mentioned smoking cannabis as her substitute for alcohol further exploration of how womens sober curiosity is shaped by differences in factors in addition to social class is a limitation of this study but seems like a relevant point of inquiry for future studies conclusions this study represents innovation in public health research to explore how current trends in popular wellness culture toward sober curiosity and normalising nondrinking or lighter drinking and increased health consciousness could increase womens preparedness to reduce alcohol consumption it offers insight into how we can drive public health change effectively to reduce population level alcohol harms via reducing alcohol consumption among midlife women and with sustained impact our findings reinstate the importance of recognising social class in public health disease prevention validating that socially determined factors which shape daily living also shape health outcomes and this results in inequities for women in the lowest class positions in this case the inequities are unequal opportunities to reduce alcohol and reduce alcoholrelated risks by exploring modifiable alcohol consumption practices through womens social class rather than focusing on individual consumption patterns we have provided ideas for structurally improving the conditions that would allow all women to feel prepared for sober curiosity if translated into tailored social classbased options to support midlife womens sober curiosity we can plan health interventions that are realistic within womens life contexts and therefore more likely to have a meaningful impactand progress toward achieving equity in the reduction of populationlevel alcohol harms data availability statement data summaries can be provided upon reasonable request from the authors informed consent statement informed consent was obtained from all subjects involved in the study

background urgent action is required to identify socially acceptable alcohol reduction options for heavydrinking midlife australian women this study represents innovation in public health research to explore how current trends in popular wellness culture toward sober curiosity ie an interest in what reducing alcohol consumption would or could be like and normalising nondrinking could increase womens preparedness to reduce alcohol consumption methods qualitative interviews were undertaken with 27 midlife australian women aged 4564 living in adelaide melbourne and sydney in different social class groups working middle and affluentclass to explore their perceptions of sober curiosity results women were unequally distributed across socialclasses and accordingly the socialclass analysis considered proportionally the volume of data at particular codes regardless socialclass patterns in womens preparedness to reduce alcohol consumption were generated through data analysis affluent womens preparedness to reduce alcohol consumption stemmed from a desire for selfregulation and to retain control middleclass womens preparedness to reduce alcohol was part of performing civility and respectability and workingclass womens preparedness to reduce alcohol was highly challenging options are provided for alcohol reduction targeting the social contexts of consumption the things that lead midlife women to feel prepared to reduce drinking according to levels of disadvantage conclusion our findings reinstate the importance of recognising social class in public health disease prevention validating that socially determined factors which shape daily living also shape health outcomes and this results in inequities for women in the lowest class positions to reduce alcohol and related risks

the south or from the north to the north at present most international migrants are of workingage and live in europe asia and north america apart from international migrants an astonishing figure of 740 million people is estimated to have migrated internally within their origin country 1 migration is as old as humankind people have always moved in search of better living conditions for themselves and for their loved ones or escaping dramatic situations in their homeland these two major drivers were the fundamentals of the push and pull theory that was first proposed by lee in 1966 3 encompassing economic environmental social and political factors pushing out from the individual homeland and attracting himher towards the destination country lees theory has the merit of being one of the first trying to identify in a modern and scientific way the drivers of such a complex phenomenon after ravenstein first addressed them in scotland in 1885 4 the main elements of the push and pull theory will also be considered in this article for didactic purposes but the author recognizes that in the current global world reality is certainly much more complex and faceted involving both local national realities and macrolevel causes as well as mesolevel and microlevel causes related to the link of the individual to hisher ethnic or religious group and the personal characteristic of the individuals respectively 5 recently the pullpush plus theory has also been proposed which considers predisposing proximate precipitating and mediating drivers of migration 6 regardless of the theoretical framework adopted the topic addressed by this article is difficult because sound scientific data are scarce existing literature is mainly qualitative and often presented as grey literature in addition geographical and cultural elements may influence the weight of the single determinant in different continents and in different periods finally although the various drivers will be presented separately we recognize that they are part of a unique complex scenario where they strongly interact definition of migrants according to the international organization for migration a migrant is any person who is moving or has moved across an international border or within a state away from his her habitual place of residence regardless of the persons legal status whether the movement is voluntary or involuntary what the causes for the movement are or what the length of the stay is a broad definition indeed under such definition and strictly limiting our analysis to southtonorth migrants two major broad categories may be identified labour migrants and forced migrants whose reasons to migrate may differ even if difference between the two categories are probably smaller that estimated once and the same migrating individual may fall in one or the other category at the same time 5 in this respect it is useful to report below the synthetic definitions of asylum seekers and refugees from iom 7 asylum seeker a person who seeks safety from persecution or serious harm in a country other than his or her own and awaits a decision on the application for refugee status under relevant international and national instruments in case of a negative decision the person must leave the country and may be expelled unless permission to stay is provided on humanitarian grounds refugee a person who owing to a wellfounded fear of persecution for reasons of race religion nationality membership of a particular social group or political opinions is outside the country of his nationality and is unable or owing to such fear is unwilling to avail himself of the protection of that country drivers of migration the factors acting together and determining the final decision of an individual to migrate may be subdivided in macroelements mesoelements and microelement those that have been more extensively studied will be discussed in this article inadequate human and economic development human development is enormously unbalanced in the various regions of the planet and the gap is increasingly wide the economic and political reasons underlying this sad situation are beyond the scope of this article and will not be addressed here the human development index is a composite index combining the performances of the different countries on health education and economics proposed by the united nations development program the 2016 hdi top ranking includes 15 western countries and 5 asian countries among the first 20 ranked nations 8 at the opposite extremity of the list 19 out of the last 20 nations with the lowest hdi indexes are from africa a striking difference however during the first decade of the new millennium many african countries experienced a remarkable economic growth with gross domestic product increases exceeding 5 in average according to the international monetary fund unfortunately the consequent relative wealth has not been equitably distributed in the population and the subsequent world economic crisis since 2011 has slowed down the economic performances of most african countries to a bare 2 yearly gdp increase as a consequence most jobs in developing countries are still in the informal sector with little salary and social protection thus nurturing the willing to find better job conditions elsewhere low performances in the health education and economic sectors are a reflex of the vulnerability of the health education and productive systems which is caused by the lack of economic and human resources with particular regard to the health sector such situations that provide little professional and economic motivation pave the way for qualified health professionals to leave their origin countries a phenomenon known as brain drain and creating a vicious circle poor health services little educated and qualified work force and poverty are a fertile background promoting migration of individuals in search of better life new communication technologies largely available in urban settings even in developing countries allows people to compare the western lifestyle with the local situations where the luxurious houses and cars of expatriates often contrast with the poor living conditions of the local populations the gradient of prosperity migration and development are strictly linked and influence each other paradoxically enough in fact migration may be driven by both a lack of development and by an increasing socioeconomic development in a specific country at least in the initial phase 9 demographic increase urbanization the worlds living population has increased in an unprecedented way during the last two centuries from 1 billion estimated to live in the year 1800 to the more than 6 billion living at the beginning of the second millennium to the roughly 11 billion that will probably inhabit the earth in 2100 10 the bulk of this massive increase is taking place in asia and africa where high fertility rates driven by infant mortality and poor birth control programmes result in high annual population increase rates on the contrary the fertility rate in western industrialized countries is shrinking according to the world bank the average fertility rates in high income countries was 17 children per woman in 2015 while it was 48 per woman in lowincome countries 11 as a global result the population of western industrialized countries is reducing in size and getting progressively old while the young workingage population of the developing countries is rapidly increasing the african continent offers a striking example from 493 million in 1990 the african population grew to 1 billion in 2015 and it is expected to rise to 22 billion in 2050 and to 4 billion in 2100 12 with particular regard to the african continent the increasingly young population will probably exceed by far the otherwise improvingbut not equitably distributedeconomy giving origin to the socalled jobless generation phenomenon this means that the increasing global wealth is not mirrored by a proportional number of jobs to satisfy the increasing expectations of the growing skilled young generation at least in the shortmedium term 13 as a matter of fact the flow of migration in relation to demographic increase could also be regarded in the opposite way raising the question why do so few people migrate 14 in fact even if the stereotype of migration proposes a model of mass invasion of rich countries by migrants from lowincome countries in terms of absolute numbers the proportion of migrating people is quite stable climate changes it is now almost universally accepted that the climate is becoming warmer and warmer at an increasing speed causing health inequalities across the world 15 apart from other unwanted effects it is also accepted that the driving causes of such climate changes started with the industrial revolution are mainly anthropogenic in nature and are largely due to the emission of greenhouse gases by industrial activities from carbonbased energy it has been estimated that 97 of such emissions occur in industrialized rich countries leaving a mere 3 emission coming out from lowincome countries 16 the impact of climate changes is astonishingly severe in the south of the world where 150000 are estimated to have died in 2000 from the consequences of the planet warming 17 drought flooding increases in arthropod borne infections due to vector spreading in regions where the contrast measures are difficult to implement due to scarcity of means also indirectly impact on morbidity and economic agricultural revenues the case of lake chad is extreme but enlightening from the nearly 25000 square kilometres lake chad had in 1963 its water now covers a bare onetwentieth of its original extension with severe impact on the fertility of the surrounding land this shortage of water food and agricultural resources forces people and livestock to move in search of a less hostile environment 1 examples of land degradation induced by climate changes are multiple and represent a driving force for people to migrate by producing food insecurity and risk of healthrelated crisis 18 according to the iom environmental migrants are those persons or groups of persons who for reason of sudden or progressive changes in the environment that adversely affect their lives or living conditions are obliged to leave their habitual homes or choose to do so either temporarily or permanently and who move either within their country or abroad 19 it has been suggested that the environment may impact on migration flows by directly affecting the hazardousness of place but also indirectly changing the economic political social and demographic context with very complex interrelationships 20 the climatic migrants as they are sometime called might possibly reach the astonishing figure of 200 million by the year 2050 according to the iom 21 however forecasts are difficult to make because sound scientific data on this topic are extremely scarce and do not permit reliable estimates 22 the assessment of the real impact of worsening environmental conditions albeit logical would greatly benefit from sound research studies wars and dictatorship even now at the beginning of the third millennium many areas of the worldin virtually all continentshost bloody conflicts and social instability where armed parties fight or where rude dictatorships are ruling and denying social rights some are wellknown to the public while others are not as is the case of the horn of africa and some areas of west africa and the sahelian region or in central and southern america 1 people may be denied basic human rights and the access to education and to a dignified life may be prevented especially for females fundamentalism is such countries may easily grow as it is the case with the deadly activities of boko haram in northern nigeria that it is estimated to have caused the internal displacement of nearly 2 million people 23 it is to be noted that the majority of displaced people in warring nations are relocated within national borders thus officially they are not considered international migrants but rather internal refugees land grabbing land grabbing is a phenomenon that has become increasingly important since the beginning of the new millennium the term land grabbing refers to the intensive exploitation of vast areas of land in rural areas of lowincome countries by private international enterprises or even by foreign governments in order to implement largescale intensive cultivations or to exploit minerals forestry or the touristic industry this happens to the detriment of the poor local population which is poorly compensated and virtually obliged to leave the rural areas to reach the degraded urban peripheries within their own countries where they often live a difficult life in a different setting from the one they and their families have experienced for centuries psychological and physical impairment is frequent in such communities and international migration may then occur apart from this direct impact the economic benefit of smallscale agricultural industry is of advantage of the local communities while the intensive exploitation of lands as a consequence of land grabbing is mainly to the benefit of the private enterprise stock owners and the international market 24 leading to the progressive impoverishment of the increasingly resourcepoor country together with environmental damages due to climate changes the loss of smallscale land property and its turning into intensive exploitation causes a progressive land degradation which leads to a progressive abandonment of native lands by a mass of people 25 religion this issue will only be briefly alluded to as it is too wide and complex to be adequately addressed in such context the history of humankind offers many examples of mass population movements caused by religion persecution or following the dream of a land where individual faith could be freely preached however these movements have often been the consequence of a political will as it has been the case of the conflictive muslim hindu and sikh movement across the newly created border between india and east pakistan in 1947 similarly jews flowed to palestine after the second world war also attracted by the law of return favouring migration of jewish people to the new state of israel in many other instances religion has been the pretext for ethnic persecution and expulsion as is possibly the case for the rohingya muslim population from myanmar or the mass movements caused by armed fundamentalists groups such as daesh or boko haram in the middle east and subsaharan west africa respectively sexual identity a number of countries have a quite restrictive policy on sexual identity and ltgb people face psychological and even physical violence forcing them to hide their sexual identity the impact of such policies on international migration has recently been the subject of some investigation that is in its infancy no doubt however that an impact exists especially from countries where machismo is considered a value 2627 a comprehensive overview of the issues related to the protection of social rights in those people forced to migrate due to their sexual orientation may be found in the 2013 thematic issue of forced migration review 28 education a final note has to be dedicated to the education level of migrants international migrants are often regarded as illiterate and poor people escaping poverty from remote rural areas this stereotype is far from being true in most instances for both economic and forced migrants migrants in search of a better future usually have a more pronounced initiative attitude and boldness than the average person with some skills and financial resources needed to plan and fund a longdistance journey as it is the case for international migration 29 in most instances they are more educated than their peers left behind in their origin country 30 sometimes they are even more educated than their peers in the destination country 31 in addition individuals from families or communities that already positively experienced migration in previous years are more inclined to migrate as their travel abroad is regarded as of possible benefit to the origin society 5 for such individuals the existence of ethnic or family links in the destination country is a further driver of migration the relationship between education and migration are twofold from one side the migration of educated people from lowmiddle income countries to oecd countries constitute a net loss of human qualified resources for the origin countries and a gain for the host country a phenomenon known as brain drain from the other side the financial and ideational remittances from destination countries may also have an impact on the education of nonmigration children and adolescents in their origin countries 30 personal willingness to migrate all the above drivers of migration act with different strength in different places to build the general frame at the macrolevel of each specific geographical economic and political situation however the mesoor even microlevels are also important in driving the final choice of the individual to migrate the influence of the ethnic group the family supportboth economic and societalis of the upmost importance for a specific individual to make the final choice to migrate or to stay educational level and access to financial means permitting to afford the migration travel have already been discussed above but other factors such as ethnic and social customs are also important the aspiration and desire to migrate is a crucial key factor that interacts with other external drivers of migration to build the final decision to actually migrate 32 health challenges in the destination country regardless of the mix of drivers leading to migration in any individual person migrants usually undergo a difficult integration process in the hosting community conversely the receiving country could also be obliged to adapt its social and health systems to face the needs of the hosted population in many instances this process is not without conflict for the cultural and economic adaptations that it implies from the health point of view although generalization is inappropriate due to the heterogeneity of provenance and epidemiology of diseases in the origin countries newly arrived migrants are usually healthy but more affected by latent infections than the host populations 33 requiring screening policies and links to care crowded and inadequate living conditions in hosting camps may also lead to infectious diseases outbreaks as recently reported in france 34 however despite the reported higher prevalence of selected infections in migrants including potentially diffusive respiratory tract infections the risk of significant spread in the receiving populations has been reported to be negligible if any 35 once resettled in the host country foreignborne individuals may face infectious exposure when travelling backoften accompanied by children born in the host countryto their countries of origin they are then referred as vfrs and represent a significant proportion of imported diseases in western countries as in is the case for imported malaria 36 pretravel advice in such vfr populations poses significant challenges to optimally address adequate preventive measures 37 however even the noncommunicable diseases burden is increasing among migrants as a result of changing alimentary habits in developing countries and to the progressive acquisition of western lifestyles after a few years in the receiving country 38 finally the cultural interaction between the migrant patient and the care provider is often not without conflicts the emphasis on the possible exotic nature of otherwise ubiquitous illnesses or on the contrary the underestimation of culturally bound complaints are often aggravated by linguistic barriers leading to potential medical errors the knowledge of culturally sensitive medical issues such as genital mutilations is generally poor in western physicians requiring specific training and research 39 conclusions in conclusion the migration flow is now a structural phenomenon that is likely to continue in the next decades while many migrants from lowincome countries aim to reach more affluent areas of the world it is to be appreciated that a similar or even bigger mass of people migrates to neighbouring lowincome countries in the same geographical area migration is always the result of a complex combination of macro mesoand microfactors the former acting at the society level and the latter acting at the family or even individual level the prevalence of a factor over the other is unpredictable among the macrofactors the inadequate human and economic development of the origin country demographic increase and urbanization wars and dictatorships social factors and environmental changes are the major contributors to migration these are the main drivers of forced migration both international or internal among the mesofactors linking the individual to hisher ethnic group or religious community land grabbing communication technology and diasporic links play an important role the role of communication technologies and social media to attract people out of their origin countries is indisputable today awareness of living conditions in the affluent worldalbeit often grossly exaggeratedcontributes to nurture the myth of western countries as eldorado the ease of communication with the diaspora and family members who migrated previously reinforces the desire of escaping from poverty to a challenging new life abroad however microfactors such as education religion marital status and personal attitude to migration also have a key role to make the final decision to migrate that is an individuals choice in any case the stereotype of the illiterate poor migrant coming from the most remote rural areas and reaching the borders of affluent countries does not stand the poorest people simply do not have the means to escape war and poverty and remain trapped in hisher country or in the neighbouring one some degree of entrepreneurship educational level social and financial support is usually requested for international southnorth economic migration and personal characteristics and choices also play a role this phenomenon has a positive aspect as the possibility of success of migrants increases as do remittances but also a negative one as the most active part of the origin country may be drained preventing local development usually even if generalization is inappropriate newly arrived migrants are in good health despite a higher prevalence of latent chronic infections however marginalization in the host country may lead to a deterioration of such health status a phenomenon known as the exhaust migrant effect host countries which may have also an economic benefit from migration in the medium longterm have to be prepared to receive migrants for the benefit of the migrants themselves and their native population conflict of interest none declared

more than 244 million international migrants were estimated to live in a foreign country in 2015 leaving apart the massive number of people that have been relocated in their own country furthermore a substantial proportion of international migrants from southern countries do not reach western nations but resettle in neighbouring lowincome countries in the same geographical area migration is a complex phenomenon where macro mesoand microfactors act together to inform the final individual decision to migrate integrating the simpler previous pushpull theory among the macrofactors the political demographic socioeconomic and environmental situations are major contributors to migration these are the main drivers of forced migration either international or internal and largely out of individuals control among the mesofactors communication technology land grabbing and diasporic links play an important role in particular social media attract people out of their origin countries by raising awareness of living conditions in the affluent world albeit often grossly exaggerated with the diaspora link also acting as an attractor however microfactors such as education religion marital status and personal attitude to migration also have a key role in making the final decision to migrate an individual choice the stereotype of the illiterate poor and rural migrant reaching the borders of affluent countries has to be abandoned the poorest people simply do not have the means to escape war and poverty and remain trapped in their country or in the neighbouring one once in the destination country migrants have to undergo a difficult and often conflictive integration process in the hosting community from the health standpoint newly arrived migrants are mostly healthy healthy migrant effect but they may harbour latent infections that need appropriate screening policies cultural barriers may sometimes hamper the relation between the migrant patient and the health care provider the acquisition of western lifestyles is leading to an increase of noncommunicable chronic diseases that require attention destination countries have to reconsider the positive mediumlongterm potential of migration and need to be prepared to receive migrants for the benefit of the migrants themselves and their native population

introduction the health of the oral cavity is part of the overall health of the body in the body health system because the mouth is the initial entrance of food into the body bad effects if the oral cavity is not healthy can cause various diseases such as cardiovascular and respiratory diseases and abnormalities in the respiratory teeth the proportion of dental and oral health problems in indonesia is also still high at 576 while in sulawesi it is around 689 which then has an impact on the prevalence of tooth loss in indonesia which is also still quite large at 2452 and cavities at 453 2 this shows that the prevalence of tooth loss still requires serious attention corroborated by tooth loss data reaching 23 at the age of 60 years while 7 at the age of 20 years 3 the complexity of dental problems and their treatment has caused various responses from the community in the search for treatment both modern and traditional although the era has been sophisticated until now dental care is still traditionally preserved for generations by the community in locality and has become a characteristic of andarea the inheritance of local culture that has become a value of trust in the community and preserved by its generation is a way to honor its predecessors this tradition is held as true traditions related to dental care are always maintained and not easily eroded because of the support from family or social environment where the individual grows and develops attention to dental health is very important but it is necessary to note the impact that can be caused if done without expertise and just preserving tradition data released by basic health research in 2018 stated that there is a high proportion of dental and oral health problems in indonesia at 576 while in south sulawesi there are 689 which has an impact on the prevalence loss of teeth and cavities one of the reasons is that people usually check their teeth if they experience complaints that cannot be treated by themselves the traditional habit of caring for teeth that is still carried out in the bugis community in south sulawesi is mappanetta isi the tradition of mappanetta isi is not only carried out when a person is still a child but until adulthood the tradition is still carried out because it is believed to strengthen and tidy the arrangement of teeth this tradition is introduced and carried out by parents to children since childhood especially for those who have grown permanent teeth by biting firmly into the cloth that has been wrapped so that the teeth of the upper and lower jaws meet while rubbing left and to the right and back each morning usually for a week and can be repeated at any time based on the data obtained that there is pain and soreness felt after doing mappanetta isi this could be due to strong pressure when biting the cloth however this did not last long and the next morning mappanetta the contents can be restarted this study is important to conduct to analyze family support on the preservation of mappanetta tradition of contents associated with dental health in modern medicine if the pressure is applied continuously without knowing how much energy is given it will result in the occurrence of trauma from occlusion or occlusion trauma to the patients teeth muscle mass disorders and jawbone or dental periodontal tissue that can result in periodontal tissue injury based on the previous background description the purpose of this study is to analyze family support in the mappanetta isi tradition as an effort to maintain dental health in the bugis community in south sulawesi methods using qualitative methods to interpret and analyze in depth family support for mappanettaisi as a cultural tradition of local wisdom of the bugis tribe in wajo regency in maintaining dental health data were obtained through observation indepth interviews and documentation related to mappanettas content activities during the study the research was located i n w a j o r e g e n c y s o u t h s u l a w e s i data types and sources primary data obtained directly at the research site by using interview guidelines and observation sheets as well as measuring the degree of tooth shakiness purposive selection of informants 1 key informant is a religious figure and community leader 4 main informants are people who carry out mappanettaisi activities and 1 supporting informant is a dentist secondary data in the form of dental patient visits and dental and oral diseases obtained from the health office books and related journals data collection observations related to the direct implementation of mappanettaisi and the interaction of each party involved indepth interviews on three categories of informants regarding tradition support beliefs family and impacts or complaints related to the activities of mappanetta isi and documentation related to the implementation of the mappanetta isi tradition data analysis using thematic analysis to find patterns of meaning from data that has been collected validity of data using source triangulation engineering triangulation and time triangulation extension of observations will be made if additional data are required results and discussion the research was conducted in marchmay 2023 in wajo district south sulawesi with 4 main informants 1 supporting informant namely the local dental health officer and 1 key informant based on table 1 it can be described that the age of informants who carried out the mappaneta content tradition during the study was not only children but until adolescence and parents were still doing it this asserts that if an individuals habits are considered positive for him then they will be preserved based on work and education it is illustrated that the tradition of mappanetta isi developed in the bugis community in this study and formed habits and values for its conservationists regardless of the level of education and occupation the results of research on family support for the preservation of the mappanetta isi tradition were generally introduced by their parents who also still maintain the custom as revealed by informants mappanetta isi ini saya lakukan karena saya percaya supaya tidak cepat sippo gigi dan dulu saya selalu diingatkan oleh orang tua dan sekarang juga saya selalu ingatkan anak dan cucu saya the same was expressed by another informant saya mappanetta isi setiap bangun tidur pagi sejak kelas 6 supaya gigiku kuat tidak cepat ompong seperti yang dikatakan dan dilakukan oleh orangtua saya the system of inheritance of traditions carried out by parents will be carried out by their children especially if it is easy to practice as revealed by informants based on table 2 regarding the frequency of informants based on tooth shak according to miller obtained from 5 people as informants it was found that in general all informants had 5 degrees of tooth shambles category 1 namely mild tooth wobble this happens because the average informant conveys doing mappanettaisi and routinely to the dentist 2 times a year so that the process of tooth growth and development is still well maintained saya diajarkan based on the information that has been described it can be concluded the theme and meaning obtained from family support for the mappanetta tradition content as follows there are many habits that grow and develop in society related to health as well as in south sulawesi which consists of several tribes and customs and is still preserved today one of the customs that is still carried out in the bugis community is mappanetta isi which vol 11 issue 1sp august 2023 4045 doi 1020473jpkv11i1sp20234045 ©2023 jurnal promkes the indonesian journal of health promotion and health education open access under cc byncsa license received 09062023 accepted 02072023 published online 02082023 began in childhood mappanetta isi is a traditional dental treatment to be strong and not easily toothless done with biting the upper and lower teeth using a holster usually done in the morning the trick by twisting the tip of the sheath and then bitten while the upper and lower teeth are back and forth back and forth the same thing is done left and right the goal is to make the jawbone more solid so it is not easy to shake another benefit felt by people who have mappanetta isi is not easy to experience dental rice disorders in old age masalah gigi terutama periodontal including loss in old age is indeed the most common complaint and is usually caused by a lack of attention to dental and oral hygiene and care based on the results of the study it was found that the habit of mappanetta isi because it has been felt the benefits by the previous people in the bugis community there is a sense of satisfaction and trust in dental care traditionally in order for the tooth structure to be strong so it was continued by subsequent societies according to sutana the nature of his research on the nginang tradition reveals that peoples charities determine their usefulness habits in the activities of a tradition show that society manifests self in the context of time and space associated with this study activities carried out for generations are efforts to preserve culture expressed orally and behavior aimed at maintaining healthy teeth and gums if it is associated with the theory of behavior formation by l green 14 family is a reinforcing factor in behavior especially if there are facilities that support the formation of such behavior as well as the tradition of mappanetta isi the role of the family in the formation of behavior is very influential on the individuals in the family the values taught will be internalized and become habitual patterns that will be passed on to their generations family is the most important part and is the first source of support in social life that a person receives as well as family functions expressed by friedman that families provide informational instrumental judgmental support and emotional support so that modeling or inheritance of behavior occurs in the home environment in the mappanetta isi tradition the family performs its function by providing emotional support in the form of attention and concern for their children informational support related to introducing and providing information and understanding of mappanetta isi instrumental support in the form of facilitating the implementation of these habits by using materials in the house such as sarong cloth as a basis for biting as well as assessment support in the form of motivation and direction to children to take care of their teeth so that they are neatly arranged and not easily shaken with meppanetta filling in the process of inheriting cultural values and traditions in the family environment played by parents by carrying out habits that will be seen noticed and internalized by children so that they feel these cultural values and carried out from generation to generation conclusion based on the results of the study it can be concluded that the role of family support in the preservation of mappanetta content is in the form of a process of socializing values by introducing practicing sharing experiences and paying attention to the aesthetics of their childrens teeth so that it is internalized and functions into a habit from generation to generation

background dental and oral health is very important because it is one of the highest indicators of individual health and disease that people complain about so various ways are done by individuals to maintain dental health both medically and traditionally various traditions of caring for teeth have been carried out for generations by the community one of which is mappanetta isi which is a traditional way of the bugis community in south sulawesi in maintaining dental health objective to analyze family support in the mappanetta isi tradition as an effort to maintain dental health in the bugis community in south sulawesi method research is descriptive qualitative with an ethnographic approach using observation techniques indepth interviews and documentation during the research informants consisted of 1 community leader as a key informant 1 health officer and family as support and 4 main informants of purposively selected research with the criteria of the bugis community who preserve the tradition of mappanetta isi the data that has been collected will be reduced catagorized and presented in narrative form data analysis with taxonomy data validity plan using triangulation results it was found that the preservation of the mappanetta isi tradition could not be separated from family support or other social support the role of the family is always to introduce and carry out the tradition to its generation using simple tools this strengthens the instillation of values and beliefs of the bugis community in wajo regency on mappanetta isi dental care conclusion family support is a factor in the preservation of the mappanetta isi tradition so that the custom can be accepted and is still practiced today

e p u b a h e a d o f p r i n t introduction retirement is a multifaceted decision with broad economic and social implications for modern society leaving the workforce has an inexplicable relationship with health outcomes and subsequent public policies however the cost and benefits of retirement on health and wellbeing has seen conflicting results some reviews find that retirement decreases stress improve health perceptions and lower the severity of medical diseases other studies however found that retirement increase social isolation and even advocate the benefits of working beyond retirement evidently different phases of retirement have unique effects on different dimensions of health demographic factors like age gender education marital status and socioeconomic status moderate the relationship between retirement and health there is also little consensus regarding the cost and benefits of retirement on health across different countries these suggests that there is substantial heterogeneity of health experiences among retirees making the relationship unique to each society several asian countries have conducted longitudinal aging and retirement studies but none exists in singapore singapore has experienced a significant decline in birth rate since the early 1970s with historic lows averaging 119 over the past ten years in 2018 older adults aged 65 years and above equaled that of youths 15 years and below described as a demographic time bomb by 2030 youths 15 years and below will plunge to 11 while older adults 65 years and older will reach 27 of the population simultaneously disability prevalence were projected to grow by fivefold in 40 years medical ailments like cardiovascular diseases cancers musculoskeletal disorders mental disorders will be the top leading causes of disabilityadjusted life years from 2017 in singapore as a result lifetime hospital expenditure is projected e p u b a h e a d o f p r i n t to increase by 30 posing economic and policy difficulties for long term care based on these predictions trajectories and profiles of retirement and health are likely to diversity presenting a challenge for policy makers on issues such as retirement adequacy healthcare spending longterm care and psychosocial issues such as ageism subsequently local policies need accurate data to format appropriate longterm health plans for the population to circumvent challenges related to the rise of aging in singapore the government convened an interministerial committee on the ageing population in 1999 to produce a report on the challenges opportunities and a policy roadmap to prepare for a rapidly aging population the report underscored the need for nationally representative cohort studies to inform policy the rhs was designed to obtain information with a clear understanding of aging in singapore especially to map longitudinal trajectories of health social and economic developments of the aged population this contribution provides microdata for policy making longrange planning for aging and simultaneously informs research practices about the current state of health e p u b a h e a d o f p r i n t adequacy among older singaporeans its aims are not restricted for local use and is aligned with international efforts to reframe aging and preventive health policy developments especially during covid19 recent efforts in southeast asia have amassed several longitudinal surveys of the aged population across the region the rhs compliments these international efforts to enable comparative studies of aging across datasets of other countries this rhs also contributes to the literature extant about the relationship between retirement and wellbeing detailing trajectories of retirement while accounting for a broad range of pertinent demographic factors and its impact on several health outcomes study participants in e p u b a h e a d o f p r i n t was unable to provide consent due to physical or mental disabilities and approximately 079 of wave one and 057 of wave two required an lar in particular the educational qualifications are representative of the baby boomer generation characteristics of singapores early beginnings as a third world country in the 1950s attrition attrition is of concern for longitudinal studies the rhs circumvents this in two ways the rhs oversampled during the initial phase to maximize sample size to ensure a reasonable number of followups by the second wave 18 participants were deceased an additional 2069 of the participants declined to followup this resulted in 7765 who were eligible for the second wave to ensure that the sample remains representative of the wider population the sample was refreshed by including an additional 1142 new ageeligible participants among these new participants 228 were proxy respondents and 079 required lars measurements the survey was catalogued into 10 sections with a broad range of topics related to physical and mental health employment and retirement characteristics financial status utilization of healthcare and insurance lifestyles and recreation and cognitive function these reflect psychosocial socioeconomic and health characteristics of the aging population in singapore health related developments in the rhs assessed for cancer high blood pressure hypertension cholesterol levels diabetes arthritis depression cognitive function and dementia among these diabetes hypercholesterolemia hypertension dementia and depression were identified as the top five chronic noncommunicable diseases in singapore e p u b a h e a d o f p r i n t table 3 provides a brief overview and describes items measured in each section to maintain consistency and comparability of data efforts were made to ensure that differences between the survey items for the first and second wave were kept to a minimal however some changes were required to enhance the clarity and relevance of survey respondents this primarily served to accommodate new priorities by the government in policy development data collection was outsourced to a global survey company through a public tender processwas done via facetoface interviews lasting between 15 to 2 hours participants were briefed about the scope and aims of the study and informed that all responses were strictly confidential to maintain anonymity the survey included questions about the respondents spouse or partner participants were allowed to disclose information on their behalf or have their partners answer directly for those portions of the survey participants were contacted within two months of the interview if necessary to ensure accuracy of the information respondents were compensated for taking part in the survey with cash vouchers worth s 50 if they completed the first wave of interview and cash voucher of s 10 upon completing the second wave of interviews to reinforce data representativeness weights were assigned to all sample units indicating how the respective population sizes are represented by each unit with adjustments for nonresponses both longitudinal and crosssectional weights can be applied to account for within sample and time variant characteristics this ensured that samples were nationally representative of census for gender ethnicity marital status education and socioeconomic status in singapore although no physical examination was conducted during the interview process the study was validated by forming limited linkages to relevant administrative data of the respondents and this also circumvented missing data the rhs sought approval from respondents to access administrative data from the ministry of health this enabled crossreferencing health data such as mortality morbidity comorbidities and e p u b a h e a d o f p r i n t disability additionally this link gave information about public healthcare utilization such as usage of community clinics outpatient visits and medical expenditure linkage consent rate was 94 for wave one and 96 for wave two key findings and publications the rhs was primarily set up to track retirement and health trends but this extends into evidencedinformed policy agenda setting formulation scenario planning communication and evaluation across domains of social and family development table 3 present a preliminary snapshot of demographics known to be important toward the relationship between retirement and health the data included adults from 45 years to enable researchers and policy makers to track retirement trajectories and transitions the proportion of ethnicities were also representative of the overall ethnic composition in singapore with a chinese majority broadly the rhs include participants from low and middle socioeconomic status which is generally representative of our broader society in general a large proportion of the population reside in midrange priced public housing subsidized by singapores housing development board compared to more expensive private housing also a smaller number attained a higher education which is reflective of the characteristics of local baby boomers in the early 1950s we present a preview of health and retirement descriptors over two waves for comorbidities high cholesterol and high blood pressure are the most prominent clinical diseases followed by diabetes among adults impairment for activities of daily living were relatively consistent across most activities but difficulties were relatively higher for managing finances and indoor mobility a unique feature of the rhs was that it accounted for the intention to seek work as well as employment status while there are studies that examine the intersection between work and wellbeing few articulate how underlying motivations to e p u b a h e a d o f p r i n t engage employment impact on health outcomes among retirees in this data most participants were either still under employment or unemployed with no desire to seek employment a report from the central providence fund in 2019 from rhs data found that 42 of participants did not withdraw their pension funds taking advantage of the interest rates from their pension scheme up to 51 of those who withdrew from their pension deposited the monies into private saving accounts and finance companies reflecting a desire for liquidity among older cohorts decisions to withdraw or retain finances in their pension depend on the tradeoff between meeting their current financial needs and investing their pensions funds for retirement in the same report 86 of working participants opted to transit into partial retirement before full retirement amongst them 58 preferred to enter partial retirement by gradually reducing their work hours and 33 preferred to reduce their workload beyond this other fields of disciplines such as health and epidemiological research have used data from the rhs e p u b a h e a d o f p r i n t another study examined the association between retirement intentions and employment after the statutory age of 67 in singapore where older adults with higher ses had a decreased risk of unemployment while those from the manufacturing sector posed an increased risk of unemployment this suggests that health care services need to help older adults clarify their intentions and attitudes toward retirement to prepare for productive aging additionally two studies demonstrated that the lack of intention to seek employment increased the risk of developing disability over a twoyear period and inversely those actively looking for work demonstrated a higher probability of recovering from a disability engaging in meaningful work activities potentially help adults with disabilities recover toward independence this meant that therapeutic efforts for disabilities may consider the benefits of purposeful engagement toward employment beyond retirement and health the rhs also found collaborations with other fields of study exemplifying its contribution to a broader extent of the literature recently a published study utilized the rhs to project longterm care needs the researchers modelled not only functional disability but also included social factors such as isolation and living arrangements including social factors such as these to project longterm care has received less attention especially for ethnic minorities in southeast asian societies they found that physical disability was projected to increase by fivefold and social isolation would escalate by fourfold over the next 40 years the study also found ethnic disparities in social functioning where malays were more likely to be socially isolated compared to chinese after adjusting for demographic variables therefore social functioning and ethnicity are potential factors to consider for local long term care policies strengths and weaknesses there are several strengths and weaknesses it is the first and largest nationally representative longitudinal study of aging in singapore providing significant detail on health e p u b a h e a d o f p r i n t psychosocial socioeconomic processes of aging the sample is nationally representative with weights that closely approximate the socioeconomic and ethnic composition of singapores population this therefore provide valuable insights for evidencebased policy interventions at a nationallevel the studys biennial design ensures that longer term withinsubject effects can be accounted for during modelling with unbiased estimates of factors affecting health outcomes across the study population furthermore the interview questions were carefully designed to provide rich resource for researchers undertaking research into the social wellbeing of seniors in singapore for instance the survey design introduced an innovative focus on family structure finally efforts were made to validate the survey by linking the respondents administrative data this serves to crossreference responses to ensure a high quality of reliability and representativeness of the data however the rhs is not without limitations administering the questionnaire with a plethora of topics proved challenging as such it is difficult to strike a balance between the breadth of the survey and its ability to track aging factors in greater detail the experience of aging can vary over time and thus the importance of different aspects of lives can change as a function of social and environmental pressures furthermore the survey may need to consider that cohorts are not always homogenous and aging can be experience differently according to the individuals lifetime experiences this means that standardized procedures to alter items and procedures in the survey to fit the changing socioeconomic landscape of aging need to be articulated b indicates the number of respondents who declined after completion of wave 1 to be followed up in wave 2 c legally acceptable representatives this project laid the groundwork to design resilience programs for older adults to promote recovery from disabilities e p u b a h e a d o f p r i n t frequent admission to public hospitals this project sought to distil the psychosocial factors associated with frequent admission to public hospitals in singapore insights from this study will lay the groundwork to design social service and community programs to decrease the risk of frequent readmissions e p u b a h e a d o f p r i n t ethics approval for the rhs was granted by the health promotion board medical and dental board section c employment status history and retirement respondents employment status and characteristics job history workplace features and employment characteristics of spousepartner section d financial background and status comprehensive assessment of assets primary sources of income residential property characteristics attitude toward housing debt loans liabilities bequest investments life insurance and includes financial information of spouse or partner section e sources of financial support and subsidies other sources include financial assistance from spouse children agency subsidies family adhoc and regular transfer of funds section f household expenditure amount spent on food transport recreation utility bills rent section g health insurance plans covers government schemes company healthcare benefit plans family insurance and any other insurance plans section h healthcare utilization consist of dental care outinpatient care nursing costs localoverseas surgery home care services day care usage family healthcare expenses usage of health aids health supplements and alternative treatments section i lifestyle factors linked to health assess for physical activity smoking drinking social connectedness and recreational lifestyles

restrictions apply to the availability of the studys data data were analyzed via limited secure access at the ministry of health collaborations are encouraged and interested parties may contact the corresponding author author contributions rn conceptualized the cohort profile outlined the methodology analyzed the data wrote the manuscript and acquired the funding ywt wrote the manuscript kbt provided valuable input into the conceptualization of the cohort profile

background a population is hidden when no sampling frame exists and public acknowledgment of membership in the population is potentially threatening 1 2 3 as a representative of hidden populations people who are infected with hiv aids tend to suffer pressure and discrimination however due to social environmental pressure and other factors there are many difficulties in conducting comprehensive and representative studies of the hiv population to date the study of this population has mainly focused on interviews and questionnaire surveys based on offline or online population sampling in most cases these traditional methods are inefficient limited in sample size and representativeness and challenged by privacy concerns and reporting error 4 5 6 7 8 as a result of the development of internet technology peoples social lives have undergone tremendous changes from offline to online people frequently publish send and share information in various virtual communities 9 thereby generating large amounts of data concerning online activity which can be useful for the study of hidden populations through analyzing such data it is possible to excavate the behavior patterns of hidden groups effectively particularly as the number of online community users is unprecedentedly large and it has been found that people are usually more honest and trusting when talking online 10 11 12 it is expected that characteristics excavated from largescale online community data may be more reliable representative and broad than those derived from offline data hidden populations are gathered in all kinds of virtual communities such that many scholars recruit or investigate hidden populations online 1314 especially recruiting respondents through links of online social networks 15 in recent years there have been many studies of hidden populations that have used snowball sampling and respondentdriven sampling in online communities 16 17 18 however studies of hidden populations that have directly analyzed their online data in virtual communities are rare and existing studies have mostly investigated social support for the targeted population for example winefield examined the content and frequency of messages in an internet support group to analyze the emotional support of women with breast cancer 19 im et al used thematic analysis to explore the social support of patients with cancer in internet cancer support groups through an online forum 20 coursaris conducted content analysis of postings from a selected online hivaids forum to assess the types and proportions of social support exchanged among the hiv population 21 instead of discussing social support for hidden populations in this study we try to understand the multidimensional characteristics of a hidden population by analyzing the massive data generated in the largest chinese online community baidu tieba specifically we aim to extract features of the online users in the hiv group with regard to various aspects including temporal patterns of online activity social network structure community structure and its connection to social distance and similarity of content emotional tendency etc most of these characteristics are typically difficult to study with traditional survey methods therefore online data mining serves as an important supplement for the study of hidden populations allowing researchers to investigate multidimensional characteristics of hardtoaccess groups with unprecedented richness of information methods data sources as the worlds largest chinese online community baidu tieba has attracted a large number of social groups based on common interests 22 baidu tieba is provided by baidu the dominant chinese search engine company established on december 3 2003 it functions by having users search or create a bar by typing a keyword if the bar has not yet been created it is then created upon the search bar refers to a forum providing a place online where users can interact covering topics related to games films popular stars books news diseases etc currently baidu tieba has more than 20 million bars and the number of active users has reached 300 million 23 to collect activity data on the hiv population in the online community we chose the largest bar related to hiv on baidu tieba hiv bar and used scrapy a fast webcrawling framework to extract the data we needed from the webpages by elaborately designing the crawler we were able to retrieve a complete dataset from the hiv bar for all records from january 2005 to august 2016 the dataset contains user information content of posts and the complete text of comments and replies the collected data are saved in the local postgresql database as three tables including a total of 72328 user records 76865 posts and 1726227 comments there is considerable heterogeneity in the number of posts and comments generated by each user while the majority of users wrote fewer than 4 posts and 15 comments a small proportion of users actively generated a large number of posts and comments the distribution of users comments and replies is shown in fig 1a based on the time of users posting in the hiv bar we can analyze the temporal characteristics of the online hivrelated group and differences from other groups as shown in fig 1b compared with the newsrelated users and men who have sex with men related users the peak time of posting for hivrelated users is 22002300 and the lowest period is 300500 it is worth mentioning that while the posts of ordinary users decline from 2000 those for the two representative hidden populations msmrelated and hivrelated users are on the rise initial inspection of the posts reveals that for ordinary users their online topics are around news concerning politics the economy and social issues for msmrelated users their motivation for online posting is mostly for entertainment and to meet partners and they are more active around midnight for hivrelated users their online topics are mostly related to consultation about hivaids and as they are more concerned about their health status they tend to go to sleep earlier than msmrelated people more sophisticated analysis of the online content can be found in the results section community mining for many online activities it has been shown that users tend to interact with others who are similar to themselves forming distinct network communities and stimulating studies on influencebased contagion or homophilydriven diffusion 24 25 26 27 however indepth examination of the characteristics and dynamics of online community structure for hidden population was rarely found in literature 2829 to fill in this gap of knowledge in this study we explore possible communities in the hiv population who are active in the hiv bar and analyze the characteristics and links of different communities to study the organizational model and behavioral characteristics of the hiv population using the response and comment relationships between users in the hiv bar as links and users as nodes we construct an interaction network of the hiv population as can be seen from fig 3a the degree distribution of this network follows a power law indicating large heterogeneity in the number of users with which each node interacts using community detection in concert with topic modeling is a useful way to characterize communities for online population 30 in this study we implement community mining from two perspectives first we classify the users according to the content of their posts and then discover user communities according to the topological structure of the interaction network it is worth noting that the clustering based on text similarity only focuses on the content of users posts regardless of links in the interaction network after extracting all the content in the posts of active users in the hiv bar we start the preprocessing of text such as text cleaning and word segmentation then use the doc2vec algorithm to construct the feature vectors of documents 31 finally we implement text clustering with the unsupervised algorithm kmeans to divide the users into groups with similar features since the kmeans needs to determine the number of clusters manually we use the sum of distances from all nodes to their cluster centers as a criterion to select the best number of clusters sse ¼ x k i¼1 x x∈c i j xu i j j j 2 where k denotes the number of clusters u i denotes the cluster center in cluster c i and xu i denotes the distance between node x and the corresponding cluster center u i k is then determined by minimizing sse we also carry out community mining from the perspective of the network topology based on the structure of the users interaction network we choose infomap 3233 which is a highly efficient algorithm for detecting nonoverlapping communities in directed weighted networks 3435 to detect communities in the interaction network the sizes of the two groups of communities we found are shown in fig 3b we can see that while the sizes of text similaritybased communities are all quite similar the interaction networkbased communities exhibit a wide range of sizes to explore the relationship between the text clusters and topological communities we first use topic modeling algorithm to extract the topics of documents and measure the similarities of topics among users in the same cluster since the latent dirichlet allocation model 3637 requires the specification of the number of topics the hierarchical dirichlet process model 3839 which is derived from lda and can automatically determine the optimal number of topics is used in the process of topic extraction in this study then for each cluster we calculate the average topic similarity which is the average of the similarities between all pairs of users in a cluster s c ð þ ¼ 2 n n1 ð þ x i j∈c s i j ð þ where n denotes the number of users in a cluster c and s denotes the topic similarity between a user i and another user j to measure the social distance of users in each community we calculate the network efficiency 40 which is defined as e g ð þ ¼ 2 n n1 ð þ x i j∈g 1 d i j ð þ where d denotes the length of the shortest path between a node i and node j in the figures of this paper the average topic similarity is denoted by s and network efficiency is denoted by e text mining to analyze popular terms in hiv communities and the context in which these words are used we use keyword discovery to extract the words the hiv population frequently posts online it is worth mentioning that these hiv communities are those found by community mining based on the content of posts in this study we discover popular keywords according to their tf idf values based on the word segmentation results we can calculate the tf idf value of each word so the popular keywords can be selected after removing stop words for the purpose of this study we define the popular keywords as the top 100 meaningful words with the largest tf idf value in a community in addition to analyze the topics the hiv population tends to discuss and the purpose of the members online activity topic detection is then carried out topics are discovered using the hdp model and we develop document clusters based on topic similarity thereby we can conveniently identify the themes of clustered documents ie the topics addressed by different users sentiment analysis sentiment analysis concerns analysis processing induction and reasoning related to emotional subjective text aimed at discovering the attitude of the speakers on certain topics or their emotional state by mining the text content of posts of users in the hiv bar we can analyze the emotional state of this group while both supervised learning and unsupervised learning can be used in this case 41 42 43 in this study we mainly adopt the rulebased method to analyze the emotions of each user in the hiv group and the tendency in sentiment of different communities to uncover the emotional characteristics of the hiv population 44 sentiment words extraction is mainly based on two popular chinese sentiment dictionaries the hownet lexicon and the national taiwan university sentiment dictionary both have approved ability of achieving high precision in the chinese sentiment analysis 4546 all posts by a user consist of a document according to the text of each document we extract the sentiment words then calculate the sentiment score based on the frequency and intensity of sentiment words it contains positive words score from 1 to 5 negative words score from 1 to 5 and the absolute values represent sentiment intensities if the sum of positive scores is greater than the sum of negative scores the document is considered positive finally each community is assigned a positive and negative score representing the percentages of positive and negative users respectively the precision and correctness of the dictionarybased sentiment analysis are further validated with a comparison to human judgments on a sample of 100 posts randomly selected from the data as one can see from table 1 additional file 1 table s2 and table s3 the precision and recall rate are above 85 and 89 respectively results community mining based on text similarity using text clustering we find 150 clusters each of which corresponds to a network formed by interaction between users we find a positive correlation between the average topic similarity of each cluster and the network efficiency of the clusters corresponding community as shown in fig 4a the correlation coefficient is r 070 indicating that the higher the network efficiency of the textbased community the greater the average topic similarity that is the closer the association within the community the more similar the topics the community members discuss moreover the average topic similarity of each textbased community also shows a positive correlation with the size of the largest weakly connected component 47 the maximal subgraph in which for every pair of vertices there is an undirected path and the correlation coefficient is 074 to explore this finding further we also analyze the correlation between the topic similarity and the network density 48 the results reveal that there is a significant positive correlation between the average topic similarity and the network density and there is a weak negative correlation between the topic similarity and the community size therefore the more frequent the interaction between users the greater the density and the efficiency of the users community and the greater the similarity among the topics discussed comparing the average topic similarity of the largest connected component in the community to the average topic similarity of all users in this community we find that the theme similarity of the connected component is much greater than the theme similarity of the community that is after excluding the nonconnected nodes the theme similarity within a community increases this is because there is a greater difference between the topics discussed by users who do not interact with each other community mining based on network topology based on network topology we find a total of 1948 communities of which 1605 are meaningful it can be observed that the degrees of connectivity of these communities are very high and the proportion of fully connected communities is 9988 ie 1603 out of the 1605 communities are themselves formed by nodes that are all weakly connected calculating the network efficiency and the average topic similarity of each topologybased community we find a significant positive correlation indicating that the greater the network efficiency the higher the topic similarity within the community this is in line with the finding concerning textbased communities above validating the positive correlation between network efficiency and text theme similarity from a network perspective communitybased text mining after extracting keywords for each community we find that there is a significant overlap of popular keywords between different communities the keywords appearing in most communities are presented in fig 5 we can see that words related to hivaids counseling and diagnosis eg hope infection feel may know appear very frequently most of the selftagged hivaids patients are willing to share their physical states as well as their own diagnosis or counseling on the online social network in addition among these popular keywords the negative words eg do not not cannot is not appear frequently indicating that there is a negative emotional tendency among the users in hivaids communities online moreover most negative words are related to anxiety and fear of aids eg these symptoms make me worry but i do not dare take a test it is worth noting that the phrase the first time occurs with high frequency such as the first time i checked hiv was in shanghai xinhua hospital for the first time i kissed a man and then we got a room in the bathhouse where people can sometimes call for sexual services in china i drank last night and had wtgj the short form of the chinese spelling for anal sex without a condom ie highrisk behavior for the first time this indicates that many people who suspect initial infection with hiv or have first contact with highrisk behavior tend to seek help and advice on a social networking platform in the beginning rather than immediately going to a hospital for blood tests we find a positive correlation between the topic similarity and the degree of interaction among community members the closer the community members the more similar the topics discussed in the community analysis of the topics discussed in these communities can reveal the needs and interests of hiv population we analyze the top ten communities with maximum network efficiency and topic similarity values and find that topics concerning hivaids diagnosis and treatment comprise a high proportion of the main topics of the hiv population as shown in fig 6 in addition it is worth noting that people tend to relieve their emotions in online communities expressing their anxiety horror compunction gratitude or other feelings communitybased sentiment analysis because sentiment analysis of communities based on network topology is very sensitive to the size of the community we implement the analysis for each user community based on the results of text clustering in the size of scatter represents the size of community and the color corresponds to the level of topic similarity fig 7a we can see that in most communities the proportion of users with negative emotions is greater than 50 indicating that most members emotions in these communities are negative moreover the proportion of negative users in each community is around 60 and has a weak positive correlation with community size we select communities in which emotional tendencies are extreme ie there are many more positive users in the community than negative users or vice versa to provide a comprehensive analysis of emotions specifically we choose the top five communities in which positive users or negative users respectively account for the largest proportion and extract the popular keywords posted in different communities according to the tf idf values the results are shown in fig 7b which shows that posts in extreme negative communities exhibit greater similarity with a percentage of different popular keywords of only 3575 that is 6425 of the keywords discussed in all these communities overlap in addition we find that most of these keywords are about hivaids testing and treatment physical condition and family in contrast the percentage of different popular keywords is as high as 56 in extreme positive communities and most keywords are about hivaids symptoms counseling testing treatment sentiment and family comparing popular keywords between the extreme positive and extreme negative communities we can see that in the extreme negative communities more words are related to horror anxiety repentance and other negative emotions eg acute high risk side effects however in the extreme positive communities users tend to express confidence inspiration gratitude hope and other positive emotions and most popular keywords are about the hivaids diagnosis and active treatment discussion summary of findings in this paper we analyze the mentality behavior and needs of the hiv population based on online communities formed by similar text content or by social interactions to understand the current living conditions and emotional status of the hivaidsrelated population online based on community data mining we have found that there is a positive correlation between the average topic similarity of the hiv community and the degree of internal interactions that is users discussing similar topics are more likely to interact and vice versa in hiv communities the topics of the online hiv groups are primarily related to hiv fig 5 common popular keywords appeared in more than 80 and 50 of hiv communities fig 6 distribution of topics in the hiv communities inner pie represents topics and the outer ring represents popular keywords in each topic aids diagnosis and treatment and there is a domination of negative emotions in this community discussion of the main results while it is a longstanding hypothesis that there is a correlation between similarity and friendship in human social activities 49 50 51 we demonstrate with real data that this is the case for online hidden populations the degree of interaction and the topic similarity among users is positively correlated in hivrelated online communities moreover this finding may provide insights for general social network studies for which there may also be a relationship between interaction content and network topological structure this study reveals that most topics of concern to the online hiv community are related to hivaids testing treatment and hivrelated consultation consistent with existing studies in which social support for the hiv population has been studied through textonly analysis 52 and we also find that many users who suspect initial infection with hiv or have first contact with highrisk behavior tend to seek help and advice on social networking platform as their first choice because of the traditional conservative culture in china people who are infected with hiv bear considerable social pressure and discrimination in china it is difficult to investigate the hiv population and to understand their needs accurately through traditional survey methods however we have found that the main topics of the hiv group online are related to hivaids diagnosis and treatment indicating that the hiv population tends to acquire hiv knowledge and seek help through online channels these all supports the notion that we can provide more effective and timely help for the hiv population through text mining of data they post online and it is important to improve support from online services for hivaids consultation and diagnosis to avoid privacy concerns and social discrimination through sentiment analysis we can see that negative emotions dominate in hiv communities and these emotions are mostly related to the anxiety of initially infected patients who tend to seek help and advice on social networking platforms as their first choice to foster better social management relevant agencies should pay more attention to the extreme negative communities it is important to put these potentially hivinfected groups under constant surveillance and to analyze their emotions continuously so that we can understand their needs and provide relevant guidance and interventions promptly with the rapid expansion of internet use in china a large number of people who are interested in hivrelated topics are involved actively online nowadays we have shown that there is great potential in extracting behavioral characteristics of such populations by analyzing the content and interaction networks generated online strengths and limitations by analyzing the text content and social network of the hiv group from the largest chinese online community we have demonstrated the usefulness of online data mining for systematic investigation of the characteristics of hidden populations there are several advantages with this methodology first the number of users in online communities is fairly large in comparison to the sample sizes achieved through traditional survey methods for hidden populations such as people infected with hiv second the richness of the data provided by online communities enables researchers to extract multidimensional characteristics of the target population including features s5 for details that are traditionally very hard to infer eg social networks emotional needs etc third the anonymity of online communities mitigates the privacy concern and users can express their views at liberty which ensures the accuracy of studies on hidden populations however it is worth noting that it remains to be validated that whether the findings concerning users in online communities can be extrapolated to the target population in real life the representativeness of the online populations in topicspecific communities differences in population characteristics across social networking platforms and the design and implementation of public health intervention strategies are yet to be studied in the future conclusion by analyzing the text content and social network of the hiv group from the largest chinese online community we have demonstrated the usefulness of online data mining for systematic investigation of the characteristics of hidden populations including temporal patterns of online activity social network community structure and its connection to social distance and similarity of content emotional tendency etc the methodology is of particular importance to china which is experiencing a heavy burden of hiv infection with surprisingly high number of new infections among certain populations such as msm 53 the rapid expansion of internet use and increasing online engagement thereby offer new opportunities for the study of hidden population with unprecedented sample sizes and richness of information our study also suggests that public health agencies should promote education online to reduce high risk behaviors and expand channels for hivaids counseling and testing such that those who are suspecting of initial infection could seek for advice in addition psychological counseling and guidance for hivaids patients are also in need as newly infected patients are greatly worried about their condition and are psychologically fragile 54 additional file additional file 1 supplementary information abbreviations aids acquired immunodeficiency syndrome hdp hierarchical dirichlet process hiv human immunodeficiency virus lda latent dirichlet allocation msm men who have sex with men authors contributions xl conceived and designed the research ccl and xl performed the research and analyzed the data xl and ccl wrote the paper both authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background traditional survey methods are limited in the study of hidden populations due to the hard to access properties including lack of a sampling frame sensitivity issue reporting error small sample size etc the rapid increase of online communities of which members interact with others via the internet have generated large amounts of data offering new opportunities for understanding hidden populations with unprecedented sample sizes and richness of information in this study we try to understand the multidimensional characteristics of a hidden population by analyzing the massive data generated in the online community methods by elaborately designing crawlers we retrieved a complete dataset from the hiv bar the largest bar related to hiv on the baidu tieba platform for all records from january 2005 to august 2016 through natural language processing and social network analysis we explored the psychology behavior and demand of online hiv population and examined the network community structure results in hiv communities the average topic similarity among members is positively correlated to network efficiency r 070 p 0001 indicating that the closer the social distance between members of the community the more similar their topics the proportion of negative users in each community is around 60 weakly correlated with community size r 025 p 0002 it is found that users suspecting initial hiv infection or first in contact with highrisk behaviors tend to seek help and advice on the social networking platform rather than immediately going to a hospital for blood tests conclusions online communities have generated copious amounts of data offering new opportunities for understanding hidden populations with unprecedented sample sizes and richness of information it is recommended that support through online services for hivaids consultation and diagnosis be improved to avoid privacy concerns and social discrimination in china

introduction as with other healthcare systems across the world the early months of 2020 saw the beginning of the covid19 pandemic and its effect across the canadian healthcare system the impact was widespread and included not only an increase in hospitalizations of patients with the virus but also other ripple effects including scarcities of supplies such as personal protective equipment and staffing shortages additionally throughout the pandemic healthcare providers in british columbia were faced with balancing professional duties and responsibilities with personal considerations including public backlash 1 and their own health issues which could include the effects of long covid in many cases healthcare workers were redeployed due to staff becoming sick or needing to isolate numerous surgeries and healthcare visits were postponed and there was a shift toward virtual visits andor decreased visits overall at this time many morally complex issues were encountered throughout the healthcare system including ethically fraught decisions related to resource allocation duty to care vaccine prioritization exacerbations of social and systemic inequities and being required to make choices when data were suboptimal 2 3 4 evidence from previous pandemics such as the 2003 severe acute respiratory syndrome outbreak the 2009 h1n1 influenza outbreak and the 2014 ebola outbreak indicates that having to face morally complex situations has a strong impact on healthcare workers emotional wellbeing and can lead to increased moral distress and injury 5 6 7 8 9 10 moral distress occurs when an individual identifies the ethically appropriate action but that action conflicts with personal values perceived obligations or institutional constraints 1112 when moral distress is severe and is left unresolved it may lead to moral injury 13 recent studies have shown that as with previous public health emergencies the covid19 pandemic has also led to moral distress experiences among nurses 14 15 16 17 18 physicians 15 16 17 18 19 20 and nonclinical healthcare workers 1718 additionally it has been suggested that covid19driven moral injury remains stable for three months even while moral distress declines 19 however the cause and nature of the moral distress related to the covid19 pandemic requires further exploration to determine how this experience manifests across different geographical regions and stages of the pandemic response this study is unique in that it sought to gain a better understanding and broader view of the moral distress experiences of bc healthcare workers during the covid19 pandemic to achieve this goal participants from varied professional backgrounds were invited to complete online surveys over different stages of the pandemic response the ultimate aim of the project was to identify effective ways to enhance individual and organizational resilience in order to support the healthcare system in managing pressures related not only to pandemics but also to other unknown or known potential stressors on the healthcare system such as climate change events and aging populations methods study design in designing the study we relied on interpretive description methodology an established approach to qualitativeknowledge development within the applied clinical fields proposed by thorne and colleagues 21 22 23 interpretive description supports the process of describing and interpreting the lived world as experienced in everyday situations to capture themes and patterns therefore its goal is not to study a representative sample to allow for generalizing findings to a wider population but to explore describe and explain human experience the study design was also informed by two contextual characteristics of the covid19 outbreak the existence of significant differences in terms of impact infection rates and management across geographical regions and the unprecedented dynamic nature and scale of the impact on society thus survey questions were original and unvalidated developed based on qualitative feedback from the population under study instead of using established moraldistress surveys which were developed and validated under different circumstances and with different populations in the first survey respondents answered a series of openended questions and the results were analysed for common themes the most common themes were then used to construct the second and third surveys which were deployed to validate and assess changes in the expressed themes over time ethics approval to conduct this study was obtained from the university of british columbias behavioural ethics board participant recruitment we used purposive sampling a strategy commonly employed in qualitative research to identify informationrich cases 24 the study was restricted to one canadian province bc individuals were eligible to participate if they were employed by one of the six provincial healthcare authorities that provided clinical care during the covid19 pandemic there were no specific exclusion criteria other than working in a health authority as we wished to capture experiences of moral distress at all levels of the healthcare system to identify participants study team members disseminated invitation letters through listserves posters and presentations and by snowball sampling data collection three surveys were distributed to bc healthcare employees between may 2020 and july 2021 all surveys included demographic questions such as age gender health authority religious affiliation ethnicity role number of years in the role and area of service and questions related to moral distress the questions related to moral distress varied between surveys as they were adjusted to align with different stages of the provincial response to the pandemic and to probe themes arising in the concurrent analysis it is worth noting that while the vast majority of healthcare workers were vaccinated for covid19 in early 2021 the vaccine order that mandated all bc hcws to be vaccinated came into effect on 26 october 2021 after these surveys were completed provincial healthcare authorities that provided clinical care during the covid19 pandemic there were no specific exclusion criteria other than working in a health authority as we wished to capture experiences of moral distress at all levels of the healthcare system to identify participants study team members disseminated invitation letters through listserves posters and presentations and by snowball sampling data collection three surveys were distributed to bc healthcare employees between may 2020 and july 2021 all surveys included demographic questions such as age gender health authority religious affiliation ethnicity role number of years in the role and area of service and questions related to moral distress the questions related to moral distress varied between surveys as they were adjusted to align with different stages of the provincial response to the pandemic and to probe themes arising in the concurrent analysis it is worth noting that while the vast majority of healthcare workers were vaccinated for covid19 in early 2021 the vaccine order that mandated all bc hcws to be vaccinated came into effect on 26 october 2021 after these surveys were completed figure 1 timeline of surveys superimposed on a graph depicting the waves of covid19 cases in bc canada as published by bc centre for disease control most relevant publichealth measures in effect during each survey period are also summarized 25 survey 1 was deployed between 8 may and 28 may 2020 at a time when the number of covid19 cases in bc had just started to increase several restrictive measures were in place and there was heightened social uncertainty that precipitated coping behaviours such as panic buying this survey included mostly openended questions that were then coded for common themes the most common themes were used to develop the closedended questions for surveys 2 and 3 to validate and assess changes in these findings over time freetext options were also included in surveys 2 and 3 to allow participants to describe new experiences survey 2 was deployed between 22 october 2020 figure 1 timeline of surveys superimposed on a graph depicting the waves of covid19 cases in bc canada as published by bc centre for disease control most relevant publichealth measures in effect during each survey period are also summarized 25 survey 1 was deployed between 8 may and 28 may 2020 at a time when the number of covid19 cases in bc had just started to increase several restrictive measures were in place and there was heightened social uncertainty that precipitated coping behaviours such as panic buying this survey included mostly openended questions that were then coded for common themes the most common themes were used to develop the closedended questions for surveys 2 and 3 to validate and assess changes in these findings over time freetext options were also included in surveys 2 and 3 to allow participants to describe new experiences survey 2 was deployed between 22 october 2020 and 17 march 2021 during this period there was a significant and stable increase in the number of covid19 cases and gatherings were still restricted but some facilities were able to operate to some extent and schools and daycares were open the third survey was distributed between 18 march 2021 and 31 july 2021 at a time when the number of covid19 cases reached the highest peak in bc and started to decrease again the widespread public vaccination program was launched and some restrictions such as on small gatherings were lifted data analysis sociodemographic data were analysed using descriptive statistics qualitative data analysis was conducted simultaneously with data collection each informing the other in an iterative process the analysis followed braun and clarkes 6step framework 26 to identify themes and patterns of meanings across the dataset this method involves the following steps reading and familiarization coding generating themes reviewing themes defining and naming themes and finalizing the analysis 26 results a total of 135 hcws completed survey 1 320 completed survey 2 and 145 completed survey 3 as shown in table 1 the majority selfreported as white females between the ages of 31 and 60 participants represented a diverse collection of professional backgrounds including nurses physicians paramedics allied health professionals researchers administrative staff managers and executives most participants across all surveys stated that they were experiencing moral distress in their work when asked to describe their experiences several interrelated themes emerged from the openended responses of survey 1 and continued to be expressed by respondents of surveys 2 and 3 as described in more detail in the next sections environ participants represented a diverse collection of professional backgrounds includi nurses physicians paramedics allied health professionals researchers administrati staff managers and executives most participants across all surveys stated that they were experiencing moral distre in their work when asked to d scribe their experiences several interrelated themes emerged from the openended sponses of survey 1 and continued to be expressed by respondents of surveys 2 and as described in more detail in the next sections experiences of moral distress theme 1 healthcare professionals capacity to serve patients as shown in figure 2 the main theme emerging from survey 1 centred on the hcw capacity to serve patients this theme included three subthemes changes introduc compromise the ability to provide patientcentred compassionate care pandemic pro cols prevent hcws from carrying out their professional duties and the effectiveness telehealth prefer not to respond 5 6 3 1 please note that numbers may not equal 100 due to rounding and for raceethnicity because participants could select more than one option 2 indigenous was not offered as an option in survey 1 as shown in figure 2 the main theme emerging from survey 1 centred on the hcws capacity to serve patients this theme included three subthemes changes introduced compromise the ability to provide patientcentred compassionate care pandemic protocols prevent hcws from carrying out their professional duties and the effectiveness of telehealth experiences of moral distress as explained by a survey 1 participant the very pillars of healthcare and social work practice patient centeredcare consent to accept risks right to selfdeterminationagency are no longer upheld these themes were corroborated and further explicated by participants responding to surveys 2 and 3 for example a survey 2 participant wrote ive witnessed a steep decrease in quality of care that can be provided by myself and other colleagues due to restrictive measures during an outbreak a survey 3 participant similarly wrote we see clients based on a waiting list however clients eligible for service were skipped over if they needed interpreters or had more complex needs which were difficult to meet under pandemic management protocols some respondents across all three surveys expressed concerns about how the effectiveness of telehealth and how a shift towards virtual visits could impact their capacity to serve patients with certain populations for example a survey 2 participant stated i am very limited in my facetoface encounters with my clients due to covid precautions and many of the ways i would have been able to support them are currently on hold almost none of my clients have phonesother means to telecommunicate so i really rely on facetoface encounters theme 2 risks a second theme emerging during the initial stage of the pandemic response centred on the risks that healthcare professionals were facing one subtheme focused on concerns over risks to themselves while a second subtheme focused on risks to colleagues family members and friends for example a survey 1 participant wrote i had to express my concerns to senior leadership and refuse to participate in a plan that was putting my colleagues at risk these subthemes were corroborated by participants of surveys 2 and 3 thus one survey 2 participant wrote i felt very scared about possibly having to provide direct clinical care which i dont usually do my family has risks for severe covid19 and poor outcomes while a survey 3 participant wrote i was asked by my manager to swap roles with a colleague in a highrisk area of the hospital early on during the pandemic due to their preexisting health conditions i felt uncomfortable doing so because little was known about how covid19 was transmitted it felt unfair that i was asked to put myself at risk in place of another colleague one additional subtheme related to the theme risk also emerged from surveys 2 and 3 which centred on participants being required to work regardless of personal challenging circumstances thus one survey 3 participant wrote personal and family struggles related to covid19 stress has been difficult i have felt forced to put my work over my family because it is so busy and it will let my team and patients down if i call in sick some respondents across all three surveys expressed concerns about how the effectiveness of telehealth and how a shift towards virtual visits could impact their capacity to serve patients with certain populations for example a survey 2 participant stated i am very limited in my facetoface encounters with my clients due to covid precautions and many of the ways i would have been able to support them are currently on hold almost none of my clients have phonesother means to telecommunicate so i really rely on facetoface encounters theme 2 risks a second theme emerging during the initial stage of the pandemic response centred on the risks that healthcare professionals were facing one subtheme focused on concerns over risks to themselves while a second subtheme focused on risks to colleagues family members and friends for example a survey 1 participant wrote i had to express my concerns to senior leadership and refuse to participate in a plan that was putting my colleagues at risk these subthemes were corroborated by participants of surveys 2 and 3 thus one survey 2 participant wrote i felt very scared about possibly having to provide direct clinical care which i dont usually do my family has risks for severe covid19 and poor outcomes while a survey 3 participant wrote i was asked by my manager to swap roles with a colleague in a highrisk area of the hospital early on during the pandemic due to their preexisting health conditions i felt uncomfortable doing so because little was known about how covid19 was transmitted it felt unfair that i was asked to put myself at risk in place of another colleague participants stated that their disagreements with the new protocols were causing moral distress for example a survey 2 participant explained that it is not clear that there is a balance between the costbenefit of some significant changes similarly a survey 3 participant was concerned that the restrictions were not always supported by logic or the current epidemiology the reasons for the disagreements were diverse including disagreements related to scientific understanding operational concerns or the provision of care impact of moral distress the impact of moral distress on survey respondents is shown in figure 6 by far the most common impacts were reports of stress anxiety and irritability many also expressed feelings of helplessness had difficulty sleeping and reported that their one additional subtheme related to the theme risk also emerged from surveys 2 and 3 which centred on participants being required to work regardless of personal challenging circumstances thus one survey 3 participant wrote personal and family struggles related to covid19 stress has been difficult i have felt forced to put my work over my family because it is so busy and it will let my team and patients down if i call in sick to take care of my familys mental health another participant wrote i have friends that work at the hospital who have immunocompromised spouses or roommates that were still required to work in highrisk areas and management was not supportive of them temporarily moving to a lower risk area disagreements with the new covid19 protocols a third theme was focused on disagreements with the new covid19 protocols participants stated that their disagreements with the new protocols were causing moral distress for example a survey 2 participant explained that it is not clear that there is a balance between the costbenefit of some significant changes similarly a survey 3 participant was concerned that the restrictions were not always supported by logic or the current epidemiology the reasons for the disagreements were diverse including disagreements related to scientific understanding operational concerns or the provision of care impact of moral distress the impact of moral distress on survey respondents is shown in figure 6 by far the most common impacts were reports of stress anxiety and irritability many also expressed feelings of helplessness had difficulty sleeping and reported that their experience of moral distress had either increased or decreased their ability to empathize with others for example a survey 2 participant expressed im now having literal nightmares about lack of vaccine lack of ppe etc especially on the night before i come back to work while a survey 3 participant said that they were suffering from ptsd and will need counseling unfortunately there is no time to find help right now with the workloads demands and endless amounts of needed overtime we are forced to decide whether we leave our colleagues working short or to put our mental health first always mental health is pushed aside while yet another survey 3 participant said i am burnt out i would like to leave the healthcare profession at this point i dont feel that the financial compensation is worth the mental and physical distress disagreements with the new covid19 protocols a third theme was focused on disagreements with the new covid19 protocols participants stated that their disagreements with the new protocols were causing moral distress for example a survey 2 participant explained that it is not clear that there is a balance between the costbenefit of some significant changes similarly a survey 3 participant was concerned that the restrictions were not always supported by logic or the current epidemiology the reasons for the disagreements were diverse including disagreements related to scientific understanding operational concerns or the provision of care impact of moral distress the impact of moral distress on survey respondents is shown in figure 6 by far the most common impacts were reports of stress anxiety and irritability many also expressed feelings of helplessness had difficulty sleeping and reported that their since participants could select multiple themes it is not possible to calculate percentages current and anticipated ethical challenges survey respondents were also asked to describe the main ethical challenges they believed hcws currently faced or would be facing in response to the covid19 pandemic table 2 shows responses in descending order of popularity with more detailed explanations of each theme provided below current and anticipated ethical challenges survey respondents were also asked to describe the main ethical challenges they believed hcws currently faced or would be facing in response to the covid19 pandemic table 2 shows responses in descending order of popularity with more detailed explanations of each theme provided below covid19 fatigue a new theme that arose in surveys 2 and 3 was the most popular overall in response to the question about current or future ethical challenges this theme referred to being tired of all covid19 related matters as stated by a survey 2 participant i for sure have covid fatigue definitely i have compassion fatigue i am snippy with my colleagues i am exhausted helping family patients and my colleagues deal with their lives and issues this has been a hard time and serious struggle collateral impacts of covid19 a second new theme that emerged in surveys 2 and 3 as an ethical challenge that respondents were facing or could face in the future referred to the collateral impacts of covid19 including exposing social inequities in healthcare and effects on the overall populations mental health for example a survey 2 participant wrote the collateral impacts of the covid restrictions and policies are a huge problem and it feels as if its not being talked about or acknowledged enough beyond the frontline many healthcare workers see it and worry about it every day and its extremely upsetting while another participant wrote i am concerned about the social inequities and further impact on families that are already challengedreduced access to services technology mental health safety additional current or anticipated sources of ethical challenges other themes that were considered by the participants to be a current or future source of ethical challenges were similar to previous answers about moraldistress experiences these themes were again centred around the ability to serve patients disagreements with the implemented pandemic management protocols and the risks faced by the participants their colleagues or family members and to a lesser extent the effectiveness of telehealth interestingly participants stated that not having a safe environment to discuss disagreements with colleagues or leadership regarding the covid19 protocols that should be implemented was also identified as a current or future ethical challenge sources of support respondents were also asked to identify the main sources of support they had used to cope with the negative psychological impacts of covid19 informal resources such as selfcare resources and support provided by colleagues family members or friends were identified as the mostpopular sources of support followed by professional or formal sources of support such as discussions with supervisors or the use of counselors finally respondents to surveys 2 and 3 were asked to identify the top sources of support they would like to see established by their employer mental health supports were the mostpopular response for both surveys these supports included improved access coverage and quality of mental health support and increased resources for staff wellness including mindfulness sessions yoga gym time a place to relax and opportunities to socialize in survey 2 improving communications was identified as the secondmostpopular recommendation which included suggestions such as creating a safe place for discussions about pandemicrelated challenges and providing consistent clear unbiased transparent and personalized communications done at regular timely intervals and scheduled effectively to allow time for planning the secondmostpopular theme for survey 2 was directed at leadership this theme was followed by recommendations related to improving workload management and increasing financial compensation for all employees including administrative staff and management as well as introducing paid wellness days as a survey 2 participant explained it has been difficult to restrejuvenate a few personalpaid days off would be helpful the fulltime grind is more arduous than normal for a year now increased fatiguestressmentally emotionally exhausted interestingly by survey 3 the relative predominance of these categories had changed while improving access to coverage of and quality of mental health support remained as the mostpopular support suggested to be implemented workload and financial compensation emerged as the secondmost popular while improving communications and lead finally respondents to surveys 2 and 3 were asked to identify the top sources of support they would like to see established by their employer mental health supports were the mostpopular response for both surveys these supports included improved access coverage and quality of mental health support and increased resources for staff wellness including mindfulness sessions yoga gym time a place to relax and opportunities to socialize in survey 2 improving communications was identified as the secondmostpopular recommendation which included suggestions such as creating a safe place for discussions about pandemicrelated challenges and providing consistent clear unbiased transparent and personalized communications done at regular timely intervals and scheduled effectively to allow time for planning the secondmostpopular theme for survey 2 was directed at leadership this theme was followed by recommendations related to improving workload management and increasing financial compensation for all employees including administrative staff and management as well as introducing paid wellness days as a survey 2 participant explained it has been difficult to restrejuvenate a few personalpaid days off would be helpful the fulltime grind is more arduous than normal for a year now increased fatiguestressmentally emotionally exhausted interestingly by survey 3 the relative predominance of these categories had changed while improving access to coverage of and quality of mental health support remained as the mostpopular support suggested to be implemented workload and financial compensation emerged as the secondmost popular while improving communications and leadership was lowered to third place discussion these findings offer a snapshot into the moral distress experience of bc hcws at several time points during the covid19 pandemic the longitudinal and regional aspects of this study improve our understanding of how moral distress experiences during covid19 manifest differently in different contexts and how they evolve over time in response to a continued stressor the majority of participants who selfselected to complete these surveys stated that they experienced moral distress which is unsurprising given that they may have been attracted by the topic of this study and the title of the surveys and therefore decided to participate due to their current situation at work the themes identified by the first survey offer an overview of participants common concerns during the initial stage of the public health response to the covid19 pandemic in bc this initial stage was characterized by the presence of heightened uncertainty and the introduction of several restrictive social measures and pandemic management protocols across the healthcare system in this context bc hcws participating in this study stated that they experienced moral distress due to two main reasons the impact that introduced changes were having on their capacity to serve patients and the new risks related to covid19 transmission and infection that they had to personally face more specifically bc hcws were concerned about not being able to provide patientcentred compassionate care not being able to carry on their professional duties effectively and about the impact of telehealth they were also concerned over the risks that they their colleagues family members and friends were facing including the presence of personally challenging circumstances in some cases an additional source of moral distress centred on having disagreements with the pandemic management protocols that were being introduced these results align with previous studies 14161720 and highlight how by challenging standard professional routines and approaches to effective compassionate and patientcentred healthcare delivery the implementation of pandemicmanagement protocols contributes to moral distress they also suggest that the pressure to prioritize the health and safety of patients and communities over their own safety and that of those closest to them leaves hcws feeling vulnerable and overburdened these sources of moral distress continued to be present during surveys 2 and 3 despite the fact that those surveys were deployed at a time when some social restrictions had been lifted and progress was being made in the provincial vaccination program this finding highlights the constant pressure that bc hcws experienced during at least the first 15 months of the bc pandemic response and contrasts with that of song 27 in their study which also included several surveys deployed at different times during the covid19 pandemic the authors found that by stage 2 the participants expressed resignation around adapting to the new normal 26 the fact that this theme did not emerge in our study highlights how contextspecific the impact of the covid19 pandemic can be importantly participants identified two sources of current or anticipated ethical challenges covid19 fatigue and the collateral impacts of the pandemic response as the pandemic progressed and hcws had to continue to endure the moral stressor as they simultaneously experienced increasing fatigue interestingly this fatigue was associated to an increased concern over the unanticipated consequences that the pandemic was causing to more vulnerable populations with concerns over the quality of the clinical care provided and to disagreements with the protocols in place study participants stated that they were relying on personal sources of support to cope with moral distress this result highlights the importance of individual factors in managing this type of negative experiences which are deeply personal 28 however as previous studies have indicated 2930 broader institutional strategies are also required our study shows that it is important for hcws that such institutional strategies are individualized centred on meaningful effective communications between leaders and staff members and address operational concerns by for example managing workloads effectively and introducing financial compensation limitations of the research this research was limited by several factors first the research was conducted solely in bc which compared to other areas of canada and the world had a unique experience of the pandemic in terms of the timing of certain events including the impact of different waves of the pandemic vaccine roll out vaccine acceptance etc however while the experience was unique there were also many commonalities to other geographic regions including significant disruptions to societal functioning due to public health measures such as lockdowns social distancing and travel restrictions as well as significant disruptions to the healthcare system as such although our study was geographically circumscribed its results can likely apply across other jurisdictions a second limitation relates to the characteristics of the hcws who selfselected to complete the survey the majority of participants worked for two of the five health authorities and the sample size is insufficient to be scientifically representative therefore the results discussions and conclusions described in this paper are strictly related to the sample researched and are not necessarily representative of the experience of all hcws in bc however as aspects of the pandemic response were unified across the province results are nonetheless informative in addition survey respondents were more likely to selfselect if they were interested in the study due to their experience of moral distress during the pandemic however because the aim of the study was to characterize the experience impact and response to moral distress during the pandemic the selfselection bias likely had a positive impact on the permeation of moral distress in the sample finally the study was predominantly completed by individuals who identified as white females between the ages of 31 and 60 this demographic characteristic is reflective of the makeup of the healthcare system yet underrepresents the voices of those who likely faced significant and unique impacts of the pandemic including those who were nonwhite newer immigrants and of lower socioeconomic status future research directions several future research directions are suggested to improve the ability of the healthcare system to respond effectively to moral distress in particular our team plans to conduct additional work to test the reliability of the survey tool and complete followup research regarding the experience of healthcare workers who are racialized and face systemic barriers and inequities in order to determine whether the coping mechanisms identified in this study are applicable accessible and likely to be effective to them and the communities they represent in addition further efforts to address psychological health and wellness in effective lowbarrier and culturally appropriate manners are essential finally further work and consideration should be given to how to prepare healthcare workers during early stages of their careers for the conflicting values and responsibilities they may face during publichealth emergencies conclusions this qualitative study showed that many bc hcw survey participants experienced moral distress during the initial stages of the covid19 pandemic as they struggled to provide effective compassionate and patientcentred care while also facing significant personal risks many also disagreed with aspects of the pandemic management protocols results demonstrate that covid19 fatigue and the collateral impact of the pandemic introduce additional layers to hcws experiences of moral distress coping strategies were identified at the individual team and organizational levels including providing personalized support increasing the effectiveness of the communications between leaders and staff members addressing operational concerns by managing workloads effectively and introducing financial compensation these strategies can be used by organizations as potential starting points to facilitate both individual and system recovery this study adds to the literature on moral distress by highlighting the scale of the impact that pandemics can have on all aspects of the healthcare system that is beyond critical care which is the main focus of the moraldistress literature it also highlights how the societal impact can be a source of moral distress for hcws finally study results identify specific measures that healthcare organizations can implement to mitigate the experience of moral distress and inform healthcare leaders about the importance of maintaining and retaining a skilled workforce that has been significantly battered by the pandemic this is particularly important given the impacts on healthcare workers and the healthcare system by long covid19 and the continuing impacts of variants of concern leading to staffing shortages as well as supplychain shortages these shortages continue to place pressure on the healthcare system in multiple ways including complex and morally distressing triage decisions and fatigue ongoing monitoring of the impacts of long covid19 and the pandemics successive waves on the moral wellness of staff are essential to ensure adaptive and evolving strategies to aid in healthcare workers wellbeing and overall system function data availability statement the deidentified aggregated study findings are contained within this article individual survey data are available on request from the corresponding author and will be deidentified prior to sharing supplementary materials the following supporting information can be downloaded at supplementary s1 survey 1 supplementary s2 surveys 2 and 3 author institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and was approved by the university of british columbias behavioural research ethics board approval was given on 28 april 2020 informed consent was obtained from all participants involved in the study informed consent statement written informed consent was obtained from all participants to conduct and publish this paper and all participants were assured during the informed consent process that their responses would remain confidential

pandemicmanagement plans shift the care model from patientcentred to publiccentred and increase the risk of healthcare workers hcws experiencing moral distress md this study aimed to understand hcws md experiences during the covid19 pandemic and to identify hcws preferred coping strategies based on a qualitative research methodology three surveys were distributed at different stages of the pandemic response in british columbia bc canada the thematic analysis of the data revealed common md themes concerns about ability to serve patients and about the risks intrinsic to the pandemic additionally it revealed that covid19 fatigue and collateral impact of covid19 were important ethical challenges faced by the hcws who completed the surveys these experiences caused stress anxiety increaseddecreased empathy sleep disturbances and feelings of helplessness respondents identified selfcare and support provided by colleagues family members or friends as their main md coping mechanisms to a lesser extent they also used formal sources of support provided by their employer and identified additional strategies they would like their employers to implement eg improved access to mental health and wellness resources these results may help inform pandemic policies for the future

introduction background african americans continue to experience disproportionately higher rates of cardiovascular disease and metabolic disorders than their white counterparts 1 although health disparities have been attributed to multiple factors african americans have been more likely than other racial and ethnic groups to report perceived racial discrimination 2 3 4 in extensive research exposure to racial discrimination events or perceived racial discrimination contributes to poor health health behaviors and health disparities 45 social stress derived from systems of inequality such as racial discrimination may provoke severe psychological and physiological responses and has been associated with unhealthy behaviors 67 studies have shown that perceived racial discrimination is linked to the consumption of fatty foods smoking and alcohol intake 48 increased physical activity may buffer the impact of social stress resulting from racial discrimination 910 to date studies on the relationship between racial discrimination and pa have shown inconclusive findings for example in a multiethnic study of pa racial discrimination was not associated with pa as measured by pedometers when examined among the full sample or separately by race and ethnicity 11 an unexpected finding was reported in the jackson heart study cohort 12 with higher daily and lifetime racial discrimination associated with more pa in women based on their selfreported pa in addition although not in the context of racial discrimination some studies of psychological stress in other populations have linked perceived stress with less pa 1314 in recent studies that examined both betweenand withinperson effects of daily stress on pa there was significant betweenperson variability in the relationship between pa and stress 1516 for example the relationship may be bidirectional for some people for others it may be unidirectional or have no association suggesting that examining the withinperson effect of stress on pa may address the limitations of betweenperson analysis that predominate in traditional research 1516 to date data on the relationship between racial discrimination and pa are sparse and inconsistent part of the reason is that the literature to date on the effect of perceived racial discrimination on pa comprises mostly crosssectional studies that capture retrospective measures of lifetime discrimination associated with individuals current health outcomes such data may be subject to recall and rumination biases furthermore racial microaggressionsthe brief and commonplace daily verbal or nonverbal denigrating messages directed toward racial and ethnic minorities that carry the offending partys implicit or unconscious biashave been shown to disempower racial minorities and may negatively impact health outcomes 1718 however this subtle form of racial discrimination may be difficult to capture by retrospective measures and has been understudied in research on perceived racial discrimination and health in this study we prospectively examined racial microaggression as a subtle form of racial discrimination as well as lifetime racial discrimination examining perceived racial discrimination or microaggression at a single point in timenot incorporating the perspective that this experience fluctuates but combining with cumulative past experience of racial discriminationmay have limitations in examining the differences in behavioral responses across settings and time ecological momentary assessment is a realtime selfreport datacapturing method in which people report behavior in real time at multiple time points in their natural environment it may reduce recall biases and enhance ecological validity by collecting selfreport data that are more proximal to the time and place in which stressful events and behaviors occur 19 recently a growing number of studies that explore discrimination and health outcomes using ema have been published for example the relationships between realtime discriminatory experiences and health behaviors have been examined in various sexual and gender ethnic minority groups 20 21 22 the ema method provides the opportunity to examine how fluctuations in daily perceived racial discrimination or microaggressions are associated with pa among african americans at the withinperson level in addition the use of accelerometers can minimize the weakness of selfreport measures of pa objectives therefore the purpose of this pilot study is to describe the relationship among demographic anthropometric and clinical factors and psychological factors with lifetime racial discrimination and to examine the effects of realtime racial discrimination on total energy expenditure sedentary time and moderatetovigorous physical activity patterns of objectively measured pa using accelerometers and a realtime data capture strategy that is ema in healthy african american adults at both the group and individual level methods study design this study is a substudy of an intensive observational casecrossover design to examine the effects of perceived racial discrimination on physiological and behavioral responses in african americans details of the overall study protocols have been published elsewhere 23 in a casecrossover design each participant serves as their own control to assess the withinperson effects on repeatedly measured pa outcomes 24 withinperson analysis of effects on pa occurred at the 2hour interval level and day level participants and recruitment building on a relationship developed over the past 10 years the research team recruited participants from greater new haven communities in connecticut via flyers and wordofmouth communication within african american communities before implementing the study we held meetings with community stakeholders to discuss an effective recruitment plan and the details of the pilot study protocols potential participants were called in and were screened by phone and scheduled for a baseline orientation visit the inclusion criteria were selfreported african american or black aged between 30 and 55 years currently employed ownership of a smartphone able to respond to smartphonebased random survey prompts at least 3 times per day and english speaking we excluded participants who were pregnant or who had serious acute or terminal medical conditions that would preclude pa the sample size was largely based on guidelines for pilot studies that suggest 10 to 40 participants per cell 25 even assuming moderate attrition of 20 we would have 10 subjects which is still within the guidelines for pilot studies 26 we also estimated the minimum detectable effect sizes of other outcomes our observations would be able to detect medium effect sizes of 053060 on primary outcomes repeatedly measured within the individual with 80 power at a 5 significance level based on a previous study using stress biomarkers 27 baseline measures baseline surveys included sociodemographic characteristics current smoking status and alcohol consumption by the alcohol use disorders identification test 28 which includes frequency of drinking and amount of alcohol consumption we also used validated selfreport measures collected at baseline that are mentioned below perceived racial discrimination was measured at baseline using 2 scales the major life discrimination scale is a 9item selfreport measure of past exposures to lifetime discrimination in diverse domains respondents indicated whether they had ever experienced each listed major discrimination event 29 the mld score represented the sum of each yes or no item higher scores indicate more lifetime discriminatory experiences the racerelated events scale has 22 items to assess exposure to stressful and potentially traumatizing experiences of racerelated stresses in adults respondents indicated whether they had ever experienced each event and the items were summed for a total res score ranging from 0 to 22 30 higher scores indicate more experiences of racerelated stressful events the black racial identitycentrality subscale is an 8item 7point likert scale the centrality dimension of racial identity refers to the extent to which individuals normally define themselves with regard to race it is a measure of whether race is a core part of an individuals selfconcept 31 after reversescoring 3 items the overall score was calculated by averaging all items with higher scores indicating stronger racial identity for subjective social status participants were asked to place an x on the rung that best represented where they thought they stood on the ladder with 10 rungs described as follows at the top of the ladder are people who are the best off those who have the most money those who have the most education and those who have the best jobs and at the bottom are people who are the worst off those who have the least money those who have the least education and those who have the worst jobs or no job 3233 the center for epidemiological studies depression scale is a 4point likert scale that captures current depressive symptoms with 20 items on how respondents have felt or behaved during the past week by selecting 1 of the 4 options the items were summed to obtain a total score higher numbers indicate greater depressive symptoms 34 a recent metaanalysis 35 showed that a cutoff point of 20 yields a more adequate tradeoff between sensitivity and specificity compared with the cutoff point of 16 which has been used to indicate probable clinical depression ema measures perceived racial discrimination was measured using the experiences of discrimination 29 and racial microaggression scale 3637 adapted for ema data collection the eod has subscales for worry global filed complaint response to unfair treatment daytoday discrimination and skin color 29 the rmas has subscales for invisibility criminality lowachieving or undesirable culture sexualization foreigner or not belonging and environmental invalidations 36 as the eod and rmas measure experiences of unfair treatment over the past month to year of which response options are not relevant for realtime ema assessment response choices were revised for the ema time frame using yes or no answers or likert scale options we also used a random subscale inclusion strategy so that only 60 of the items would be included in each ema survey to reduce the subject burden and survey fatigue 38 when prompted participants were asked to report whether they had experienced any unfair treatment from a list of 11 common daily racial discriminations since their last prompt or within the past 23 hours if they missed or did not complete their last prompt and also from a list of 32 microaggression experiences possible daily scores of the eod range from 0 to 10 with higher scores indicating more racial discriminatory experiences possible daily rmas scores range from 15 to 105 with higher scores indicating more microaggression each survey consisted of 815 different combinations of questions varying by time of day pa measures pa was measured using a triaxial hip accelerometer which samples movement at 30 hz and aggregates data into 60second epochs the intensity cut points for pa were defined using validated thresholds for vertical axis accelerometry 39 energy expenditure was calculated using respective validated triaxial vector magnitude equations for 2453 vm counts per minute 40 and ≤2453 vm counts per minute 41 the nonwear periods were defined as ≥60 consecutive minutes of zero activity intensity counts with allowance for 12 minutes of counts between 0 and 100 we considered a day valid if ≥10 hours of activity counts were collected 39 and a 2hour interval valid if the full time was collected accelerometer data were downloaded into actilife software using the softwares normal filters and scored to create the following variables total wear time daily wear time total daily energy expenditure mvpa and sedentary time for withinperson analyses these were normalized to the wear time procedures institutional review board approval was obtained from yale university and written informed consent was obtained from all participants at the initial study visit facetoface baseline interviews were completed using validated questionnaires body weight and height were measured using a portable electronic scale and a stadiometer following standard procedures bmi was calculated as weight height squared percent body composition was measured using the same digital scale that measures foottofoot bioelectric impedance this method has demonstrated significant correlations with the gold standard of body fat calculation 42 after 5 minutes of rest blood pressure was measured twice with an automated cuff with 1 minute between readings and the average of the 2 readings was recorded to tailor the ema survey delivery time we asked participants for their sleep wake or commuting schedules by phone before the baseline study visit at the baseline visit we loaded the mema app which is compatible with both ios and android operating systems into each participants smartphone the ema survey prompted each participant at a random time within the 5 preprogrammed windows daily for 7 days to ensure adequate spacing throughout the day except for nighttime and commuting time upon hearing the signal or vibration the participants were instructed to complete a short electronic question sequence using their smartphone each ema survey took approximately 34 minutes to answer the ema data collection system recorded the date and time it took each participant to respond to a random prompt survey and the date and time the survey expired the survey expired after 40 minutes of nonresponse after no entry was made the ema program became inaccessible until the next recording opportunity participants were instructed to wear an accelerometer on their right hip during waking hours for 7 consecutive days to obtain at least three weekdays and one weekend day to determine the daily variability 3943 a paper diary was provided and participants were instructed to fill out the diary on the time they took off and wore their accelerometers all participants received oneonone inperson training in the ema surveys and accelerometers we also provided pictures and stepbystep written instructions on the use of ema accelerometers a tiered payment schedule and research staff contact information in addition to the study questions we sent reminders through ema to wear their accelerometer daily for all 7 days we also assessed the risks and symptoms of participants with a risk for depression and suggested primary care office visits or made referrals per study protocol data management and analysis ema data were exported from the mema server to a commaseparated values file format we entered the ema and accelerometer data as well as the baseline surveys and anthropometric and clinical data into a database uploaded into sas for analysis we reviewed the data and corrected errors missing data outliers and skewness and calculated the scale scores for the ema responses descriptive analysis was used for demographic characteristics anthropometric and clinical data and the average values for ema and pa data pearson and spearman correlation coefficients were calculated at the individual level using the following variables age sex bmi cesd res sum mld sum annual income education blood pressure body fat racial identity subjective social status smoking and alcohol consumption ema survey data and accelerometer data ema and pa data were scored for daily and individual levels intraclass correlation coefficients were calculated to quantify the proportions of total variance of pa explained by withinand betweenperson variances multilevel models for predicting pa were developed to examine the associations with ema survey data at the 2hour interval daily and individual levels the models included withinand betweenperson levels of racial discrimination or microaggression with covariates compound symmetry was used as a withinperson correlation structure standardized coefficients were obtained using standardized outcomes and covariates with 0 mean and 1 sd results overview the mean response rate for ema surveys was 83 and the mean number of ema responses per day was 40 out of a possible maximum of 5 per day a total of 833 of participants met the inclusion requirements for valid accelerometer data and wore the accelerometer on the hip 6 out of 7 days the mean emareported daily racial discrimination was 061 per day with a range of 0228 three participants reported no daily racial discrimination over the 7day period for the emareported daily microaggression the mean score was 5026 with a range of 19147671 participant characteristics and descriptive statistics from the survey and anthropometric and clinical and accelerometer data are presented in table 1 the mean age was 434 years the majority worked fulltime approximately 67 had an annual income of less than us 60000 the mean cesd score was 2108 the mean black racial identity was 521 indicating that most of our participants selfdefined black race as a core part of their selfconcept the mean subjective social status was 708 indicating that most rated their social status as high in the community the mean bmi was 3419 kgcm 2 approximately 42 of the participants were obese the mean mvpa was 185 minutesday and the mean sedentary time was 86 hoursday paired data including both ema and valid accelerometer data resulted in a sample size of 9 betweenpersons survey and ema analyses in the bivariate analysis using baseline surveys and anthropometric and clinical data depressive symptoms were associated with major lifetime discrimination and a higher frequency of major lifetime discrimination visceral fat was associated with diastolic blood pressure and sedentary time but was not associated with major lifetime discrimination income level was not significantly associated with black racial identity table 2 shows the bivariate correlations between the baseline sample characteristics and the average of the emareported daily racial discrimination variables or pa variables greater emareported daily racial discrimination was significantly associated with younger age black racial identity was not significantly associated with emareported daily racial discrimination or microaggression daily emareported microaggression was associated with depressive symptoms past racerelated events and major lifetime discrimination a higher total energy expenditure was significantly associated with less major lifetime discrimination less sedentary time was significantly associated with a stronger black racial identity more mvpa was significantly associated with lower levels of subjective social status withinand betweenperson ema analyses intraclass correlation coefficients were calculated to represent the proportion of the total variance of the pa outcomes explained by the betweenperson levels they were 054 026 and 066 for total energy expenditure sedentary time and mvpa respectively the withinperson intervallevel analysis found that during the 2hour windows in which people reported more perceived racial discrimination they had moderately greater sedentary time and slightly more mvpa similarly during the 2hour windows in which they reported more perceived microaggression they had less sedentary time and less mvpa however none of these relationships during the 2hour windows reached statistical significance the withinperson daily levels and betweenperson analyses are presented in table 3 in the withinperson dailylevel analyses the association of racial discrimination and sedentary time was significant indicating that during days when participants reported more perceived racial discrimination they had moderately more sedentary time discussion principal findings perceived racial discrimination is a significant psychological stressor that is hypothesized to have negative mental and physical health consequences with potential interactions with unhealthy behaviors the relationship between overall psychological stress level and pa using ema and objective measures has been evaluated in the general population however in what we believe to be the first published study of its kind we examined momentaryand dailylevel perceived racial discrimination and pa levels using ema and accelerometers in african americans we collected repeated realtime racial discrimination exposure data in the natural environment while simultaneously collecting objective measures of sedentary behaviors and pa among african americans we also demonstrated the utility and feasibility of ema coupled with accelerometers in studying the relationship between daily racial discrimination and pa in african americans conventional accelerometer protocols require only 4 valid days for a 7day wear period to be considered valid 3943 approximately 83 of our participants met the inclusion requirement for valid accelerometer data and wore the accelerometer 6 out of 7 days and they also showed high adherence to the ema protocol in the examination of withinperson level data on days when participants reported more perceived racial discrimination than usual more sedentary time was observed in the accelerometer data the betweenperson analysis did not duplicate this finding in our study however this is consistent with the findings of betweenperson analysis in a prior study examining the relationship between general psychological stress and sedentary behaviors in other populations endofday general stress ratings were not associated with sedentary time in the betweenperson analysis 16 the influence of stress on sedentary behavior varies according to the source of stress within individuals 1644 heterogeneity in the effect of stress on the amount and pattern of sedentary behaviors has been documented for example argumentrelated stress was associated with increased sedentary time whereas workrelated stress was associated with decreased sedentary time 1645 similarly in a study of sexual and gender minority individuals betweenperson associations of discriminatory experiences and substance use were not significant whereas more discriminatory experiences were significantly associated with more nicotine alcohol and drug use within the person 21 this highlights the potential limitations of betweenperson methods that predominate in research and suggests that the withinperson level precision health approach may be highly relevant to target reductions in sedentary time and other unhealthy behaviors 1644 an important advantage of the ema methodology is its ability to examine the frequency of racial discrimination experiences in real time and assess the impact of the experiences in a microtemporal relationship in our study participants reported on average 061 overt racial discrimination experiences per day and most participants experienced substantial daily microaggressions the reported frequency of racial discrimination varies widely across studies 46 47 48 49 in earlier crosssectional studies using retrospective measures discrimination was reported to occur only infrequently 50 however recent studies using ema or other types of daily diaries have revealed that discrimination may occur multiple times per day for example in a study using ema african american participants reported about 2 experiences per day of racism 20 in another study using ema among african american adolescents 22 participants reported 5 experiences of racial discrimination per day when comprehensive measures of racial discrimination were used including social media vicarious and teasing experiences along with the more commonly measured individual and general forms of racial discrimination in several studies of psychological stress not specific to racial discriminationrelated stress in the general population episodic stress predicts less pa more sedentary behaviors and reduced total energy expenditure 1551 consistent with these studies we found that major lifetime discrimination was significantly associated with lower total energy expenditure measured by the accelerometer however emareported microaggressions were not associated with pa outcomes in our withinor betweenperson analyses the nonsignificant relationship may be because of the small sample size and lack of variability in terms of the frequency of microaggression experiences within and across days overall our participants reported frequent daily microaggressions which may not have had a significant impact on their daily pa levels however the observed effect size based on standardized β coefficients 52 suggests the need for more studies to examine the determinants of pa and sedentary behaviors with a larger sample size and a longer assessment period consistent with other studies 465354 retrospectively measured exposure to racebased discrimination over a lifetime was significantly associated with more depressive symptoms and with more daily microaggression experiences measured by ema given the different data collection methods in this study we could not determine the temporal relationship between racial discrimination or microaggression and depressive symptoms and the findings may reflect a reverse causal relationship however lagged effects of racial discrimination on depressive symptoms in subsequent days were reported among african americans and hispanics or latinos in other studies 4955 suggesting that individuals may not easily or fully recover from discrimination and racial discrimination may have lasting effects on mental health 5056 taken together our findings highlight the important association between racial discrimination and mental health furthermore future studies examining additional psychological factors such as traits and personality are needed to determine both the concurrent and lagged effects of racial discrimination on health and health behaviors such studies may inform the development of individualized interventions that can buffer the harmful effects of racial discrimination on health strengths and limitations this study had several limitations although we found similar trends in withinor betweenperson effects on sedentary behaviors and pa compared with other studies of general psychological stress our small sample size offers limited evidence supporting racial discrimination as an antecedent to sedentary behaviors or pa ema minimizes recall bias and errors however it is also possible that our study findings may have been influenced by vigilance to discrimination from the repetitive assessment involved in ema in addition the high cesd scores observed in our participants may have influenced the associations with perceived racial discrimination or pa although findings are mixed previous studies have shown that neighborhood environments such as walkability safety or crime were associated with individuals pa levels in the general population 5758 we obtained walkability and crime index data based on participants zip codes however the predominantly black neighborhoods in our sample showed a lack of variability future studies with measures of social environment segregation and perceived neighborhood environments in addition to objective built environments would be helpful in understanding the relationship between pa and relevant correlates owing to the exploratory nature of our pilot study with the scarcity of ema studies of racial discrimination we conducted a 2hour withinperson promptlevel analysis however assessment may need longer time frames to determine the association between racial discrimination and pa levels in addition using eventcontingent sampling may be helpful in determining the frequency of racial discrimination one caveat is that it may not accurately measure events if many participants forget to report them in addition our study included only inperson and individual racial discrimination experiences including webbased and vicarious discrimination experiences may provide more valid frequency estimates 2259 future efforts should include studies with a large sample more extensive racial discrimination measures and ema sampling to determine the optimal frequency of ema to accurately capture discriminatory experiences and to examine its relationship with health behaviors despite these limitations this study provides valuable insights into examining the withinperson effects of racial discrimination on health behaviors and suggests the need to examine a more complex relationship between racial discrimination and lifestyle behaviors with timevarying factors there is a growing emphasis on withinperson examination of health behaviors and psychosocial correlates and on the importance of leveraging these data to develop personalized justintime interventions 5060 examining this daily process using a withinperson approach has the potential to elucidate the mechanisms of which racial discrimination may have on health and health behaviors and to guide the development of personalized interventions for increasing pa and decreasing depressive symptoms in racial ethnic minorities conclusions in conclusion the results of this study highlight the utility and feasibility of a withinperson approach to target reductions in sedentary time and improvements in pa associated with daily racial discrimination by using ema and an objective measure of pa further studies are needed to confirm the observed findings in light of the limitations of this study including its small sample size a precision health approach that incorporates betweenperson associations and accounts for withinperson variations in the relationship between racial discrimination and health behaviors is warranted to mitigate racebased health disparities conflicts of interest none declared ©soohyun nam sangchoon jeon garrett ash robin whittemore david vlahov originally published in jmir formative research 07062021 this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in jmir formative research is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included abbreviations

background a growing number of studies indicate that exposure to social stress such as perceived racial discrimination may contribute to poor health health behaviors and health disparities increased physical activity pa may buffer the impact of social stress resulting from racial discrimination however to date data on the relationship between racial discrimination and pa have been mixed part of the reason is that the effect of perceived racial discrimination on pa has primarily been examined in crosssectional studies that captured retrospective measures of perceived racial discrimination associated with individuals current pa outcomes the association between realtime perceived racial discrimination and pa among african americans remains unclear objective the purpose of this study is to examine the relationship among demographic anthropometric and clinical and psychological factors with lifetime racial discrimination and examine the withinand betweenperson associations between daily realtime racial discrimination and pa outcomes total energy expenditure sedentary time and moderatetovigorous pa patterns measured by ecological momentary assessment ema and accelerometers in healthy african americans methods this pilot study used an intensive observational casecrossover design of african americans n12 recruited from the community after participants completed baseline surveys they were asked to wear an accelerometer for 7 days to measure their pa levels ema was sent to participants 5 times per day for 7 days to assess daily realtime racial discrimination multilevel models were used to examine the withinand betweenperson associations of daily racial discrimination on pa results more emareported daily racial discrimination was associated with younger age r075 p02 daily emareported microaggression was associated with depressive symptoms r066 p05 past racerelated events r082 p004 and lifetime discrimination r078 p01 in the withinperson analyses the daylevel association of racial discrimination and sedentary time was significant β30 se 014 p03 indicating that on occasions when participants reported more racial discrimination than usual more sedentary time was observed betweenperson associations of racial discrimination se 028 p29 or microaggression se 036 p34 with total energy expenditure were suggestive but inconclusive conclusions concurrent use of ema and accelerometers is a feasible method to examine the relationship between racial discrimination and pa in real time examining daily processes at the withinperson level has the potential to elucidate the mechanisms of which racial discrimination may have on health and health behaviors and to guide the development of personalized interventions for increasing pa in racial ethnic minorities future studies with a precision health approach incorporating withinand betweenperson associations are warranted to further elucidate the effects of racial discrimination and pa

introduction and rationale despite advances in prevention hivaids remains a serious public health concern among women around the globe with seroprevalence variation by geographic location age race ethnicity and other factors epidemiological data for the new york city metropolitan area indicate that the rate of hiv diagnosis was 150 per 100000 women in 2011 which reflects a decrease from the prior year however while there has been a decrease in the annual number of women diagnosed with hiv the proportion of hiv diagnoses attributable to heterosexual transmission has increased the percentage of reported hiv diagnoses for women in new york city attributed to heterosexual transmission was 456 in 2001 and 781 in 2011 the percentage attributed to injection drug use went from 148 to 37 at these same time points the continued risk for women associated with heterosexual transmission demands further examination particularly among women with substance use problems who often experience multiple hiv sexual risk factors readily apparent factors include substance use with sexual activity which negatively affects safer sex practices involvement with intimate partners who are at high risk for hiv and diminished relational power to request condom use by partners additional risk factors include this groups high rates of posttraumatic stress disorder and exposure to traumatic events which are associated with increased hiv sexual risk behavior among women more specifically prior estimates have shown that approximately 29 of women in methadone treatment in new york city experience ptsd exceeding the general population of women in the us by 25 times approximately 90 experience lifetime exposure to intimate partner violence exceeding the general population of women in the us by 34 times approximately 58 experienced childhood sexual abuse exceeding the general population of women in the us by 134 times and approximately 22 are living with hiv exceeding the general population of women in new york city by 275 times these collective experiences underscore the numerous vulnerabilities experienced by women in methadone treatment and the critical need to examine and address factors associated with hiv sexual risk behavior among this population as a precipitant of ptsd intimate partner violence sexual exchanges for drugs money or other goods and early onset of substance use childhood sexual abuse may be an important distal factor in hiv risk among women with substance use problems numerous studies document a relationship between csa and hiv sexual risk behaviors among women in the community in clinics and in schools far fewer have examined this relationship exclusively among women experiencing substance use problems while not unanimous quantitative studies conducted exclusively with women experiencing problematic substance use or heavy substance use patterns generally find statisticallysignificant relationships between csa and hiv sexual risk behaviors however prior research with this population has not examined ways in which types and characteristics of csa may be differentially associated with hiv sexual risk behaviors and has yet to focus on a random sample of women in substance use treatment the absence of such research is notable given prior findings that csa types and characteristics are differentially associated with longterm risks including substance use and mental health problems among women with substance use problems for example csa involving force and family has been found to be associated with increased risk of ptsd among women in methadone treatment csa severity has been found to be associated with days of cocaine use among women who recently completed inpatient treatment for cocaine dependence these findings further support the importance of addressing this substantive gap in knowledge in this area in a review of 73 studies that examined relationships between csa and sexual risk behaviors senn carey and vanable note that the absence of a common definition of csa is a major limitation in the body of knowledge regarding relationships between csa and hiv sexual risk behaviors definitional requirements regarding age at the time of sexual activity type of relationship and age differences between those involved in the sexual activity type of sexual activity the presence of force and the coding of csa variables frequently differ across studies making it difficult to compare findings in this area this study aims to strengthen the existing body of knowledge and future efforts to achieve a common definition of csa by examining ways in which observed relationships between csa and hiv sexual risk behaviors among women in methadone treatment may differ depending on how csa is defined and coded it also aims to strengthen the existing body of knowledge by considering childhood physical abuse in the analyses as research has shown that this experience is often associated with both csa and hiv sexual risk behavior however it is frequently overlooked in csahiv sexual risk behavior research conceptual framework in order to explicate connections between csa and hiv sexual risk behaviors several models that conceptualize mediated relationships between csa and hiv risk have been proposed for example miller posits that csa contributes to problems related to substance use mental health and sexual risk taking which in turn contribute to increased hiv risk wyatt and colleagues describe the relationship between csa and sexual risks as mediated by mental health problems and revictimization the miller and wyatt et al models are augmented by malow and colleagues who postulate that in addition to substance use mental health problems and revictimization assertiveness and selfefficacy are also important mediators between csa and hiv sexual risk these conceptual models and prior empirical findings suggest that mental health concerns substance use and revictimization are likely to be key factors and potential mediators in the csahiv sexual risk relationship as such they should be included in analytic models that examine csahiv sexual risk behavior relationships it should be noted that although assertiveness and selfefficacy are not available in the current dataset prior research has found that depression is negatively associated with them including depression in the multiple regression models in the current study facilitates important examination of the role of depression in hiv sexual risk behaviors as well as a degree of statistical control for assertiveness and selfefficacy there are several additional individual relational and situational factors that are salient among women in substance use treatment and are associated with hiv sexual risk behavior these factors include ones hiv status partner hiv risk status cohabitation with partner social support recent incarceration and homelessness in recognition of prior empirical and conceptual work related to the csahiv sexual risk behavior relationship the current analyses draw upon a multisystemic conceptualization of the relationship between csa and hiv sexual risk behaviors this multisystemic conceptualization posits that individual factors such as hiv status mental health concerns and substance use relational factors such as exposure to intimate partner violence partners hiv risk status and social support and situational factors such as recent homelessness and incarceration are likely to be important covariates and potential mediators in the relationship between csa and hiv sexual risk behaviors among women in substance use treatment study aims informed by this studys multisystemic conceptual framework and the need to address substantive and methodological gaps in research in this area the primary aim of the current analyses is to examine associations between csa and hiv sexual risk behaviors and any differences in the observed relationships between csa and hiv sexual risk behaviors based on csa coding types and characteristics among a random sample of women in methadone treatment in new york city it is anticipated that csa involving force family and greater severity will be associated with increased hiv sexual risk behaviors as a secondary aim we examine mediation in csahiv sexual risk behavior relationships when indicated by findings from the primary analyses methods recruitment of random sample this study involves secondary analysis of baseline data from the womens health project which focused on intersections between problematic substance use intimate partner violence and hiv among women in methadone treatment in new york city to recruit a random sample of women in a large methadone treatment program the whp used random number generation in spss 70 and selected 753 of the 1708 women enrolled in the program between november and december 1997 a total of 559 women completed screening interviews to determine study eligibility 416 women were eligible and agreed to participate in the study women enrolled in methadone treatment for at least 3 months and involved in a sexual dating cohabitation childcare or economic relationship with someone described as a boyfriend girlfriend spouse regular sexual partner or father of their children in the past year were eligible to participate in the parent study a total of 26 women who reported all female main partners were excluded from the present analyses due to distinctions in their hiv sexual risk behaviors procedures data were collected between 1997 and 2000 following informed consent processes inperson interviews were conducted in english and spanish by trained female interviewers who administered interview questions and recorded participants responses the institutional review boards at columbia university and at the methadone treatment program approved the study measures childhood sexual abusethe childhood sexual abuse interview focuses on sexual activities at age 15 or younger and includes 11 items based on interview schedules by finkelhor and sgroi the full scale of 11 items has a cronbachs alpha of 87 with this sample six items inquire about touchingexposure three items inquire about penetration single items inquire about picturetaking and other sexual activity consistent with definitions used in prior research the activity was classified as abuse when it involved someone 5 or more years older force or a relative in order to examine ways in which csa coding types and characteristics affect the observed relationships between csa and hiv sexual risk behaviors csa was coded in three ways first we used dichotomous coding to reflect any experience of childhood sexual abuse across the 11 items of the csai second we used continuous coding of two csai subscales which emerged from factor analysis with varimax rotation touchingexposure and penetration third we created a 5level mutuallyexclusive categorical variable that assessed no sexual abuse sexual abuse with someone 5 or more years older sexual abuse involving force sexual abuse involving a relative and sexual abuse involving force and a relative in the final category 950 of the cases involved force and a relative simultaneously and 50 of the cases involved force and a relative across discrete events hiv sexual riskwe focused on two types of hiv sexual risk behaviors in the past six months first we included inconsistent condom use with up to three main partners to begin we dichotomized responses to questions regarding sexual activity in the past six months categorical response options ranged from not once in the past six months to 6 or more times per week or 150 or more times in the past six months next we dichotomized responses to separate questions regarding frequency of condom use with vaginal and anal sex responses of never less than half of the time about half of the time and more than half of the time were coded as inconsistent condom use and responses of always were coded as consistent condom use we then combined these responses to identify vaginal or anal sex with inconsistent male or female condom use as applicable for each type of sexual activity across up to three main partners the association between consistent condom use and reduced sexually transmitted infections among men and women seeking sti care supported this dichotomous coding of condom use second we included substance use with sexual activity across up to three main partners any report of vaginal anal or oral sex while high on or using any drug heroin crack or cocaine or after consuming 4 or more drinks was dichotomously coded as drug use with sexual activity for each substance covariates sociodemographic characteristicsbecause of associations between sociodemographic characteristics and hiv risk behaviors they are included in the multiple regression analyses in this study sociodemographic variables included participants age raceethnicity highest grade completed in school legal marital status and annualized average monthly income we used the log of annualized monthly income in the multiple logistic regression analyses due to the wide range of reported values for this variable posttraumatic stress disorderto measure ptsd we relied on the 49item posttraumatic stress diagnostic scale which follows dsmiv diagnostic criteria and has reported sensitivity of 820 and specificity of 767 depressionto measure depression we dichotomized scores on the widelyused brief symptom inventory depression subscale to reflect values that were above and below 1865 the published median value in psychiatric outpatient norms for women substance usebased on responses to substancespecific questions regarding frequency of use in the past 6 months any reported use of heroin cocaine crack marijuana nonprescription stimulants nonprescription narcotics or nonprescription tranquilizers hypnotics or barbiturates was coded as drug use in this dichotomous variable the same coding was applied to any alcohol use in the past 6 months years in methadone treatmenta single continuouslycoded question for how many years altogether have you been on methadone assessed years in methadone treatment intimate partner violenceacross up to three main partners any positive response on the sexual coercion physical assault injury and psychological aggression items of the revised conflict tactics scale was coded dichotomously to reflect presence of ipv childhood physical abuseto measure childhood physical abuse we drew upon two separate questions asking participants if before they were 18 years old they were punched pushed hit shoved kicked whipped beaten or suffered painful physical injuries all beyond what is considered discipline by parents caretaker or guardian or if they were choked strangled or threatened with a knife gun or any other weapon by parents caretaker or guardian affirmative responses to either of these questions were coded as childhood physical abuse hiv main partner hiv risk status and cohabitation with partnerparticipants selfreported responses to a question regarding the result of their most recent hiv test were coded dichotomously the presence of any of the following factors across up to three main partners was coded as partner risk hivpositive status other sexuallytransmitted disease in the past 6 months sexual activity with other partners sexual activity with someone who is hivpositive or uses injection drugs or sexual activity in exchange for money or drugs participants reports of living with a partner were dichotomously coded social supportwe dichotomously coded the 12item multidimensional scale of perceived social support to indicate agreement or strong agreement with having social support from family friends and a significant other cronbachs alpha of the 12item continuous scale with this sample is 88 incarceration and homelessnesstwo singleitem questions inquired about incarceration or homelessness in the last 6 months data analysis plan reliability analysis was conducted with fullyobserved data using ibm spss statistics version 20 multiple imputation of missing data was conducted with the ice program in statase 101 which was used for all descriptive and logistic regression analyses univariate analyses were conducted in order to describe the sample and identify prevalence of csa hiv sexual risk behaviors and covariates bivariate analyses were conducted to examine relationships between csa and hiv sexual risk behaviors for each of the three csa coding schemes described earlier in order to examine relationships between csa and hiv sexual risk behaviors while adjusting for potential confounders multiple logistic regression analyses were conducted a set of multiple logistic regression analyses predicting each hiv sexual risk behavior was conducted for each csa coding scheme while bonferroni correction is often applied when conducting multiple analyses its limitations and risk of inflating type ii errors prompted us to retain the conventional pvalue of 05 in these analyses analyses are displayed in tables 1234 we conducted subsequent path analyses using mplus version 71 when the comparison of bivariate and multiple logistic regression findings suggested the possibility of mediation in the csahiv sexual risk behavior relationship when the statistical significance of the csahiv sexual risk behavior relationship at the bivariate level was absent in the multiple logistic regression analyses we conducted path analysis in which statisticallysignificant predictors of the dependent variable were entered as possible mediators in each of these situations we examined three models 1 the direct effect of csa on the dependent variable 2 the direct effects of each of the potential mediators on the dependent variable and 3 a final model of the direct effects of csa on the potential mediators and on the dependent variable and indirect effects of csa on the dependent variable through the potential mediators a weighted least squares parameter estimate method was used due to the binary nature of the variables this method handles missing data as a function of the observed covariates and not the observed outcomes however all 390 participants were included in the path models the following fit indices and values indicating good fit were used chisquare statistic comparative fit index and root mean square error of approximation a nonsignificant chisquare value is generally useful in representing good fit for sample sizes 75200 however in larger samples the chisquare value is regularly statistically significant additionally it should be noted that rmsea estimates with small sample sizes and in particular small degrees of freedom often falsely indicate a poor fitting model further some scholars have argued that there are no golden rules for interpreting fit indices in order to test mediation bootstrap analyses were conducted resampling 5000 samples and examining the standardized confidence intervals of the indirect effects of csa on the dependent variable through the potential mediators the indirect effect is significant if zero is not included in the 95 confidence interval results sample characteristics as displayed in table 1 the majority of the participants were latinahispanic or african americanblack single never married involved with one main intimate partner and residing with an intimate partner approximately half of their main intimate partners were at risk for hiv participants mean age was 399 years mean level of education was 110 years and mean level of annual income was 10228 in the past 6 months 95 of the women were homeless and 59 were incarcerated more than half of the participants experienced csa and more than a quarter of the participants experienced csa involving force and family touchingexposure was the most prevalent type of csa affecting 518 of the participants childhood physical abuse was reported by 373 of the participants and most often cooccurred with csa more than threequarters of the participants experienced ipv in the past 6 months a total of 278 of participants met diagnostic criteria for ptsd and 149 experienced depression alcohol and drug use in the past 6 months was reported by 495 and 631 of the participants respectively as shown in table 1 the most common hiv sexual risk behavior in the past 6 months was inconsistent condom use with vaginal sex followed by sexual activity while high on or using any drug sexual activity while high on or using heroin sexual activity while high on or using crack or cocaine sexual activity after consuming 4 or more drinks and inconsistent condom use with anal sex csa coding scheme 1 dichotomouslycoded childhood sexual abuse and hiv sexual risk behaviors dichotomouslycoded csa significantly predicted just one hiv sexual risk behavior as displayed in table 2 at the bivariate level a statisticallysignificant relationship was found between dichotomouslycoded csa and drinking four or more drinks prior to sexual activity women who reported csa were nearly twice as likely to report drinking four or more drinks prior to sex this relationship became statistically insignificant in the multiple logistic regression analysis which prompted further analysis to test for possible mediation in this relationship path analysis was used to examine the following possible mediators having a partner at risk for hiv drug use and exposure to ipv the direct effect model indicated a significant direct relationship between csa and drinking four or more drinks prior to sexual activity however the model was justidentified and model fit could not be assessed 000 p 001 results of the indirect model indicated relatively poor fit with the data 1630 p 003 cfi 81 rmsea 09 with statisticallysignificant relationships between csa and having a partner with hiv risk and between having a partner with hiv risk and drinking four or more drinks prior to sex there were statisticallysignificant relationships between csa and ipv and between ipv and drinking four or more drinks prior to sex while the relationship between csa and drug use was not statistically significant the relationship between drug use and drinking four or more drinks prior to sex was statistically significant figure 1 illustrates the final model 1425 p 003 cfi 83 rmsea 10 the fit of this final model was poor and while not unexpected given the sample size and small degrees of freedom results should be interpreted with the fit in mind when having a main partner with hiv risk drug use and ipv were added to the model the direct relationship between csa and drinking four more drinks prior to sex was no longer statistically significant indicating that full mediation is present a statisticallysignificant positive relationship was found between csa and having a main partner with hiv risk and between having a main partner with hiv risk and drinking four or more drinks prior to sex the indirect effect was significant indicating that having a main partner with hiv risk mediates the relationship between csa and drinking four or more drinks prior to sexual activity as in the indirect model a statisticallysignificant positive relationship was found between csa and ipv and between ipv and drinking four or more drinks prior to sex however in the final model the indirect effect was not statistically significant indicating that ipv is not a mediator finally csa did not significantly predict drug use however there was a significant positive relationship between drug use and drinking four or more drinks prior to sex thus having a partner with hiv risk was the only mediator in the relationship between csa and drinking four or more drinks prior to sex together all of the variables accounted for 25 of the variance in drinking four or more drinks prior to sexual activity csa coding scheme 2 childhood sexual abuse involving touchingexposure and penetration and hiv sexual risk behaviors csa involving touchingexposure was associated with increased risk of heroin use with sexual activity even when adjusting for potential confounders as indicated in table 3 csa involving touchingexposure or penetration was not associated with any other hiv sexual risk behaviors we examined csa coding scheme 3 childhood sexual abuse involving force a relative or someone five years older and hiv sexual risk behaviors the only statisticallysignificant findings in the relationships between this csa coding scheme and hiv sexual risk behaviors were as follows csa involving force and a relative and csa involving someone 5 or more years older than the participant were both associated with heightened risk of drinking four or more drinks prior to sexual activity as shown in table 4 when adjusting for potential confounders these relationships became statistically insignificant which prompted further analyses to test for mediation path analysis was again used to further examine whether having a main partner with hiv risk drug use and ipv mediates this relationship in two separate path analyses examining 1 csa involving force and a relative and 2 csa involving someone 5 years or older in order to test these models the 5level csa variable was dummy coded into two separate independent variables which were used in their respective models 1 indicating whether a participant had experienced csa involving force by a relative and 2 indicating whether the participant had experienced csa involving someone 5 years or older the direct effect model for csa involving force and a relative was justidentified 000 p 001 and indicated a significant direct relationship with drinking four or more drinks prior to sexual activity results of the indirect model 1787 p 001 cfi 74 rmsea 09 indicated a statisticallysignificant relationship between csa involving force and a relative and having a main partner with hiv risk and between having a main partner with hiv risk and drinking four or more drinks prior to sex there was a statisticallysignificant relationship between ipv and drinking four or more drinks prior to sex and between drug use and drinking four or more drinks prior to sex csa involving force and a relative did not significantly predict drug use the final model examining both the direct and indirect paths is presented in figure 2 1517 p 002 cfi 81 rmsea 10 again model fit was poor though not surprising given the sample size and small degrees of freedom however the fit should be taken into consideration when interpreting the findings the direct relationship between csa involving force and a relative and drinking four more drinks prior to sexual activity remained statistically significant there was a statisticallysignificant relationship between csa involving force and relative and having a main partner with hiv risk and between having a main partner with hiv risk and drinking four or more drinks prior to sex the indirect effect was significant indicating that having a main partner with hiv risk partially mediates the relationship between csa involving force and a relative and drinking four or more drinks prior to sex additionally a statisticallysignificant positive direct relationship between ipv and drinking four or more drinks prior to sexual activity was found and between drug use and drinking four or more drinks prior to sex thus having a partner with hiv risk was the only mediator in the relationship between csa involving force and a relative and drinking four or more drinks prior to sex together all of the variables accounted for 26 of the variance in drinking four or more drinks prior to sex next we examined whether csa involving someone 5 or more years older was directly related to hiv sexual risk behaviors and whether that relationship was mediated by having a main partner with hiv risk substance use andor intimate partner violence in contrast to the findings of the bivariate logistic regression analyses findings of the direct path model found no statisticallysignificant direct relationship between csa involving someone 5 or more years older and drinking four or more drinks prior to sexual activity thus further path analysis to test for mediation was not pursued posthoc analyses childhood physical and sexual abuse and hiv sexual risk behaviors the analyses yielded unexpected findings regarding reduced risk of inconsistent condom use and nonspecific drug use with sexual activity among women who reported childhood physical abuse as displayed in tables 2 and3 to further understand these findings and the potential that childhood physical and sexual abuse may interact to influence them we conducted posthoc analyses to examine relationships between childhood physical abuse and sexual abuse alone and in combination and inconsistent condom use and drug use with sexual activity using a 4level categorical variable we found no statisticallysignificant relationships between childhood physical and sexual abuse alone or in combination and inconsistent condom use during vaginal sex or anal sex in the bivariate or multiple logistic regression analyses as with the models predicting inconsistent condom use with anal sex displayed in tables 2 3 and 4 this posthoc model also remained statistically insignificant additionally there were no statisticallysignificant relationships in the bivariate or multiple logistic regression analyses between childhood physical and sexual abuse alone or in combination and nonspecific drug use with sexual activity discussion this study is the first to our knowledge that examines ways in which csa coding type and characteristics may affect observed relationships between csa and hiv sexual risk behaviors among women in substance use treatment although it finds statisticallysignificant often mediated relationships between csa and hiv sexual risk behaviors with main intimate partners the findings regarding associations between csa and hiv sexual risk behaviors are more limited than anticipated particularly given the scope of analyses conducted there are multiple ways to understand these unexpected findings first prior research with women in methadone treatment also found no association between csa and condom use or number of male sex partners however it found that other factors including race alcohol use residing with a partner suicidality and hiv status predicted sexual risk behaviors similarly our findings point to the significance of residing with a partner alcohol use hivnegative status ipv exposure and lack of social support as key predictors of inconsistent condom use during vaginal sex with main intimate partners other individual relational and situational factors including depression alcohol and drug use having a partner with hiv risk and recent incarceration also differentially predicted having sex with main partners while under the influence of drugs or alcohol together with prior research with women in methadone treatment and women recruited from the community who used drugs our findings indicate that the role of csa in most of the hiv sexual risk behaviors examined in this study may be less salient than current psychological substance use relational and situational factors second it is possible that methodological issues influenced the findings this study focused only on sexual risk behaviors with main partners and considered these risks across three main partners it may be that associations between csa and sexual risk behaviors differ between main and secondary partners and that this differential association was not captured in our analyses additionally this study relied on dichotomouslycoded sexual risk variables it is possible that continuouslycoded sexual risk variables may yield different findings regarding relationships between csa and sexual risk behaviors with main partners finally this study collapsed all drug use into a single category which may have obscured the specific roles of different drugs in csasexual risk behavior relationships in contrast to expectations based on prior research this study found that touchingexposure and not penetration or other csa measures predicted increased risk of heroin use with sexual activity this unexpected finding suggests that unobserved contextual aspects of these experiences which may include age relationship frequency duration and circumstances of the touchingexposure have important bearing on the longterm sequelae of csa similar to findings by wyatt and peters that different definitions of csa result in variations in prevalence estimates this study indicates that definitional differences also affect findings regarding observed associations between csa and sexual risk behaviors further this study suggests that childhood sexual and physical abuse may interact in ways that are important to further understand in relation to hiv sexual risk behaviors among this population the most consistent finding regarding the csahiv sexual risk behavior relationship was the statistical significance of the association between csa and increased likelihood of drinking four or more drinks prior to sex with main partners this finding held with dichotomouslycoded csa and with csa involving force and a relative in both logistic regression and path analyses when dichotomously coded the csaheavy alcohol use prior to sex relationship was mediated by having a partner with hiv risk having a partner with hiv risk also partially mediated the relationship between csa involving force and a relative and heavy alcohol use prior to sexual activity drug use and ipv were not mediators but they were associated with drinking four or more drinks prior to sexual activity and the total combination of variables explained a considerable portion of the variance in consuming 4 or more drinks prior to sex there are several ways to understand the links between csa involvement with partners at risk for hiv and drinking four or more drinks prior to sex involvement with an intimate partner at high risk for hiv may reflect engagement in a highrisk social network and hindered ability to identify and address risks sexual or otherwise among women with histories of csa it may also reflect continuation of a highrisk sexual trajectory that was initiated through early sexual abuse additionally women may use alcohol prior to sex as a form of avoidant coping with their partners risks particularly when the threat of violence is present while these possibilities can facilitate understanding of the mediated relationship between csa and heavy alcohol use prior to sex there remains a need for additional research to further understand the relatively consistent associations between csa and heavy alcohol use prior to sex and the relatively limited associations between csa and drug use with sex among women in methadone treatment in this study ipv was the most consistent predictor of hiv sexual risk behavior this finding is consistent with prior crosssectional and longitudinal research among women in methadone treatment in the context of violence women may fear retaliation for requests to use condoms additionally they may use drugs and alcohol with sexual activity to manage psychological and physical trauma associated with victimization the findings underscore the critical importance of ongoing efforts to design and test interventions to address cooccurring substance use and ipv as part of hiv prevention this study makes novel contributions to understanding relationships between csa and sexual risk behaviors with main partners among women in methadone treatment however it is not without its limitations as discussed earlier and further addressed here while the multiple questions regarding types of sexual activities were a strength of the csa measure it relied on retrospective recall although events that occurred at sufficient age are likely to be recalled the personal nature of such disclosure may have resulted in underestimated csa prevalence in this study further emerging trends in reported hiv diagnoses among women in new york city indicate an overall decrease in the annual number of hiv diagnoses reported with a tenfold decrease in the number of women whose diagnoses were attributed to injection drug use between 2001and 2011 this studys data which were gathered between 1997 and 2000 may reflect higher hiv risks when compared to current data interpretation of study questions may have also affected the studys findings in particular the cpa items may have resulted in underestimates of cpa prevalence as one of the items involved participants making a determination regarding experiences that exceeded discipline finally the crosssectional data suggest caution when making causal inferences regarding the correlates of sexual risk behaviors and mediators in the csahiv relationships conclusion this study finds that csa type and characteristics are differentially associated with consuming four or more drinks prior to sexual activity and using heroin with sexual activity additionally the study finds that having a main partner with hiv risk mediates relationships between both any csa and csa involving force and a relative and drinking four or more drinks prior to sex although women with histories of csa are at heightened risk of having sex under the influence of alcohol and depending on the csa characteristics having sex under the influence of heroin the associations between csa and sexual risk behaviors are more limited than expected especially in light of the numerous analyses conducted in this study the findings suggest that ipv polysubstance use depression social support recent incarceration and relational contexts are salient factors in hiv sexual risk behaviors as such they highlight the critical importance of further research to develop and test multifaceted comprehensive approaches to hiv prevention among women in methadone treatment dr louisa gilbert is a licensed social worker with 25 years of experience developing implementing and testing multilevel interventions to address hivaids substance abuse trauma partner violence and other cooccurring issues among vulnerable communities in the us and central asia she has served as the codirector of the social intervention group since 1999 and the codirector of the global health research center of central asia since 2007 her specific area of research interest has concentrated on advancing a continuum of evidencebased interventions to prevent intimate partner violence among druginvolved women and women in the criminal justice system more recently her funded research has also focused on identifying and addressing structural and organizational barriers in harm reduction programs to implementing evidencebased interventions to prevent overdose among drug users in central asia katherine winham received her doctoral degree from the kent school of social work at the university of louisville where she was awarded the john m houchens prize for outstanding dissertation she is a practicing social worker and licensed marriage and family therapist and holds masters degrees in both fields with the goal of developing interventions her research focuses on investigating relationships between victimization experiences and physical and mental health outcomes and high risk behaviors among vulnerable and underserved populations especially women involved with the criminal justice system zimet gd dahlem nw zimet sg farley gk 1998 the multidimensional scale of perceived social support journal of personality assessment 523041 figure 1 final fitted path model with estimated regression coefficients for the direct path between csa and four or more drinks prior to sex and as mediated by main partner with risk drug use and intimate partner violence final fitted path model with estimated regression coefficients for the direct path between csa involving force and a relative and four or more drinks prior to sex and as mediated by main partner with risk drug use and intimate partner violence

backgroundchildhood sexual abuse csa is often considered an important distal factor in hiv sexual risk behaviors however there are limited and mixed findings regarding this relationship among women experiencing substance use problems additionally research with this population of women has yet to examine differences in observed csahiv sexual risk behaviors relationships by csa type and characteristics objectivesthis study examines relationships between csa coding type and characteristics and hiv sexual risk behaviors with main intimate partners among a random sample of 390 women in methadone treatment in new york city who completed individual interviews with trained female interviewers resultsfindings from logistic regression analyses indicate that csa predicts substance use with sexual activity with variations by csa coding type and characteristics however the role of csa is more limited than expected having a main partner with hiv risk mediates some relationships between csa and drinking four or more drinks prior to sex intimate partner violence is the most consistent predictor of sexual risk behaviors other salient factors include polysubstance use depression social support recent incarceration and relationship characteristics conclusionsimportancethe study contributes to understanding of relationships between csa and hiv sexual risk behaviors and key correlates associated with hiv sexual risk behaviors among women in methadone treatment it also highlights the complexity of measuring csa and its association with sexual risk behaviors and the importance of comprehensive approaches to hiv prevention that address psychological relational situational and substance use experiences associated with sexual risk behaviors among this population

introduction one of the significant characteristics of employment in russia is a fairly large share of people employed in the informal sector of the economy according to researchers it is about 2030 of the employed population the selfemployed in russia find themselves in a zone of informality working without registering their relations with the state this is a significant group of informally employed people currently the state is trying to take this group under control formalize its relations with this group in order to receive taxes from its representatives in exchange for providing a number of social guarantees the states initiatives find a contradictory response among the selfemployed which makes the success of state initiatives questionable all this raises the problem of building a mutually beneficial dialogue for both the state and the selfemployed in which it would be possible to find common ground between the interests of the state and the selfemployed for this purpose it is necessary to specify the attitude of the selfemployed to state initiatives based on their interests the aim of this paper is to determine the attitude of the selfemployed in russia to the formalization of their relationship with the state on the basis of an empirical sociological address correspondence to this author at the saint petersburg state university saint petersburg russia email study the practical significance of the paper is that this knowledge will be useful for the formation of the state socioeconomic policy in relation to the selfemployed in st petersburg which is already implementing the initiative of the state to build a dialogue with the selfemployed knowledge of the socioeconomic characteristics and interests of the social group of selfemployed in saint petersburg which will be targeted by the state initiative will help to organize optimally the process of interaction between the state and this social group literature review the problem of informal selfemployment in russia has been most actively developed over the past 152 years in the russian scientific literature which is associated with the preparation and implementation of state reforms in this segment of employment at the same time attention is paid to such aspects of this problem as a comparative analysis of selfemployment in developed and developing countries highlighting the factors that form informal employment in russia special attention is paid to the aspect of how effective taxation of the selfemployed should be at the same time it is noted that the activity of the state in relation to the selfemployed is aimed only at increasing tax collection while in western countries this aspect is primarily about increasing the flexibility of the labor market it is also indicated that social guarantees for the selfemployed should be more clearly defined if they are formalized as the reform process has already its own results these results are also evaluated by experts in the world literature the study of the informally selfemployed goes in two directions in the study of selfemployment and in the study of informal employment and the informal economy researchers of selfemployment note its unstable nature for the security of income and stability of the wellbeing of the family of the selfemployed the author studies the preference of selfemployment for certain social groups in different countries informal employment in turn interests researchers in many aspects such as its scale the features of its existence in cities compared to the countryside the comparison of the welfare of the formally and informally employed the role of informality in the deployment of business cycles studies of informal employment in russia are also presented in the world scientific literature and relate mainly to the comparison of the situation in russia with the situation in developed countries the comparison of welfare in terms of formal and informal employment in russia the existence of informal employment in russia in terms of global trends in employment development at the same time both in the world and in the russian scientific literature there is a lack of research on informal selfemployment in russia which would study the attitude of various groups of informally selfemployed to formalization in this work we tried to fill this gap problem statement a significant negative effect of informal employment on the informally selfemployed is their alienation from social guarantees provided by the state this alienation as our research has shown is quite disturbing for the informally selfemployed forcing them to look for ways to overcome it at present the russian state offers such selfemployed people an effective way to join the social guarantees provided by society and the state this is the formalization of relations with the state moreover a simplified registration procedure and a preferential tax scheme are offered for the selfemployed the state initiative was launched in 2016 in four pilot regions moscow the moscow and kaluga regions and the republic of tatarstan however as of 01012019 only 28 thousand people were officially registered which gave the experts reason to talk about the failure of this experiment experts say that the informally selfemployed do not want to register officially ignoring government initiatives in saint petersburg the state initiative was launched on 01012020 based on the analysis of the experience of the pilot regions it was expected that 16 thousand people would register in saint petersburg during the first year of the project but as of the end of february 2020 about 12 thousand people have registered which indicates that in st petersburg there is a greater interest of the selfemployed in the states proposals in comparison with the pilot regions however this figure is not so large as we are talking about near 115 million people employed in the informal sector of st petersburg among which there are more than 100 thousand people who are selfemployed it seems to us that the real situation with the attitude of the informally selfemployed to the formalization of their relations with the state is quite complex the social group of informally selfemployed is heterogeneous and subgroups are distinguished in accordance with the weakest point of such selfemployed alienation from social guarantees provided by society different attitudes and intentions regarding state initiatives form differences in this and this attitude is more diverse than simply accepting or not accepting the states offer to formalize its status methodology we followed the approach proposed by the ilo which refers to informal employment as activities that are not regulated by labour law and that are outside the scope of tax statistical and insurance accounting this approach is called the legalist approach this approach postulates that informality and formalization can also be combined in the functioning of the formal sector in our study we used a legalistic approach that allows considering as informally employed not only those for whom selfemployment is the only source of income but also those who combine selfemployment with employment in the formal sector another methodological problem was the need to determine the empirical object of the study namely the group of selfemployed that will be studied in the framework of the study the fact is that the selfemployed in saint petersburg are a very heterogeneous group in terms of their social characteristics thus the selfemployed in saint petersburg can be classified according to permanent residence in the city and temporary residence in the city in the latter case we are talking about migrants who come to the city for work and as a rule provide various services to the population of a productive and nonproductive nature in our study we focused on the selfemployed who live permanently in saint petersburg as a relatively stable social group at the same time based on the theoretical grounds we have adopted in defining the informally employed we believed that selfemployment can take place not only for the informally employed but also for the formally employed in the latter case informal employment is present in their spare time from their main work but these people are also informally selfemployed therefore in our study we decided to cover both these groups of informally selfemployed and compare their attitude to formalization assuming that it will be different for them the study was conducted in februarymarch 2020 using semistructured indepth interviews respondents were selected using the network method and the snowball method in total we interviewed 36 people of which 18 were women and 18 were men in the interview guide there were 32 questions related to various characteristics of the work activity of selfemployed with special attention paid to questions about the readiness of the selfemployed to formalize their activities research results the main problem of the study was to determine the basis for the allocation of subgroups in the social group of informally selfemployed which has a key influence on the attitude to formalization we found such a reason as it was the presenceabsence of the fact of formal employment and the corresponding presenceabsence of access to social guarantees provided by society as our research has shown the attitude of informally selfemployed people in saint petersburg to formalization is negative which confirms the opinion of experts but it is negative in different ways for different groups of such selfemployed people first of all this is a group of informally selfemployed people for whom selfemployment is the only source of income and who are not associated with employment in the formal sector our research has shown that this group of selfemployed people is generally wary of government initiatives and takes up a waiting attitude towards them these selfemployed do not intend to register in the near future but they will consider registering in the future if the state can offer them conditions that suit them or put them in a position where they will not be able to refuse official registration the selfemployed say that the state now has no effective levers to force them to register there is no concept of illegal selfemployment in the criminal code which means that their activities are not criminally punishable in addition the state has only limited capacity to track their activities but representatives of this group say that the state can table 1 groups of informally selfemployed identified as part of an empirical sociological study presenceabsence of formal status description of the group there is no formal employment status informally selfemployed whose only source of income is their informal selfemployment and who do not have employment in the formal sector informally selfemployed whose additional source of income is their informal selfemployment and who are actually employed in the formal sector informally selfemployed whose only source of income is their informal selfemployment and who are fictitiously employed in the formal sector informally selfemployed students there is formal employment status informally selfemployed pensioners start tracking advertising of their services in the media and check whether advertisers pay taxes on the income received from their activities the results of the study show that there is a direct correlation between the ways of finding customers and attitude to formalization taking into account the governments ability to track the offer of services in this sector so those selfemployed who have been working in this field and has acquired an extensive clientele have rather negative attitude to the formalization of their relationship with government and those selfemployed who work recently forced to offer their services through the media tend to take up a waiting position thus those informally selfemployed who have been working for a long time intend to continue working informally therefore state initiatives should be aimed at young representatives of this social group or those who are in middle age selfemployment is the only source of income not employed in the formal sector 2 3 13 selfemployment is the only source of income fictitiously employed in the formal sector 0 5 0 selfemployment is an additional source of income and there is a stable income from formal employment 0 3 0 selfemployed students 0 3 3 selfemployed pensioners 0 4 0 thus the group of young and middleaged selfemployed is potentially ready to formalize so the state should think through its initiatives primarily in accordance with its interests among which the leading place is occupied by the interests of access to social guarantees among the latter the greatest interest relates to pension provision and a decent amount of pension in the case of official registration of activities this group is also interested in the stability of government decisions currently such selfemployed people in st petersburg say that the institutional field of their activities formed by the state is unstable due to the fact that the state adjusts its decisions on the one hand such an adjustment is necessary due to the need to regulate rationally those aspects of the selfemployed who for any reason has not received this regulation or regulation have proved to be insufficiently rational on the other hand the adjustment means instability for selfemployed in their interaction with government in this situation the state needs to think carefully about its initiatives in relation to the selfemployed as they weigh all the pros and cons of their registration and as our research has shown this process is quite relevant for this group of selfemployed at the same time we did not find any significant differences in the attitude to formalization between the interviewed men and women we would like to focus in more detail on four groups of informally selfemployed which can be combined on the basis of categorical rejection of state initiatives first of all they are informally selfemployed who combine their informal selfemployment with real employment in the formal sector this group of informally selfemployed people has access to social guarantees and the formalization of their relationship with the state in terms of their selfemployment will mean the withdrawal of part of their net even gray income which such selfemployed people strongly oppose this group of selfemployed people noted that if the state takes steps to force them to register they will respond by looking for ways to avoid it so for example the state now has a limited lever to track noncash payments to the bank cards of such citizens to which such citizens respond by shifting the focus from noncash to cash payments which the state currently does not have the ability to track another group of informally selfemployed is the informally selfemployed who are fictitiously employed in the formal sector but their only source of income is their selfemployment this group of selfemployed people also has access to social guarantees provided by their official employment among the respondents we surveyed there were only five such selfemployed people which suggests that the opportunities for the selfemployed to find fictitious employment are now significantly narrowed such employment should be beneficial to the formal employer and not to the organization as a whole but to specific responsible persons in the organization who derive their private benefit from the fact of fictitious employment these selfemployed people are also categorically against formalizing their selfemployment status their designated behavior strategy is the same as that of the previous group they noted a weak link between the amount of contributions to the pension fund and the size of the pension saying that if they deduct funds from their selfemployment in addition to what their official even fictitious employer deducts for them their pension will increase only by a very small amount and they will lose more than they deserve the next group of informally selfemployed is informally selfemployed pensioners they are united with the two previous groups by their categorical rejection of state initiatives the main motive of this group is that they already receive their small pension and if they contribute funds to the state and to insurance funds the size of their pension will practically not change they will only lose without gaining anything in return we identified another group among the informally employed selfemployed parttime students they were found to have a negative waiting attitude to the possibility of their registration firstly there is uncertainty as to whether they will continue to be selfemployed or go to work in the formal sector secondly it is the instability of their earnings which they must combine with their studies thirdly it is a reluctance to have relations with government agencies and difficult forms of reporting on the financial side of their activities fourthly this group of selfemployed people almost has not thought about retirement yet so they do not see any sense in making contributions to the pension fund fifthly it is a reluctance to give away part of their earned income the greatest weight among the above reasons for refusal of registration is the reason for the uncertainty of the future of selfemployed students this group is probably the most unstable among the informally selfemployed as its representatives are very often actually employed in the formal sector after graduation discussion in the works that address the problem of informal employment in russia and st petersburg the problem of this phenomenon is seen in the fact that the state wants to take control of representatives of this social group in order to expand its tax base and selfemployed citizens do not want to be controlled by the state which is expressed in extremely low activity in relation to their official registration in some works attempts are made to analyze at least partially the reasons for such rejection of state initiatives it is assumed that the social group of informally selfemployed is a monolithic unified group with a common opinion and the intention not to register the novelty of our paper is that we assumed and in our research confirmed this assumption that the informally selfemployed are a heterogeneous social group in which we can distinguish a number of subgroups each of that in its own way relates to the possibility of being officially registered so it turned out that a number of informally selfemployed people do not reject this possibility but have taken up a waiting attitude towards the ongoing reform of the relationship between the state and the selfemployed we also found that young representatives of this social group and middleaged people are waiting for events to develop and are potentially ready to register conclusion the study of the attitude of the informally selfemployed to formalization is very relevant for the development of public policy measures to build relations between the state and this social group we have proved that the group of informally selfemployed is a set of different groups that are distinguished on the basis of accessexclusion from access to social guarantees provided by the state as well as that the division of informally employed on this basis is significant as such access is one of the essential interests of representatives of this social group we also studied the attitude of each of the selected groups of informally selfemployed to formalization the most interesting and unexpected result of the study was the conclusion that there is a group of informally selfemployed people who take up a waiting attitude towards the process of launching the reform of the institutional field of interaction between the state and the selfemployed and who are generally quite positive about the possibility of official registration as a recommendation for state bodies engaged in developing measures that form the institutional field of interaction between the state and the selfemployed it should be indicated that the focus is primarily on a group of informally selfemployed who are waiting for the results of the reform in order to make a decision to formalize them or not this is a group of young selfemployed and middleaged selfemployed in addition we would like to recommend that we be more consistent in the reform process and adhere to the promises made to this social group in order to preserve the stability of the institutional environment for the selfemployed as much as possible

the paper examines the attitude to the formalization of informally selfemployed in russia on the example of the city of st petersburg the authors proceeded from the position that this social group is heterogeneous and different characteristics of representatives of this social group affect the attitude to the formalization of their economic activity the negative attitude to formalization of representatives of this social group was revealed on the surface however this negative attitude among different subgroups of informally employed people turned out to be different the results of the study show that different age groups of informally selfemployed people react differently to government initiatives regarding registration of such activities the presence or absence of social status in the sphere of formal employment which many selfemployed people combine with informal economic activity proved to be a significant social characteristic in forming the attitude of the informally selfemployed to formalization thus the great value has stability of the institutional framework of formal selfemployment generated by the state and the states determination to follow its promises given to informally selfemployed so that this social group formalized its economic activity it was found that a fairly large proportion of the informally selfemployed took up a waiting attitude towards the states initiatives to formalize the economic activities of this social group this paper will be useful for representatives of russian state authorities who are developing measures of socioeconomic policy in relation to informally selfemployed citizens

introduction gender is the differentiation of roles status and division of labor made by society based on sex there are other forms of differentiation for example based on class color caste skin color ethnicity religion age and so on each of these distinctions often gives rise to injustice including gender gender is also an analytical tool that can be used to dissect cases to understand more deeply the causeandeffect relationships that produce reality gender analysis analyzes the power relationships and roles between men and women in human life through gender analysis we can examine the injustice between women and men caused by the building of human civilization and culture accelerating the reduction of stunting rates in indonesia remains a priority development program until 2024 in 2024 the government is targeting a stunting prevalence of 14 percent this target is achieved with two holistic interventions namely specibic interventions and sensitive interventions specibic interventions are aimed at children in the birst 1000 days of life and at mothers before and during pregnancy which are generally carried out in the health sector meanwhile sensitive interventions are carried out through various development activities outside the health sector and constitute crosssector collaboration who estimates that the total number of disease cases that occur at a certain time in an area of stunting throughout the world will be 22 percent or 1492 million people in 2020 in indonesia based on data from the asian development bank in 2022 the prevalence of stunting among children under 5 years of age in indonesia will be 318 percent this number causes indonesia to be in 10th place in the southeast asia region furthermore in 2022 based on data from the ministry of health indonesias stunting rate will decrease to 216 percent stunting according to tsaralatifah is a condition where the growth of toddlers is disrupted resulting in their height being shorter than their estimated age this chronic nutritional problem is caused by various factors including poor nutrition maternal nutrition during pregnancy economic conditions a lack of nutritional intake for babies and other causal factors standard height measurements below the who growth median for children are usually used to assess stunting for example if a twoyearold boys height is 87 cm then the minimum expected height is 81 cm causes of stunting include direct factors such as inadequate nutritional intake and infectious diseases as well as indirect factors such as maternal care practices family food insecurity and environmental health services the root causes of stunting are limited access to adequate health services poor family economic conditions and various social cultural economic and political factors that inbluence the surrounding environment all of these factors interact with each other and contribute to the occurrence of stunting in toddlers if stunting in this country is not taken seriously by the government it will have an impact on the development and dignity of the country due to a decrease in productivity an increase in the number of children under bive with weight and height below average in the future and an increase in the risk of disease that accompanies the process aging this kind of impact can increase poverty in the future and will automatically affect family food security when they grow up children who experience stunting will have the potential to earn income from their work that is 20 lower than the income of healthy children the indonesian government has set a target to reduce the prevalence of stunting but these achievements still need to be strengthened through effective and integrated solutions the proposed solution includes a comprehensive approach including increasing public awareness about balanced nutrition broader nutrition education increasing access to nutritious food and improving sanitation and hygiene apart from that strengthening public policies effective intervention programs and the use of modern technology are also part of the solution to facing the challenge of stunting in the modern era the city of bandung is one of the 100 priority citiesdistricts for dealing with and overcoming stunting with the number of toddlers with stunting conditions in bandung city decreasing to 5660 children in 2022 from 7568 in 2021 according to the ssgi in 2021 the prevalence rate will be 264 percent in 2022 it will decrease by 7 percent to 194 percent in 2023 it is hoped that the prevalence of stunting will decrease to 14 percent this is a factor that plays a very important role in reducing the stunting rate in the city of bandung fast action by various regional apparatus organizations involved in resolving stunting which are members of the stunting reduction acceleration team tpps carries out activities that are divided into two types specibic actions related to health and intervention actions outside of aspects of health one of which is through data unibication with the epenting application the epenting application emerged in line with the implementation of convergence to accelerate stunting reduction through six strategic actions one of which is a data management system responding to challenges that arise related to stunting data problems in its application epenting covers various elements starting from providing questions to standard operating procedures related to managing stunting data this includes data integration data cleansing and veribication processes as well as the transformation of data into digital forms that are easier to access and manage apart from its data management function epenting also acts as a onestop data publication medium providing integrated and easy access to information related to stunting not only that this application is also equipped with data analysis tools making the policymaking process more effective and efbicient thus epenting not only responds to the problem of stunting data but also provides a comprehensive solution to support convergence efforts in overcoming chronic nutritional problems in the city of bandung the epenting program is a genderresponsive innovation designed as a concrete step in encouraging gender equality and womens empowerment in the city of bandung by providing freer space for women this program becomes a forum for raising womens rights and access to public services the existence of epenting is not only a stunting data collection tool but also an inclusive tool that takes into account the special needs and contributions of women in i i i i journal of governance volume 8 issue 4 december 2023 608 overcoming this chronic nutritional problem thus this program not only measures the overall impact of stunting but also empowers women in the process of monitoring evaluating and formulating policies thereby creating a fairer and more equitable environment for all citizens of bandung city the aim of this research is to explore gender mainstreaming in the implementation of the electronic stunting data collection program in bandung city with a special focus on policy monitoring and evaluation aspects it is hoped that the research results will provide an indepth understanding of how gender aspects are integrated into epenting and contribute to the overall effectiveness of the stunting program it is also hoped that the resulting policy recommendations can serve as a guide for policymakers in strengthening the gender dimension in similar programs in the future more broadly it is hoped that this research can provide conceptual and practical contributions to the literature regarding the implementation of health programs with gender mainstreaming so as to enrich knowledge and understanding in this bield method this research uses a qualitative approach with descriptive methods according to yulianah qualitative research is a qualitative researcher develops theory during the data collection process this more inductive method means that theory is built from data or grounded in data many researchers use grounded theory it makes qualitative research blexible and lets data and theory interact qualitative researchers remain open to the unexpected are willing to change the direction or focus of a research project and may address their original research question in the middle of a project meanwhile according to sugiyono the descriptive method is a search for facts with the correct interpretation descriptive research studies problems in society as well as procedures that apply in society and certain situations including relationships activities attitudes views and ongoing processes that inbluence a phenomenon data collection techniques consisting of semistructured interviews were selected based on purposive sampling techniques observation where the author was directly involved in activities in the bield as well as documentation where the author took data in the form of documents related to the epenting program in bandung city and gender mainstreaming in analyzing the data that has been obtained the author will analyze the data using the data analysis proposed by miles and huberman in sugiyono namely data reduction data presentation and drawing conclusions results and discussion gender mainstreaming development programs that are normatively declared as an effort to achieve a level of prosperity for society are often delivered with the assumption that development is neutral impartial and provides equal opportunities for all groups in society to gain benebits however this view needs to be examined further because development actually produces different impacts on each individual or group who accesses development results development cannot be considered neutral because it is able to reblect dominant interests and even contains certain ideological elements as time goes by the gap between groups that benebit from development and those that do not becomes increasingly visible creating inequality that can strengthen this nonneutrality a deeper understanding of the nonneutrality aspects of development is important in designing and implementing development policies that are more inclusive and fair awareness of the different impacts produced by development programs can be the basis for designing strategies that reduce social and economic disparities therefore efforts need to be made to strengthen the justice dimension in development so that the benebits can be felt equally by all levels of society in line with previous understanding the gender perspective shows that development cannot be considered neutral development programs designed with the aim of accommodating public interests often have an unequal impact on men and women in practice although it aims to achieve justice and prosperity for the general public there are often gaps in the distribution of benebits and accessibility between the sexes at a certain point a development paradigm that is considered ideal by accommodating public interests and fulbilling basic economic social and cultural rights can actually cause a decline in the status and welfare of womens groups it is important to identify the differential impacts of development on men and women in order to design more inclusive and genderequitable programs aspects such as access to education employment opportunities and participation in decisionmaking need special attention genderoriented development requires strategies and policies that take into account the different social and economic contexts for men and women thus efforts to understand the impact of gender in the development context are an important step in creating a more equitable and sustainable development transformation the difference in receiving development impacts is due to inequality in the level of access capacity between men and women until now socioeconomic relations have placed women in a position that tends to be left behind creating inequality in access to resources employment opportunities and education in fact this condition is one of the main factors causing the impact of development to be uneven between the two sexes even though development efforts were launched with the aim of creating equality and prosperity for society in general ironically this paradigm can strengthen existing domination especially towards women the neutrality perspective applied in the development process is often unable to overcome socioeconomic relations that still restrict women in fact when development is directed at providing equal treatment to all communities without considering existing gender inequalities this actually results in irony in the form of increasingly sharp domination the continued understanding of neutrality in development indirectly widens social disparities and injustice conbirming the position of women as a vulnerable group who are still not fully receiving equal benebits from development efforts therefore it is important to initiate a more genderoriented development approach in order to overcome inequality which is still an obstacle to achieving overall social welfare gender is not simply interpreted as a social category but rather as a perspective that opens up alternative spaces for countries to understand and overcome various social problems that become obstacles in the development process this perception embraces a deep understanding of the role and impact of gender in various aspects of society opening the door to the creation of policies that are more inclusive and responsive to the needs of all citizens in this context the public budget plays a crucial role as an instrument that represents and realizes development interests public budgets are not only a tool for measuring the states commitment to gender empowerment but also reblect the extent to which the state is willing to accommodate diversity and respond to various social challenges faced by its society budget audits are a very important tool for assessing the extent to which public budgets reblect gender justice and are responsive to social problems by conducting budget audits development projections can be anticipated earlier so as not to give rise to new paradoxes that might result in marginalization and injustice this audit process is an important mechanism for ensuring that budget allocations are not just limited to writing numbers but truly accommodate the needs and rights of every individual regardless of gender thus through this approach the country can ensure that the development process not only produces economic growth but also reduces gender disparities and creates a more equal and inclusive society the to strengthen the implementation of the presidential instruction the government established the minister of state for womens empowerment as a special institution responsible for analysis and supervision related to gender mainstreaming these steps create a solid foundation for the integration of gender perspectives in the national development agenda reblecting the indonesian governments serious commitment to realizing a more just and inclusive society the functions of analysts and controllers in the context of gender mainstreaming illustrate the essence of conceptual understanding contextualized in practice the challenges that arise relate to institutional adaptation at the regional level and the national mechanisms tasked with overseeing gender mainstreaming several regions responded by formulating institutional adaptation through the formation of new institutions that specibically focus on activity programs that are considered to represent the interests and needs of women for example the pkk in several regions adopts this approach by orienting all programs and activities exclusively for womens groups however it should be noted that there are challenges to this approach where pkk is often limited to implementing traditional programs such as cooking and beauty training this highlights the need for further reblection to ensure that these institutions are able to cover broader and deeper aspects related to gender mainstreaming in every dimension of community life gender mainstreaming is often interpreted in an afbirmative way through policies that are female in nature which tend to accommodate womens issues specibically in this context gender is considered a separate dimension that focuses on women not a perspective that summarizes the entire process of community development beyond the exclusive boundaries of sectoral institutions as a result gender has become a separate space that is treated differently compared to other sectors the conclusions from this model indicate that the understanding of gender is still ambiguous resulting in policy translation that is less relevant at the operational level this creates challenges in achieving true gender mainstreaming in every aspect of public policy as an overly femaleoriented focus can obscure the need for broader and more comprehensive gender equality in society a more holistic understanding is needed so that gender can become an integral part of the entire development process encompassing and embracing the roles and interests of all individuals without gender boundaries two important things that form the formula for gender mainstreaming are birst development programs and activities are not separated between men and women as a social construction the gender perspective does not differentiate dichotomously into specibic programs for men or women the activity program is designed to allow men and women to have an equally representative and fair space to participate contribute and gain benebits a representative and fair space is important in every program and activity to ensure accessibility for all development stakeholders second the activity program projected as gender mainstreaming afbirmation is not oriented towards obtaining calculative results but rather as a target or medium for achieving gender justice and equality afbirmative activity programs function to support the process of achieving balanced gender capacity between men and women in the implementation of development the family planning program for example is not projected to increase womens capacity to control births but is a means for women to have a balanced bargaining position in planning family welfare with the above framework the concept of guard institutions which is conbirmed based on presidential instruction no 9 of 2000 is different from institutions that are formulated as executors of womens programs the monitoring institution assumes the reachability of all crosssectoral development processes while the programimplementing institution is a special sector that does not necessarily have a gender perspective gender in the stunting recording program in bandung city the issue of stunting not only reblects a public health problem but also has a broad impact on a countrys social and economic development children who experience stunting tend to experience obstacles in their physical and cognitive development which in the end can affect their learning abilities and productivity in the future thus stunting is not only a health problem at the individual level but also a serious challenge in a nations sustainable development efforts womens or mothers lack of access to nutritious food is a serious problem that can be triggered by a number of complex factors one of the main factors is economic limitations where healthy food and ingredients become expensive or unaffordable for some women the high cost of living can hinder womens ability to meet their nutritional needs adequately apart from that local culture also plays an important role in inbluencing womens access to food customs that dictate that women or mothers have to eat later after other family members can be a real obstacle to meeting womens nutritional needs because they sometimes result in less nutritious leftovers or even a lack of healthy food choices distorted understanding of diet in adolescents and women can also exacerbate this situation social and cultural factors can create norms that support unbalanced eating patterns often with a focus on foods that are low in nutrients this can inbluence the way girls especially teenagers and women choose and consume food lack of or inadequate nutritional education can also be a cause of unhealthy diet understanding therefore efforts to increase womens or mothers access to nutritious food need to involve a holistic approach that includes economic social and cultural aspects as well as increasing understanding of nutrition among teenagers and women to support healthy lives and prevent nutritional problems such as stunting the epenting program launched by the bandung city government has the main aim of making it easier to collect data on stunting in the community this application summarizes various features such as a collection of questions related to stunting conditions standard operating procedures for managing stunting data data integration from various sources data cleaning and data veribication stages apart from that epenting also acts as a single data publication tool and as a data analysis tool that facilitates an effective and efbicient policymaking process through this application it is hoped that epenting can realize comprehensive data management starting from the planning stage to monitoring and evaluation the entire series of processes including data collection policy analysis publication and outreach are integrated into one platform so stakeholders from posyandu cadres to subdistrict subdistrict and regional government heads can make optimal use of this data in this way it is hoped that epenting can become an effective instrument in supporting stunting reduction efforts in bandung city as well as a model for managing similar data at the local level throughout indonesia the epenting program in bandung city is closely related to the principle of gender mainstreaming as reblected in its commitment to always promote womens rights and access to public services gender mainstreaming is not just about ensuring womens participation in every aspect of development but also ensuring that programs such as epenting specibically consider and integrate gender needs and perspectives in their design implementation and evaluation one way in which epenting reblects gender mainstreaming is by ensuring that all questions or modules contained in the application cover issues of a gender nature such as womens reproductive health or nutritional needs for girls the stunting data sop contained in the application can also be designed to take into account certain aspects that are more relevant to women such as monitoring the nutrition of pregnant women in terms of data publication epenting can be a medium that supports transparency and accessibility of information for all including women the use of data analysis tools can also help identify gender inequalities in stunting rates or access to health services thus epenting is not only a tool for administrative efbiciency but also an instrument that strengthens gender mainstreaming by describing and analyzing the programs impact on womens wellbeing in addition managing stunting data which involves participation from the posyandu level to heads of regional apparatus ensures that womens voices and perspectives are accommodated and respected throughout the development chain thus the epenting program in bandung city can be considered a concrete and committed step towards realizing gender equality in the dimensions of public services and public health as a whole gender mainstreaming in the electronic stunting recording program in bandung city is reblected in several aspects of policy monitoring and evaluation the following are details of several forms of gender mainstreaming in the program policy alignment with gender equality principles the epenting program in bandung city embraces the principles of gender equality in its design afbirming its commitment to creating a positive and equal impact for women and men in developing this program the principle of gender equality was the main basis for ensuring that every aspect took into account gender diversity and responded to the unique needs of both sexes from a policy perspective the program has detailed steps to ensure that every policy related to eimportance creates balanced benebits for women and men in its implementation epenting is not only a technological tool for recording stunting but also a means of ensuring that access to this service is equally open to women and men by ensuring active participation from both gender groups the program not only records stunting data but also creates opportunities to understand the specibic impact on women and men this creates a strong foundation for further policy development that can have a balanced positive impact on all citizens regardless of gender by integrating gender equality principles throughout the program cycle epenting proves that information technology can be an effective tool in realizing gender inclusion and justice inclusion of gender issues in application modules in an effort to ensure gender mainstreaming questions or modules in the epenting application in bandung city are carefully structured to cover highly relevant gender issues one aspect that receives special attention is the nutritional monitoring of pregnant women which ensures that the health and nutrition of mothers during pregnancy can be monitored in more detail this is an important step to ensure that pregnant women receive adequate health care and support throughout their pregnancy apart from that epenting also pays attention to womens reproductive health issues by including modules that monitor aspects of reproductive health such as antenatal and postnatal care and family planning the program ensures that womens health services cover the entire reproductive life cycle in this way epenting is not only a stunting recording tool but also an instrument that supports the prevention and treatment of womens reproductive health problems the focus on aspects specibic to women and girls creates opportunities to collect more indepth and relevant data by understanding these special needs epenting encourages the role of women in health and development services and creates a quality data basis for better decisionmaking in stunting management in this way epenting is not only an effective tool for recording stunting data but also a means of improving the welfare of women and girls at the local level monitoring gendered data analysis the monitoring process integrated into epenting in bandung city reblects a progressive approach by including gendered data analysis this step is key to identifying and overcoming gender inequalities in stunting levels and access to health services in the community by collecting sexospecibic data eimportant enables a deeper understanding of how the impact of the program differs between women and men gendered data analysis allows researchers and policymakers to dissect every aspect of the program with a gender lens for example such data could provide insight into the extent to which women have equal access to health services provided by epenting or the extent to which the impact of stunting is more signibicant on girls thus this analysis not only helps measure the overall effectiveness of the program but also details the specibic impact on certain gender groups in addition the data collected also provides an opportunity to identify gender inequalities in stunting rates which can help develop more targeted policies if data shows signibicant inequalities between girls and boys in stunting rates corrective steps can be taken to ensure that programs are more effective in addressing the problem with an inclusive and genderequitable approach thus epenting is not only a conventional monitoring tool but also an important instrument in the struggle to achieve gender equality in monitoring and handling stunting at the local level womens participation in monitoring in the context of epenting in bandung city the monitoring system implemented reblects a commitment to involve womens active participation in the entire data collection and analysis process inclusion of women in posyandu subdistrict and subdistrict is key to ensuring that womens perspectives and experiences are directly taken into account in evaluating the effectiveness of this program womens participation in the data collection process provides a more complete and accurate dimension regarding the programs impact on stunting levels and public health by involving women directly at the posyandu level where they have direct access to the local community ekenya ensures that the data collected reblects the realities and challenges faced by women in the context of childrens health and nutrition in addition the involvement of women in subdistricts provides an opportunity for them to provide direct input and perspectives related to program effectiveness this ensures that proposed policies and changes are not based solely on quantitative data but also take into account qualitative aspects that might be overlooked without direct contributions from women in this way epenting is not only a technical instrument for recording data but also a participatory tool that supports the inclusion and empowerment of women in development and handling stunting at the local level evaluation gender impact assessment the evaluation process for the use of epenting in bandung city focused on gender impact assessment paying special attention to the way the program affects women and men differently by conducting evaluations that examine program effects in a sexospecibic manner epenting enables an indepth understanding of the programs contribution to gender mainstreaming and efforts to reduce gender disparities in stunting management the gender impact assessment in the evaluation includes various indicators such as the level of womens participation in the program increasing womens access to health services and the programs impact on womens economic empowerment by looking at differential impacts between women and men this evaluation helps identify successes and challenges that may be related to the gender aspects of the program furthermore the evaluation reblects the extent to which epenting realizes the goal of gender mainstreaming in the context of stunting if the evaluation shows that the program is successful in reducing gender disparities and improving womens welfare by managing stunting this conbirms the effectiveness and relevance of the program in the context of gender equality thus epenting is not only considered an information technology tool but also an instrument that makes a real contribution to improving womens conditions and leads to inclusive and genderequitable development at the local level womens participation in evaluation the epenting evaluation process in bandung city marked a strong commitment to the active participation of women as direct users and stakeholders in analyzing the programs impact by integrating womens perspectives opinions and experiences evaluations not only measure program effectiveness but also create a more complete and richer narrative about their impact on women in the context of stunting management womens active participation as direct users ensures that the evaluation includes their views as direct recipients of program benebits this provides indepth insight into how eessential impacts womens daily lives including their access to health services the ease of use of the app and the extent to which the program empowers women in family health management the opinions and experiences of women as stakeholders enrich the evaluation perspective by involving them in assessing the broader impact of the program by integrating womens voices evaluations become more holistic and take into account factors that may not be directly visible in quantitative data in this way eimportant ensures that the representation of womens voices is reblected in analyses of program successes and shortcomings supporting the strengthening of womens roles in decisionmaking and the design of more inclusive policies conclusion the epenting program in bandung city is not only an information technology tool for recording stunting data but also an instrument that consistently implements gender mainstreaming in policy monitoring and evaluation in designing and implementing this program there is a clear commitment to achieving gender equality and empowering women as an integral part of efforts to address stunting in the policy aspect epenting emphasizes the principles of gender equality by ensuring that every step and policy related to the program provides equal benebits for women and men the modules and questions in the app are specibically designed to cover gender issues such as maternal nutritional monitoring and womens reproductive health recognizing the unique needs of both gender groups furthermore in the monitoring process epenting uses gendered data analysis to identify gender inequalities in stunting levels and access to health services the program not only notes general impacts but also pays particular attention to how the effects differ between women and men the monitoring system also ensures the active participation of women from the posyandu to the subdistrict level giving them a signibicant role in data collection and analysis in the evaluation phase eimportant highlights the active participation of women as direct users and stakeholders ensuring that the evaluation covers womens perspectives and experiences as a whole womens voices are integrated into analyses of program successes and shortcomings ensuring representation of womens voices in broader impact assessments overall epenting in bandung city has succeeded in becoming a model for implementing information technology that is not only effective in recording stunting data but also plays a role in realizing gender equality and womens empowerment this program provides a new perspective on how technological innovation can support government efforts to achieve inclusive and genderequitable development goals community empowerment 5 120123 imani n

collection program eimportant in bandung city with a focus on policy monitoring and evaluation in preventing stunting this research uses a qualitative approach with descriptive methods the research results show that the epenting program in bandung city has had a positive impact on recording stunting data with a strong gender mainstreaming approach the data collected involved the active participation of women at various levels from posyandu to subdistricts producing more indepth information about the impact of the program on women and men this program successfully integrates gendered data analysis into the monitoring process providing more comprehensive insight into gender inequality in stunting rates and access to health services the evaluation showed that womens participation as direct users and stakeholders supported the success of the program with womens opinions and experiences signihicantly integrated in the analysis of the programs successes and shortcomings in this way epenting is not only an effective tool for recording stunting data but also a pioneer in realizing gender equality and womens empowerment through information technology innovation

introduction lifestyle encompasses the whole set of practices undertaken by individuals in their daily life among these practices we may find some which foster a healthier life and others which could be considered risky behaviors 1 each individuals lifestyle will determine the healthillness process where individual responsibility is essential and bad habits like tobacco use poor diet or physical inactivity contribute to the development of chronic noncommunicable diseases such as diabetes high blood pressure or obesity from the holistic biopsychosocial perspective it is crucial to examine lifestyles in a contextualized manner taking into account the sociocultural influence in both behaviors and lifestyle sets 2 highlighting the importance at a clinical level of the role of those people surrounding us and the context we live in 3 having a balanced lifestyle when this disease is diagnosed is crucial to achieve a good diabetes management type 1 diabetes mellitus a paradigmatic case is a disease caused by a lack of insulin which generates persistent hyperglycemia and energy wasting 4 at a global level t1d has a prevalence of 1110100 people aged 019 in spain 15467 people are affected by this disease 5 specifically in andalusia its prevalence and incidence have progressively increased with a total estimated between 30 and 60 thousand people affected 6 seville with a prevalence of 206 cases per 1000 population and an incidence of 2396 cases per 100000 population registered in 2014 is the province with the highest rate 6 t1d has a multimodal treatment comprising insulin intensive therapy diet therapy physical exercise selfmonitoring and diabetes education the complexity of the treatment lies in the continuous requirements that should be incorporated to the individuals lifestyle as diagnosis usually takes place at an early age 7 childhood or adolescencethese individuals are in developmental stages and therefore still creating their living habits this is why achieving good glycemic control taking into account the childadolescent environment from the very beginning is crucial to ensure an optimum quality of life failure to adhere to treatment involves a metabolic disorder which may cause serious chronic complications risk of high morbidity and mortality and disabilities 8 other chronic diseases such as obesity asthma or epilepsy may appear in different ranges 89 and though they may require of basalexposure therapy it is common for this type of treatment to be occasional and discontinuous 910 according to the development of the symptomatology as it is the case of allergic asthma 10 in contrast to these chronic diseases t1d requires of a continuous baseline treatment constant daily record in which the individual has to make decisions strict and multiple selfmanagement of blood glucose level and taking different insulin shots 11 all this generates emotional stress as a consequence of an active role in selfmanagement 12 other diseases which may appear during childhood or adolescence such as cancer require of much more aggressive treatments than those related to t1d though these treatments are applied during long hospital stays 13 and there is a high rate of success in both treatment and cure in developed countries 1415 however in t1d long hospitalizations may be only to the disease debut 16 but treatment requires constant attention within the social and familiar spheres and nowadays there is no cure 16 the first years of t1d evolution are a critical stage significantly more if they overlap with the adolescent stages when young people struggle to gain autonomy and independence from their families 17 18 19 in the early stages adolescents with diabetes are highly motivated to learn about the adequate management of their treatment and comply with adherence 20 this is driven by their desire of achieving independence from families and gain integration among their peers in the social sphere 21 however the adolescent must face the ambivalence between the support and pressure to feel part of the peer group 22 as peer group support of all sociocultural influences has proven to be a key lifestyle aspect at this stage the adolescent wants to comply with expectations adopting behaviors which are socially accepted in order to feel part of the peer group 23 a whole process which leads them to generate a sense of peer group belonging and identity validation 24 in this sense adolescents with diabetes may adopt behaviors that diminish previously gained adherence avoiding treatment requirements in order to obtain a solid integration in the group 25 26 27 28 theoretical framework and background adolescence is a period of development and evolution for individuals aged 10 to 21 approximately though nowadays there are no tacit agreements on age range 29 this stage of constant development can be divided in three age brackets according to physical changes acquisition of abstract thinking and the quest for selfidentity 30 during the whole stage of adolescence there is a reduced perception of risk and a distorted feeling of power 31 this leads adolescents to believe that they must live in accordance to their feelings instead of accepting advice on the part of health professionals or their own families 32 though it may be considered that the strongest support is provided by their families adolescents may or may not perceive this support and consider it overprotective 33 or as a lack of understanding on the part of the families 34 for adolescents peer groups are very powerful support networks though they may cause conflict due to the ambivalence between the received support and the social pressure adolescents must face in order to feel part of the group 35 this is why the current literature points out the importance of peer role and the need of further research in this field 36 chronic diseases during adolescence may pose different implications according to the stage affected by the disease in an early stage adolescents are not concerned about their disease as they are fully focused on adapting to their peers and become part of the group during an intermediate stage there is a strong concern about selfimage 37 and how it is affected by the disease 3839 in the late adolescence there is a strong concern about the disease and its complications with regard to social relations and finding a partner 38 moreover a chronic disease in adolescents affect their selfesteem which is low while anxiety and depression levels are high 3840 in the context of chronic diseases peer support edges up to backing and emotional support thus being crucial in the adaptation of adolescents with chronic diseases such as diabetes to their own disease 41 this support is essential both for their emotional wellbeing and their compliance and remains a protective factor in adolescence 42 in the case of adolescents with diabetes constant compliance may affect their social relations when acute complications regular medical consultations or negative impact in the selfimage appear 38 these situations contrast sharply with their peers reality posing a risk for discrimination it may be considered that adolescents with diabetes show a potential high risk of not following an adequate selfmonitoring of the disease due to two crucial aspects sense of invulnerability and the competing daily demands of the treatment 43 for this reason it is crucial to analyze how peer relations affect group affiliation and selfcare of adolescents with diabetes as background literature on the relationship between adolescents with diabetes and their peers there are qualitative studies 224445 with results describing an erratic social support ie sometimes these adolescents receive this support and sometimes they do not in this respect the study by greco et al 46 offers a joint intervention of an adolescent with diabetes and a friend or peer showing a considerable improvement in both knowledge and support offered by this peer however in spite of the efficacy of the intervention the author 46 highlights the need of examine adolescents with diabetes from the role of their peers some interventions aimed to help adolescents with diabetes to overcome different social barriers have proved effective 47 nevertheless this type of interventions is nowadays limited as the traditional model of diabetes healthcare mainly focused on an adequate blood glucose control prevails this fact has pushed forward the challenge of acquiring social skills on the part of adolescents with diabetes 48 research on how peers influence in the behaviors both healthy and risky of adolescents with chronic diseases such as t1d is still not precise enough 242542 consequently the study of peer roles is crucial to survey the group affiliation and selfcare of adolescents with diabetes 49 the objective of this research is to know in depth the social support perceived by adolescents with diabetes from their peers identifying the roles adopted by peers regarding diabetes and their influence both on the integration and selfmanagement of the adolescent with diabetes methodology sample and procedures a pilot study was based on a descriptive phenomenological retrospective crosssectional design with the aim of analyzing in depth the feelings perceptions and experiences of participants qualitative methodology with indepth interviews to key informants was applied the duration of the interviews was not limited interviews were audio recorded and field notes were registered to encompass nonverbal communication aspects the study population consisted in adults aged 1835 living in andalusia with t1d of at least 4 years after diagnosis at the time of the interview however as it is a pilot study the sample was targeted to the province of seville the capital of the andalusian region benchmark regarding healthcare services and the province with the highest rate of incidence of t1d in the whole region besides seville hosts a flagship association of people with diabetes with a youth branch which provided the sample purposely the field research was accomplished between april and june in 2019 the first contact among participants and researcher was facilitated by a trusted figure familiar to them the president of the association youth branch who acted as key informant thus a snowball sampling was built through this key informant allowing access to the rest of participants to create a chainreferral nonprobability sampling so that participants could comply with the sampling inclusion criteria once the interview was agreed with the participant they were informed of the nature of the study and the informed consent was signed indepth interviews were semistructured covering the following dimensions relationship with peer group diabetes and social relations with peers perception of behaviors of different friends in daily situations and perception of conflicts with peers regarding diabetes interviews were conducted by the lead researcher who has a threeyear experience as academic intern plus a year as honorary assistant at the university of seville a period in which she worked conducting semistructured indepth interviews this researcher had previous experience in the subject of study after having accomplished different nursing roles with children and adolescents with t1d the sample consisted of 15 individuals with t1d aged 1835 data saturation was partially reached with the sixth participant in the dimensions peer relations and diabetes and social relations with peers data saturation was fully reached with the eleventh interviewee though four more interviews were conducted in order to bring more consistency and solidity to the study given the risk of circumventing sensitive information intentionally or not in the presence of a health professional retrospective research was accomplished working from memory though there was the risk of oblivion the more critical period of adolescence was bypassed resulting in a more holistic vision of the period in order to bypass the forgetting curve a maximum age of 35 years old was fixed as this age marks the consolidation of maturity besides peer relations during adolescence convey highly affective bonds facilitating their recall 49 for this reason the minimum age for participants was set in 18 years old t1d diagnosis entails significant changes in both affected individuals and their environment requiring an adaptation period of even a whole year 50 participants have at least a 4year t1d diagnosis at the time of the interview thus allowing them to feel fully adapted to their new routines and feel part of the therapeutic regimen in summary the selection criteria were participants aged 1835 t1d diagnosis during their childhood or early adolescence and a minimum of 4 years of evolution gender influence was not subject to this study 6 men and 9 women took part in the interviews exclusion criteria were the following being affected by a psychiatric pathology being affected by any difficulty which could block the interview communicative process cognitive impairment or intellectual disability t2d diagnosis or gestational diabetes procedure and ethical considerations each participant was provided with an accessible voluntary informed consent for them to read and sign together with an insightful verbal explanation interviews were recorded and therefore they took place in quiet places which guaranteed the comfort and confidentiality of each participant this study was validated by the research ethical committee of the hospitals virgen macarenavirgen del rocío in the session held on 30th april 2019 in order to guarantee their confidentiality participants quotations appear codified in this manuscript data analysis the lead researcher accomplished the interviews transcription including field notes and the discourse analysis through those transcriptions the first step once the interviews were transcribed was to extract all the codes which allowed a comprehensively codification of the different discourses according to their similarities right after the codified data were grouped according to the phenomenon similarities the following labels were established social support perceived and perceptions the category social support perceived covers peers instrumental or emotional support as perceived by adolescents with diabetes and was analyzed using two variables the first of these variables peer role encompassed behaviors attitudes and specific relations with regard to diabetes adopted by the adolescents peers the second one perceptions comprises the emotions and feelings generated in participants with regard to their peer relations individual differences and the contribution of these peculiarities to the information global significance were taken into account where appropriate once each variable was individually analyzed they were interrelated according to their meanings in order to build a general discourse which corresponded to the study category defined from which study results could be drawn relaying on the list of references cited 51 52 53 the validity of this qualitative study is achieved in the first place through a critical aim during the exhaustive discourse analysis accomplished by the lead researcher secondly a triangulation regarding the credibility of participants perceptions through their discourses was carried out by the different authors finally the authors triangulation set the basis to establish the composition of results faced with the impossibility of isolating variables from a complex holistic reality resulting from a qualitative study 51 52 53 the reliability of the study was accomplished through the triangulation of the recordings together with the field notes crosschecked by the different authors this process substantiated the results found results the average age in the sample was 2033 years being 893 years old the average age of debut of this disease at the time of the diagnosis with a maximum of 13 years and a minimum of 0 ostensibly the relationship established by adolescents with diabetes with their peers is similar to the one established by any other adolescent with his or her group of friends this implies that they can benefit from different types of support offered by the social network shaped by the peer group and therefore improving the adolescent wellbeing while helping to cope with stressful situations but when focusing on specific support regarding this chronic disease we may observe how certain roles emerge in the attitudes of the peers resulting from diabetes management capillary blood glucose testing carbohydrate counting insulin injections and complication management in case of hypoglycemia for instance when a group member has t1d peers adopt specific behaviors in different scenarios depending on how these attitudes are perceived by adolescents with diabetes three types of specific peer roles can be distinguished in relation to diabetes protective role indifferent role offensive role this section may be divided by subheadings it should provide a concise and precise description of the experimental results their interpretation as well as the experimental conclusions that can be drawn protective role the protective role embodies a set of peer attitudes and behaviors which foster selfmanagement favoring peer affiliation in general a protective role fosters behaviors which promote healthy habits in adolescents with diabetes favoring selfcontrol and fostering appropriate behaviors towards therapeutic compliance sometimes when they saw me i dont know eating icecream theyve asked hey are you allowed to eat that or theyve said dont you need an injection or are you watching your dose then yes maybe i didnt get it right so they were trying to help to control it even better with regard to nutrition peers try to help adolescents with diabetes to avoid unhealthy food or those which are not recommended without breaking the group dynamics that is peers also consume these types of food though food dynamics continue in the group supportive attitudes arose among these peers intake restrictions previous warnings food planning specifically devised for the adolescent with diabetes etc as they are aware of my disease they dont prepare highcarb food and use much more greens for example the other day i was having lunch at a friends and they prepared me a minced salad dish with tomato onion green pepper vinegar and tuna i ate it all they ordered some pizzashe he a delicate situation for adolescents with diabetes is related to alcohol consumption in general affiliation is fostered through responsible drinking either lead by adolescents with diabetes themselves or their closest circle though these attitudes may be questioned as protector roles because they encourage alcohol consumption adolescents with diabetes identify them as supportive two people interviewed acknowledge that though their friends tried to prevent them from drinking alcohol they rarely succeeded test yourself yo hey eat something so you dont get sick girl check your sugar but it was not like dont drink at all but if you do it do it right and thats support my friends are supportive with this issue i always said i cant drink but then i always did it so they say next week no alcohol because its bad for her but then the weekend came and they drink again and i did the same peers adopting the protective role during these moments try to suggest the type of alcoholic and nonalcoholic beverage in order to adapt consumption to the requirements of their friend with diabetes well my friends care right and if they have to buy cocacola they bring zero ® but when a mojito bottle is five euros and gin is seven and if you mix mojito and 7up we had a bowl like this arms wide open and gin is just for two i cannot impose to buy what i want in the context of selfcare adolescents with diabetes need to perform capillary blood glucose testings take insulin injections or use an insulin pump all of them procedures that often have certain impact on both selfesteem and selfimage it is common for adolescents with diabetes to hide these practices their peers out of shame or embarrassment but there is usually a close friend to share these situations with who plays a protective role offering company and emotional support i was ashamed of giving myself a shot in front of them i dont know when i needed my insulin dose i used to wait until one of my girlfriends needed to go to the bathroom i normally used to go with a friend who knew a close friend besides the closest friend the rest of peers also remind adolescents about the need of monitoring insulin administration and they even offer themselves to perform the procedure thus learning about treatment management though adolescents with diabetes prefer to undertake themselves their selfmanagement this type of attitudes on the part of the peer is really appreciated peers who adopt a protective role get genuinely involved and actively ask for information about how to proceed my friend asks me to show her everything you know testing insulin glucagon whether if she needs to call an ambulance the fear of hypoglycemia is perceived in most of discourses and specifically peers show concern about glycemic control and about how their diabetic friend feels as they become familiar with the situation they are able to anticipate hypoglycemia episodes warning their friend or alerting people around or they act directly providing sugary foods all my groups of friends have been informed about this so they have been helpful so when they feel im acting weird they always realize and tell me that my sugar is low also if i felt dizzy when i was with my classmates they told our teachers about it they even explained them everything i didnt have to tell my teacher that i needed to eat something indifferent role the indifferent role involves lack of actions or supportive behavior with respect to diabetes therefore letting adolescents to be autonomous and selfcaring in contrast to the protective role peers adopting indifferent roles do not try to avoid certain behaviors on the part of the adolescent with diabetes which could translate into lack of healthpromoting attitudes however this is perceived by adolescents with diabetes as inclusive as no difference with respect to the peer group is highlighted moreover adolescents with diabetes perceive indifferent roles as an opportunity of feeling independent in contrast with attitudes perceived from their families if they have to help me they would but i was my business they cannot be like did you take your insulin silence no but it is something they were clear about and they knew i had to take full responsibility it was mine and no one elses though indifferent roles imply the absence of direct actions adolescents with diabetes describe these peers as informed and aware of procedures in the case of complications while respectful of their autonomy normally they dont say anything about it but i knew they were watchful you know they were observing me watching this or that but saying nothing well except if something happened and then they did something but in general i could be on my own and they were ok offensive role offensive roles adopt a discriminatory behavior towards adolescents with diabetes merely because they suffer this disease and need to undertake selfcare consumption of food identity markers such as hamburgers and pizzas represents a source of conflict for these adolescents however food with high levels of simple carbohydrates becomes the major source of discrimination thus perpetuating all diabetes myths and beliefs about not consuming any sugar some peers adopting the offensive role are selfassured about the impossibility of sugar consumption on the part of adolescents with diabetes they take for granted the fact that these adolescents are not going to consume this type of food and therefore they do not have to share it these situations are usually managed in a humorous context but adolescents with diabetes may perceive them as a mockery then they started with cruel jokes associated to diabetes typical of people at that age right if we decided to go to a sweet shop and maybe i did not want to buy anything but just hang with them as we did every friday but then one of them told me that i could not go because i was diabetic and i was thinking like is he making fun of me or is he trying to protect me and i said him dont you worry im not buying candy and he was like no i say you are not allowed in because you are diabetic and then he said look the diabetic wants to enter there mocking tone i was crossed with him like forever besides nutrition other situations that lead to discrimination of adolescents with diabetes are those related to insulin therapy and glycemic control many times peers adopting the offensive role deliberately compare adolescents with diabetes to drug users due to injection practice this connection is established both inside and outside the school context and usually takes the form of scorn and derision displaying a whole range of offensive terms to address them when im in the street and i need a shot they shout to me dont smash yourself here you crackhead and that kind of stuff i felt embarrassed but also clears her throat at the beginning i was afraid i was afraid of being different you know what really worried me mmmh was that people gave me weird looks when i needed my insulin injection or that they stared at me in this situation the adolescent with diabetes claims to have felt bewildered as she cannot fathom that kind of comparison with regards to a therapeutic procedure essential for her health frequently these experiences may be potentially painful for adolescents with diabetes who confess feeling scared and embarrassed besides these situations may lead to a conflict direct or indirect or to avoid social contact with peers adopting these attitudes thus it can be concluded that offensive roles adopted y peers do not favor group affiliation and do not offer social support on the contrary it may lead to situations of verbal or physical abuse such is the emotional impact of the offensive role on adolescents with diabetes that it may endanger their health due to selfcare negligence a common illustration of this occurs when peers ridicule hypoglycemia symptoms and manifestations causing adolescents to feel embarrassed and therefore avoiding any action to reverse this situation in order to avoid subsequent mockery definitively offensive role favors situations of exclusion and undermines psychosocial wellbeing of the adolescent with diabetes i have had to fake how i was feeling when my sugar was dipping low so they dont say sad tone so they dont laugh at me as some of them did when i was all sweaty and white because this is how you look pale as a sheet discussion in their process towards social integration adolescents with diabetes aim to follow group dynamics trying not to feel different with respect to their peers 5455 up to this point previous researches 5657 try to relate peer influence to treatment adherence being this relation still limited 58 in this sense peer support does not appear clearly linked to an optimal glycemic control but peer conflict is closely linked to a worsening of glycemic control and selfcare 58 thus conflict may be considered to cause a deeper impact than support 59 de wit et al 60 systematic review claims that family support to adolescents with diabetes is nowadays a welldefined contribution however it is not clear if peer influence is negative or positive as on the one hand peers may complement the support offered by the families but also social conflict among peers may lead to negative results regarding diabetes further evidence on how peers influence health and risk behaviors in adolescents with cncds 2556 is still needed in this sense la greca et al 25 highlight the need of an inside appraisal on how and why adolescents with a cncd succeed or fail in their social relations and here the study of role is crucial with respect to these roles rankin et al 61 and kyngäs et al 62 highlight the presence of similar role to the ones observed in this study in the study by rankin et al 61 peer roles are classified into three types of support normalizers monitors and prompters and helpers those who do not offer support are labeled as insensitive and unsupportive peers for their part kyngäs et al 62 distinguish three supporting roles in their study dominating silent and irrelevant silent support described by kyngäs et al 62 consists in a group dynamic change towards a healthy lifestyle avoiding some types of food such like sweets normalizing diabetes and facilitating peer integration this study has failed to observe significant changes in group dynamics regarding the protective role but in foodrelated contexts they tried to reduce the intake of adolescents with diabetes or even try to prepare something more appropriate for healthy eating in second instance the roles of normalizers monitors and prompters and helpers proposed by rankin et al 61 come into play in selfmanagement situations complications and in general as emotional support and backing similarly qualitative studies by comisariado et al 22 and marshall et al 44 highlight that in some cases when adolescents reveal their diabetes diagnosis they receive social support on the part of their friends and this foster positive attitudes on the part of the peers all these support actions are also encompassed by the protective role and foster group integration this definition of indifferent role differs from the irrelevant support proposed by kyngäs et al 62 which contemplates no direct peer influence according to the perceptions of adolescents with diabetes on this regard this research cannot deny the possibility of this influence because although it is not implicitly manifested in any discourse certain degree of gratitude towards the peer group is observable and therefore some influence may be deducted pendley et al 45 observed that peers lack of specific knowledge about daily management of diabetes what may result in two types of behaviors absence of support or neutral support neutral support coincident with the indifferent role presented here would consist on not establishing a differentiating barrier between the adolescent with diabetes and the peer group therefore fostering inclusion but with bringing a duality the adolescent with diabetes may perceive this behavior as a form of emotional support which encourages risk behaviors or behaviors which do not favor selfcare in this sense marshall et al 44 highlight that according to the perception of adolescents with diabetes the support perceived is limited due to their peers lack of training i dont know i never felt they were doing a fuss around my issue i mean they maybe asked me how are you can you eat this those are things ive been asked but just once at a time when i answered them that was the end of it the insensitive role proposed by rankin et al 61 is similar to the offensive role in this study peers show no empathy and discrimination appears in contrast to last analysis 61 this research fund evidence of humiliating attitudes and insults resulting in selfcare restraint in order to avoid peer rejection this situation is also described by gürkam et al 63 showing that distress frustration and helplessness lead adolescents to hide their diagnoses finally the dominant role described by kÿngas et al 62 involves peer pressure so adolescents with diabetes feel forced to follow group behaviors ignoring their disease in order to comply with social integration or treatment adherence although there is no direct correlation with the roles proposed in this study the dominant role 62 is to some extent present in the behaviors adopted by both protective and indifferent peer roles here described on the one hand peers encourage the adolescent with diabetes to carry out group practices including the consumption of toxic substances in a controlled wayunder the protective role on the other if peers adopt an indifferent role and do not get involved selfcaring on the part of the adolescent may be neglected in favor of group dynamics ultimately offensive roles may cause adolescents compliance with peer group by means of a passive behavior for fear of reprisals or rejection under this assumption this may cause a dominant behavior such as the role suggested by kyngäs et al 62 most studies on peer influence in children or adolescents with diabetes do not cover the use of alcohol and other drugs as they focus on the treatment requirements glycemic control and adherence and quality of life achievements 56596162 finally with respect to the offensive role and discrimination there is a lack of scientific evidence 565962 the insensitive role observed by rankin et al 61 shows similar behaviors although analyzing an underage sample results are slightly different according with the results adolescents with diabetes ascribe great importance to the fact of feeling normal and not different from their peers and unfortunately they show a limited social success 22 continuous selfcaring and hypoglycemia disruptions easily cause stigma becoming bullying targets and conflict situations all practices associated to disease management 58 one of the stigmas more commonly highlighted by adolescents with t1d is the lack of information around the disease which consequently it is linked to the impossibility of consuming certain foods or performing certain actions 64 according to browne et al 65 adolescents with diabetes suffer from a lack of knowledge and misinformation of the rest of the population which may be caused by wrong media outreach consequently during friend meals adolescents with diabetes have to cope with social prohibitions resulting in a negative impact on their identity caused by their peers failure to differentiate the recommended guidelines for the disease therefore inner conflict arouses and some adolescents avoid disclosing their disease 226566 as revealed by participants people sometimes are a pain in the neck its a shame that due to misinformation uhm they are bothering you and in the end making you feel really bad why are you eating that and then you have to explain everything all the time its like i eat this because i want damm but you cant well i can and thats the end of it its exhausting ultimately the results obtained allow an overview of both social support as perceived by adolescents with diabetes and the identification of peer roles the influence of these roles rather vague in previous literature 2256596062 has been clarified in this pilot study in contrast to results obtained in other studies 444562 the present wok observes that the protector role not only foster healthy and selfcare behaviors which facilitate integration but also it may develop a crucial role in common scenarios of adolescence encouraging a controlled consumption to facilitate and improve the integration of the adolescent with diabetes however though this attitude may favor integration it has a negative impact on the adolescents selfcare this duality is also observable in the indifferent role matching the results of the study by pendley et al 45 by contrast this role duality has not proved to be so far the origin of the discussion on whether or not social support from peers is a positive influence for adolescents with diabetes limitations the limitations of this study should be acknowledged firstly that the research is a pilot study and it has only realized in seville despite we have reached the saturation point our sample is geographically limited secondly we chose our sample on the basis of convenience which makes it difficult to extrapolate wider conclusions from the results obtained thirdly this study has focused on the perception of adolescents with diabetes and no peer interviews were conducted an analysis of peers perceptions would provide a contrasting and therefore in order to provide further conclusions to the study of peer affiliation in the case of adolescents with diabetes finally during some interview participants acknowledged expectations about what the ideal behavior of their peers could be however this aspect requires of another indepth study given the myriad possibilities conveyed by participants subjectivity conclusions peer influence through specific roles is crucial for the group affiliation of adolescents with diabetes on the one hand both the protective and indifferent roles facilitate the integration of the adolescent with diabetes the protective role also fosters controlled consumption of food identity markers andor alcohol the indifferent role ignores the disease without realizing the personal consequences of these practices though seen as supportive on the part of adolescents with diabetes these peers pose a dilemma for adolescents who have to choose between following common social practices in order to feel part of the group or lead a healthy lifestyle on the other hand the offensive role generates stigma and social conflict which it is not conducive to the integration of adolescents with diabetes even jeopardizing their physical and emotional wellbeing this type of offensive behaviors according to adolescents with diabetes may be the result of societys lack of health information and education regarding t1d the number of studies evaluating the how adolescents with diabetes perceive their peers behaviors is very limited and in no case this literature shows a result categorization as simple and comprehensive as the one in this pilot study which highlights the importance of the duality conveyed by both indifferent and protector roles in the behavior of adolescents with diabetes thus the study offers a possible explanation on why qualitative studies have failed so far in completing the overview on peers influence in terms of positive or negative influence the innovative approach focuses on the results regarding the protector and indifferent roles and the possibility that they may introduce simultaneously both a positive and negative influence this fact enables our study as a foundation for further more extensive research which may not only confirm these roles duality but also provide an indepth extended analysis of the offensive role and its consequences the practical implications of this research may be observed at several levels in the field of research it offers a possible explanation to a phenomenon hitherto unclear expressly the acknowledgment of specific peer roles facilitates precise health care interventions which will help to improve not only the affiliation of adolescents with diabetes but their coping with social conflict scenarios therefore improving their psychosocial wellbeing in the field of education it is possible to offer a conceptual benchmarking framework on the type of behaviors that may be generated in the class context towards the student with diabetes this could facilitate the planning of prevention strategies on the part of teachers in order to avoid discriminatory attitudes posed for example by the offensive role therefore these professionals could foster the integration of adolescents with diabetes in the class together with teacher training the applications of this study could facilitate understanding of parents and families of adolescents with diabetes adolescence is a critical time where knowing what the adolescent is really doing or how they cope is very difficult for parents since adolescents rely on the group of friends for confidence and comfort therefore observing the possible behaviors that these friends may adopt will help parents to guide them understanding some behaviors and the outcomes regarding diabetes at this stage with respect to adolescents with diabetes knowing in advance the roles of peers within their social sphere provides them with the possibility of working in advance on coping strategies for the different role behaviors when approaching this knowledge from a multidisciplinary perspective together with their family adolescents with diabetes may achieve a considerably more effective group integration finally it is important to be realistic when appraising the adoption of selfcare behaviors in adolescents with chronic diseases even in the best scenario cases of social integration and when peers are well informed about the disease adolescents with diabetes can easily adopt risky behaviors perceived as controlled by them and their peers data availability statement the data are not publicly available due to privacy or ethical considerations funding the apc was partially funded by financial support for the consolidation of research groups by the andalusia regional government institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by ethics committee of the hospitals virgen macarenavirgen del rocío in the session held on 30th april 2019 informed consent statement informed consent was obtained from all subjects involved in the study

the aim of this study was to examine through the roles of peers with regards to diabetes the relationship between the support perceived by adolescents with diabetes and their peergroup affiliation this is a descriptive phenomenological and retrospective study based on a qualitative methodology indepth interviews with 15 people aged 1835 with type 1 diabetes mellitus diagnosed in their childhood or adolescence were carried out data was analyzed through the interpretation of general discourses peers have considerable influence on adolescents and provide them social support from different roles the protective role basically offers emotional support and sends reminders of different aspects of the treatment while the indifferent role does not meddle in any aspect related to the diabetes both roles can foster social integration of adolescents with diabetes into the peer group the offender role creates social conflicts through discrimination and stigma of adolescents with diabetes these roles appear during the process of socialization of adolescents with diabetes where commensality and situations of selfmonitoring or administering insulin key aspect of diabetes treatment are crucial peer groups depending on the role adopted may offer support or bring a specific conflict regarding diabetes to their adolescent peer the combination of roles that friends and peer group play with regards to diabetes will determine the degree of socialization and integration of adolescents with diabetes

i introduction this issue of oxrep is concerned with economic disparities between regions in europe and in the united states significant regional inequalities of income and wealth exist in every western european country and in north america but their extent varies from country to country exactly how one country compares with another depends upon the spatial unit of analysis studied as well as upon the measures of economic performance and inequality used on virtually all measures regional inequality is particularly high in the uk higher even than in the us regional inequalities change across time in both europe and the us it is generally thought that they tended to narrow from the early 1900s until about 1980 since when they have increased the articles in this issue are concerned with why we should care what exactly it is that we are measuring how and why regional inequalities have evolved over time and what policymakers have done and should do to address the problem ii why do spatial inequalities matter a simple classical or neoclassical view of the world would predict that regional disparities were transient in time markets would adjust to bring different areas closer to equality labour would leave poorer areas for richer areas and capital would move in the opposite direction however in regional economics as in in other relevant disciplines there are contrasting strands of literature as van dijk and edzes put it in economic geography circles the debate is between spaceneutral theories where labour is seen as highly mobile and placebased approaches that emphasize the underdevelopment traps associated with locationspecific externalities and potential market failures the latter approach is illustrated by patricia rice and tony venables who remind us of a number of reasons why convergence forces regarding labour and capital mobility might be weak to nonexistent because labour markets tend to be national there is relatively little scope for wage adjustment and this lack of adjustment will dampen the willingness of investors to move into the poorer areas the people who move out are likely to be the young and the skilled meaning that the remaining workforce is relatively unattractive to inward investors rice and venables go on to argue further that places that have experienced negative shocks may have adverse skill and demographic characteristics and also weak fiscal positions poor public services and social and health problems associated with low employment rates many of these are cumulative involving vicious feedback mechanisms with multigenerational effects thus firms are reluctant to move into such areas in some senses this is the inverse of the agglomeration argument successful areas are sustained by clusters of firms comprising a mutually beneficial ecosystem that are resilient after economic crises while poorer areas can be trapped in a lowproductivity lowincome equilibrium in particular when they are hit by national macroeconomic recessions disadvantaged regions fall into three categories those which have been relatively poor in the very long term those which failed to adjust to structural change and those disproportionately affected by a macroeconomic shock the first category would include the likes of the highlands of scotland or large parts of southern italy the second would include many former centres of manufacturing in europe and north america the third usually contains already disadvantaged areas whose disadvantage is exacerbated by a macro shock the articles in this issue by joan rosés and nikolaus wolf on europe and by trevon logan et al on the us encompass all three types thus regional inequalities can be persistent and selfsustaining some regions become and remain left behind apart from the economic consequences for many individuals across the generations there are broader social and political implications these areas often exhibit poorer health higher mortality rates lower educational attainment and greater crime in some countries deprivation has become associated with various forms of political extremism recent studies on the geography of discontent suggest that the rise of populist political parties associated with antiestablishment voting antieu voting and brexit are concentrated in places that face population and industrial decline have low land rents high unemployment rates and low levels of education of the workforce it might also be the case that too much regional divergence acts as a drag on the growth of the national economy for example it is likely that labour force capabilities are underutilized in lowproductivity regions because of limited individual mobility for both economic reasons and noneconomic reasons this means that human capital is being wasted all these negative associations with regions that are lagging or in decline or impoverished have led to the coining of the phrase places that dont matter iii measurement the variables upon which we concentrate are gdp per capita and disposable income per capita the first is measured at the workplace the second is a household measure and therefore relates to the place of residence different authors in this issue employ different spatial units of analysis depending on the specific phenomena they are studying the oecd has a standardized spatial classification system the intricacies of which are well explained by mccann tl2 is the highest level of disaggregation describing large regions in the uk for example there are 12 of them tl3 digs down into areas within these large regionsthe uk has 173 of them the third residencebased measure is of metropolitan urban areas containing more than half a million people and based on commuting flows and contiguity there are 17 such areas in the uk eurostat and the european commission employ a slightly different classification labelled as nuts 1 nuts 2 and nuts 3 mccann compares these with the oecd classifications he shows that for the uk and three of the eu countries nuts 1 corresponds with tl2 for another 14 countries nuts 2 is not much different from tl2 nuts 3 and tl3 more or less correspond for all eu countries unless one defines spatial areas very narrowly then the issue of intraarea inequalities becomes potentially important and these inequalities vary across countries as mccann writes inequalities within the uk are also across such short distances with enormous local productivity variations evident within just a twohour driving time whereas within spain comparable variations would only be evident across a sevenhour driving time and in italy and the united states across a 10hour driving time this observation is reinforced in the case of the uk by the 2070 commission the longterm patterns of inequalities are reflected at a neighbourhood level this is highlighted in the research by the geographic data science lab university of liverpool there is considerable intraregional variation in the distribution of struggling neighbourhoods within more disadvantaged regions the local patterns in neighbourhoods mirror regional disparities illustrating the way interand intraregional inequalities are reinforcing reflecting such observations enrique garcilazo et al develop what they describe as a functional typology of the oecds tl3 for europe and the us they subdivide tl3s into five categories large and medium metropolitan regions and three regions differing according to the size of the metropolitan areas to which they have access this enables them to conduct a finegrained analysis of the contribution of different types of regions to national economic growth as well as of the impact of the 2008 recession on different types of spatial entities iv the changing patterns of regional inequality rosés and wolf give a nuanced picture of the patterns of convergence in 16 countries in europe from the beginning of the twentieth century until 2015 initially there was little change from high levels of dispersion in the interwar years the significant decline in dispersion came in the years after the second world war until about 1980 rosés and wolf argue that in many areas this was not driven by the classical forces of convergence but rather by postwar reconstruction and structural change in those regions that had suffered physical destruction and massive population movementsparts of germany austria belgium italy the netherlands and eastern france from 1980 there was a significant increase in regional inequality importantly however they find that many islands of prosperity have emerged within otherwise lagging regions within this general picture there was diversity of regional experience taking snapshots in 1900 1950 1980 and 2015 rosés and rosés and wolf describe what they term a coreperiphery pattern in 1900 the regions of england northwestern europe and switzerland were richer than average the regions of france and central europe were close to the average while scandinavia and southern europe contained many poorer than average regions over time the spatial correlation has declined and a more complex picture has emerged by 2015 there were metropolitan areas and islands of prosperity such as paris and madrid which were surrounded by regions with relatively low average gdp per capita most regions of england had experienced a relative decline ireland and many parts of scandinavia had become richer than average logan et al paint a similarly detailed picture for the us general convergence has halted in the last three or so decades some of the dynamics of regional inequalities are driven by major cities nevertheless there are cities that buck the trend the southeast of the usa contains cities which are among the most innovative and dynamic regions in the countryraleighdurham nashville atlanta and richmond at the same time there are struggling cities in more prosperous areasoakland milwaukee detroit and baltimore some disparities develop over time others are abrupt structural breaks with respect to the first rosés and wolf describe how european regions from 1900 to date experienced a gradual and steady decline of agricultural employment shares a rise in industrial employment shares until the 1970s followed by a decline and a rise in the employment shares of services over the whole period the expansion of industrial and services employment was very uneven across regions while agricultural employment became significantly more concentrated todays regional disparities in income and job characteristics as well as massive differences in agglomeration effects and human capital endowments are the consequence of these historical developments logan et al describe similar longrun developments in the united states where in the early twentieth century some frontier regions had high levels of gdp per capita they put particular stress on the consequences of longrun changes for the current geographical distribution of human capital as they put it regional success is now a story of higher education human capital and the rising tech and service sectors understanding regional equalities today requires understanding these dramatic differences in human capital across space in the united states not only structural trends but also structural breaks may lead to new disparities between regions that impact regional development examples are the abolition of slavery in the united states the second world war and economic shocks such as the oil crises in the 1970s and the 2008 global financial crisis these breaks may come with both opportunities and threats with regard to the developments in the postslavery era logan et al state that the south would not develop the educational civic and financial institutions needed to promote innovation and diversify away from cotton by contrast as is shown by rosés and wolf reconstruction after the largescale destruction during the second world war stimulated regional economic growth on the western european continent any classical convergence forces at work would have had little impact but for the influence of a stable political environment and the massive marshall aid programme ironically lack of access to marshall aid may have been a reason that the uk fell behind after the second world war rice and venables explore the impact of adverse economic shocks in the 1970s using uk local authority district data they investigate the impact of the large and rapid fall in the share of the secondary sector in national output in the uk from 40 to 30 per cent in the 15 years from 1966 to 1981 they argue that if the classical forces of convergence had been at work we would have expected to observe a negative relationship between the size of the shock in employment rates in the lads and the subsequent growth of employment they do not find any such relationship twothirds of the local authority districts with the highest deprivation rates in 2015 had experienced large negative shocks about 40 years before they also found that the places that experienced negative shocks were not on average drawn from atypical starting points in other words some previously fairly prosperous regions shared the pain this is but one example of how fairly prosperous areas can succumb to fundamental shocks and of how difficult it can be to recover v the anatomy of regional inequalities rosés and wolf distinguish between geographical factors and institutional factors that account for regional advantage or disadvantage disparities in geography had large and persistent effects on past regional economic developments although these socalled first nature disparities may not be as important as they used to be reminders of their past influence can still be very much present nowadays using data on 173 european regions in 16 countries between 1900 and 2015 rosés and wolf divide geographical factors into two typesnatural and manmade favourable natural factors include climate soil quality access to coal fields and proximity to large seaports in similar vein in their longrun analysis of regional inequalities of the usa from the eighteenth century to date logan et al describe the geographic advantages of waterways and soil suitability for cotton as examples of regional endowments of natural resources that once led to fast growth in some areas institutional or second nature factors are more the consequence of previous action by economic and governmental agents rosés and wolf demonstrate how these second nature disparities between regions also affect regional development these disparities may relate to institutional differences such as simply the country to which a region belongs whether the region is a capital region whether the country is part of the european union andor the eurozone a second nature disparity of particular importance is market accessin other words the size of nearby regional markets since they reflect purchasing power not just dependent on the size of the population but critically on its employment patterns and income agglomeration effects and increasing returns to scale also fall into this category increasing returns to scale were important for the rise of manufacturing industries but were also crucial as logan et al argue in the institutionalized slavery system of the south of the us before the civil war as the terms suggest second nature disparities were frequently the consequence of first nature disparities for example proximity to coastlines or coal fields were often associated with the emergence of metropolitan regions the huge regional disparities in access to cities of different population sizes and densities is the starting point of the analysis by garcilazo et al they explore the contribution of different sized regions to gdp growth categorizing five types of region regions with a city of more than 1 million people regions with a city of more than 250000 people regions near a city of more than 250000 people regions near a city of less than 250000 people remote regions countries differ immensely in how their populations are distributed across these regional types different densities are related to agglomeration economies and to regional inequalities in productivity wages and living standards disparities in population densities and sizes determine to what extent the contribution to aggregate growth is more concentrated in metropolitan regions or more distributed across regions of different sizes they find evidence for agglomeration economies in regions with large cities in the us eu15 and eu25 their contribution to aggregate growth is higher than their population share however mediumsized cities play a larger role in europe than in the us where conversely the regions with the largest cities make a greater contribution than in europe interestingly the contribution of cities to growth is less volatile in the new member states of the eu than in the older member states they go on to suggest two different country types countries with metrodominated growth contributions in which regions with large cities dominate the contribution to national economic growthfinland france estonia greece lithuania italy and the us countries with mixed growth models of which there are two varieties the first comprises those countries with decreasing sizemonotonic growth contributions where regional growth contributions decrease with the main city sizes of the regionsaustria the united kingdom germany the netherlands and slovenia the second have mixed growth regimes where all regions contribute to growth in a roughly balanced waythe czech republic denmark hungary belgium latvia portugal slovakia sweden poland spain and norway they conduct a similar exercise for regional contributions to national productivity growth and find two broad patterns concentrated countries where most productivity growth is contributed by the top productivity regionsas in the czech republic belgium slovakia sweden france the uk greece lithuania and the netherlands distributed countries where catching up regions contributed the most to aggregate productivity growthas in austria denmark germany estonia spain finland hungary italy latvia portugal slovenia and the united states such results raise two questions the first is what impact a levelling of regional performance might have on a nations overall economic growth clearly any government would hope that the productivity of a poorer region can be enhanced via policy interventions without any cost to the productivity of more successful regions but this might in fact not be achievable the second is where future national economic growth will come from noting the sort of evidence presented by garcilazo et al mccann inter alia argues that the dominance of core cities and therefore of core regions may well fall in the future quite independently of any policy initiatives although modern globalization had made geographical proximity important for highvalue knowledge activities and for service activities reliant on trust he suggests that in the future there will be many more opportunities for noncore regions we explore this issue further later in this article it is not only disparities in population size that matter so do disparities in population characteristics not least its human capital broadly defined böhm et al studying west germany between 1975 and 2014 provide one specific example their starting point is that germany as a whole has seen rapid population and workforce ageing using a panel of labour market regions they find that workforce mean age has considerable negative effects on the wage returns to age which are arguably stronger in markets with more nonroutine jobs they also find that the employment rates of older workers also tend to fall with mean age these effects vary significantly across german regions and böhm et al explore this further workforce ageing can be driven by both demand and supply influences it may be that the demand for older workers falls in a region or that the supply of younger workers falls because of declining birth rates or outward migration lowincome regions and those in relative decline tend to lose younger people who leave in search of better jobs but also in search of a more appealing lifestyle in the more vibrant urban centres böhm et al also find a significant role for increased relative demand for younger workers but only in these urban centres as far as declining or leftbehind regions are concerned in most countries their working populations get older and if böhm et als results are true beyond germany there are harmful consequences for these older workers an important dimension of human capital are leadership skills and capabilities the more devolved responsibility for regional strategies and their implementation becomes the more important are the qualities of local leaders paul collier and david tuckett discuss one aspect of this they compare the political economies of wales and the west midlands of england they consider the role of narratives in forming investment expectations how a particular set of expectations can trap regions in low income equilibria and limit the scope for regional leaders to reset those expectations whether an area has a low income equilibrium or a high income equilibrium it will be the consequence of a whole set of interdependencies between firms operating in the tradable sector and those in the nontradable sector between firms operating internationally nationally and locally between the decisions made by the commercial sector and those made by the education sector and by local government affecting things like infrastructure and local taxation however as collier and tuckett put it resetting a lowincome equilibrium may require a coordinated change in the narratives prevailing in these different interest groups that have only limited interaction they pursue these ideas by interviewing representatives of the business communities in wales and the west midlands the main difference they found between the two regions was that narratives were overwhelmingly negative in walesnarratives of identity suggest that identities are not merely fragmented but actively oppositional a predominant explanation for economic failure is normative others are blamed within and outside the society resulting in a passive mentality of victimhood under what conditions they ask can a local leader reset attitudes and actions in the local economy the first requirement is that he must have the trust of the different parties the second is that he has a clear flexible and resilient approach only then can what they call a conviction narrative be achieved the importance of leadership is also emphasized by ties vanthillo et al in their assessment of the changing nature of regional policy in europe they discuss the evolving features of regional policies in four periods from the 1950s to date the current period is characterized by placebased policies in the construction and implementation of which they argue that political leadership is essential for the quality and implementation of effective measures to stimulate local development populist politicians in a number of european countries have blamed membership of the eu in general and membership of the euro area in particular for rising inequality among regions and households there is a welldeveloped literature considering the impact on member countries of being members of a common currency area not having control over ones own exchange rate deprives a country of an important tool of macro policy the implications for its economic fortunes are uncertain depending as they do on other policies adopted by the country itself and by other members of the common currency area thus for example the impact of the euro on the distribution across countries of gdp per head is highly uncertain less studied is the impact of the euro on inequality between households and by implication between regions within the member countries this is what florence bouvet investigates for the first time she uses a synthetic counterfactual methodology which matches individual euro countries with noneuro countries possessing similar characteristics in the period before the introduction of the euro she then compares their trajectories after the introduction of the common currency investigating how income inequality has changed within each of the euro area countries studiedaustria germany luxembourg belgium greece the netherlands finland ireland portugal france italy and spain she finds that in the absence of the euro gross income inequality would have been lower but net income inequality would have been higher in most countries in other words any market effects were more than offset by transfer payments such incountry transfer payments were doubtless enabled directly and indirectly by monies from the social fund and other eu sources vi policy the advocates of placebased policies argue that general redistributive policies through the taxtransfer system while necessary to alleviate hardship wherever it exists provide no longterm solution for individuals in the leftbehind and disadvantaged regions they are also sceptical of any suggestion that in implementing placebased policies there is necessarily a tradeoff between equity and efficiency this scepticism is in part the consequence of their doubts about the merits of arguments for agglomeration in the urban economics and new economic geography literatures agglomeration effects are typically supposed to be strong in densely populated areas because of sharing matching and learning this is related to the highly concentrated pools of labour and suppliers to the excellent infrastructure with low costs of transportation and mobility and to the easy diffusion of knowledge and innovations the elasticities of productivity with respect to employment density are estimated to be in the range of 001 to 010 subsidizing people and firms to encourage them to locate in agglomerated highdensity areas can be justified on the grounds that the social returns are higher than the private returns this policy may come to the benefit of the whole society since people will move to places with high productivity rates from where economic activity growth and prosperity will eventually spread or filter to the lagging and peripheral areas however it is far from clear that policies exploiting agglomeration economies are beneficial to society as a whole first it is not certain from historical evidence whether the filtering effects are large enough to compensate for the adverse effects of declining employment rates and brain drain in the lagging areas second policymakers probably do not have sufficient knowledge about the magnitude and the distribution of elasticities across regions and economic activities to optimally target their investments third if there is not much geographic variation in elasticities relocating economic activities will not increase aggregate production poorly designed regional policies could result in a zerosum game whereby high investments in dense and prosperous regions come at the expense of regions in which people already feel left behind fourth diseconomies of agglomeration may emerge when real living standards in the prosperous areas are reduced by rising disamenities related to air and water pollution traffic congestion and more local crime thus advocates of placebased theories are usually critical of those who put their faith in agglomeration economies and they deny any necessary tradeoff between equity and efficiency they refer to the rise and fall of big cities with large agglomerations in the past contending that high returns on public and private investments in metropolitan areas are not selfevident they also argue in favour of tailormade policies that seriously explore the untapped potential as well as the threats to progress in each place thereby they emphasize the underestimation of the economic potential of many noncore less developed or declining regions in short there is every reason to focus on the potential of a region to achieve a situation where it has a sustainable resilient regional economy in combination with acceptable levels and distributions of wellbeing for all its inhabitants without social exclusion however as far as the lagging regions are concerned there is the risk of failure of supplyled interventions since so many of them have attempted to boost sectors and activities that do not match local economic strengths and which become in perpetual need of assistance to survive furthermore welfareand supportbased measures specifically aimed at sheltering inhabitants of poorer areas can have pitfalls for example placebased policies designed to stimulate local employment for the people left behind incorporate the risk that residents from elsewhere profit from new economic activities while raising rents house prices and land prices and increasing the share of incommuters in local employment instead of lowering unemployment rates for people at the low end of the local labour market in europe regional policy is said to have changed radically in recent decades these changes are described by vanthillo et al traditional policies varied somewhat from country to country but were essentially topdown interventions these interventions involved tax incentives and subsidies both to encourage firms to remain and grow in the poorer regions and also to attract new enterprises not least multinationals in many countries government offices and parts of stateowned enterprises were moved from the centre to the periphery as vanthillo et al put it the policy focus of the range of instruments used in these regions was essentially centred on influencing economic activity through industrial location in fact regional policy was inextricably bound up with traditional industrial policy which can be defined as policies to stimulate growth and productivity and to rebalance the economy by altering the sectoral mix of production some policies were horizontal and others vertical the former applied to all firms whether nationally or in a particular region the latter were applied differentially across sectors or even firms many horizontal policies came to be seen as often ineffectivevarious forms of investment tax incentives for instance but it was the vertical policies which attracted particular criticism they often involved significant public expenditure with little return in the british context crafts and others described them as picking losers rather than picking winners too often engaging in the forlorn task of propping up ailing industries such as shipbuilding and arguably in the longer run making it more difficult to cope with structural change from the 1980s the focus of policy started to change vanthillo et al argue that there were three reasons for this the first was broader political developments leading to devolution and decentralization in many countries there were many complex explanations for these developments but one was a belief that central governments had not served lagging regions well and that more could be achieved by locally led initiatives and indeed this belief was supported by emerging research evidence that decentralized systems had been associated with less inequality in regional growth rates the second was a perception that policies centred on tax incentives and subsidies had failedin part because they had led to competition for assistance between regions certainly in england there is evidence that the northwest suffered from the fact that funds were poured much more profusely into other and more severely lagging regions like the northeast third was a shift of emphasis towards policies that were more tailormade for individual regions as we have already intimated to these might be added a fourththe realization that in the past too much public money had been wasted on trying to halt irreversible structural change influential in these developments was the european commission and in particular the reform of the structural funds in the late 1980s as vanthillo et al argue the european regional development fund had been complementary to national regional policies now brussels started to take a more central role emerging from this were smart specialization strategies interventions were based on enhancing local competitiveness and not necessarily tied to conventional administrative regions critically initiatives were placed in the hands of local actors key here was the requirement that in order to receive funding a region needed to articulate a strategy for development vanthillo et al describe how more than 120 regions in the european union have recently designed a smart specialization strategy to receive funds from the erdf in the 201420 programming period similarly some form of regional strategy was required to access eu structural funds key to formulating a strategy was to look forward rather than backwards and to take a realistic view of what the competitive strengths of a locality might be at the same time domestic spending on regional policies diminished in most countries which came to rely ever more heavily on european funding in recent years these initiatives have fallen within the eu cohesion policy whose declared aim has been to strengthen economic and social cohesion by reducing disparities in the level of development between regions the policy accounted for no less than 325 per cent of the eu budget between 2014 and 2020 if it is the case that strategy is to be devolved locally then a necessary but not sufficient condition for success is the competence of those devising the strategy this seems to be almost taken as given by national policymakers but when the competence of national policymaking generally cannot be taken for granted assuming local competence across several geographical areas in a country seems dangerous there is also the question of central funding of local initiatives is sufficient resource provided to allow local initiatives to flourish or do the local entities have sufficient local revenue raising powers any significant shortage of funding is likely to dictate suboptimal strategies or suboptimal implementation of optimal strategies inevitably there is an unresolved tension between the roles and powers of the centre and local administrations and at least in some countries it is evident that the national authorities find it difficult to let go in describing the ecosystems of poorly performing regions in the us logan et al remind us of the dangers as well as merits of devolved powers and decisiontaking that are part of the federal structure of the country they write modernday social and economic inequality is rooted in a combination of factors including geographic endowments agglomeration economies regional differences in human and physical capital investments and importantly persistence of past policy decisions investments and choices a broad set of subnational policy and expenditure decisions falling within the domain of economic development including education social safety net transfer programmes and labour market supports which have helped to shape the inequality we observe today they argue that fiscal federalism has meant that many policy decisions have harmed sections of the population and regions in particular racially motivated actions against black communities in the south have had longlingering consequences for example discrimination in education and restricted school funding have damaged the human capital of large swathes of the country the example of the southern states may seem to be an extreme one to european eyes however the possibility of the unhealthy dominance of vested interest groups and of various forms of local corruption cannot be ignored this is where the issue of striking an appropriate balance between national and local control becomes an important issue lagging regions are more often than not in a selfreinforcing selfsustaining equilibrium and because of this specific changes designed to improve performance can be ineffective since other elements of the ecosystem which remain unchanged drag the local economy back to the undesirable equilibrium collier and tuckett remind us of this in their arguments that conviction narratives are essential for buoyant local investment and the construction of a buoyant local ecosystem colin mayer et al examine one particular aspect of the local ecosystembankingwhich is vital for financing investment by small and mediumsized enterprises without vibrant local banking arrangements they argue devolution of economic policy would be limited in its effectiveness they compare the british banking system with banking in germany sweden and the us the british system they contend became over time highly centralized and transactional with weak relationships between banks and borrowers they contrast transactional banking with relationship banking and define decentralized banking as providing relationshipbased banking services to its customers by operating in close proximity to them and via a business model that relies on cultivating and utilizing the strong relationship it establishes with its customers to gather and build soft information banking centralization increased over a fairly long period of time in the uk but was exacerbated by the sectors response to the 2008 financial crisis as a consequence smaller firms in peripheral regions find it more difficult to get credit than those in london and the southeast mayer et al describe the long historical evolution of the threepillar german banking system and demonstrate that for all its twists and turns it serves the sme sector better than does british banking so they contend does community banking in the us though the authors recognize that its viability is under some threat in yet another very different financial system swedens handelsbanken serves local business communities well while acknowledging that effective regulation regimes would be needed mayer et al conclude that strong local banking based on tacit as well as codified relationships is essential for significant improvement in the economic fortunes of lagging regions vii conclusions it is perhaps ironic that at a time when devolution of strategy is all the rage for regions in europe it has been the local misuse of opportunities offered by fiscal federalism which arguably has hampered regional development in the us this reminds us that decentralization is not a magic bullet nevertheless at least in europe policymaking towards regions has made some progress but there is still much to be done there has been greater recognition of the need to move away from emphasis on broadly defined administrative regions problems and their solutions are now seen to be far more spatially specific the ability to address these problems has been massively enhanced by the emergence of robust disaggregated data however it is not always clear that national politicians make sensible decisions about what constitutes a locality for action for example some commentators argue that an obsession with city regions often overlooks the wider regional context indeed if decentralization and devolution are to be the answers then the uk 2070 commission points to some of the difficulties in the british context barriers to progress arise from 1 conflicting national policies arising from an overcentralised administrative system 2 strained centrallocal relationships arising from the desire for central accountability of local decisionmaking 3 a flawed strategy for growth that assumes the benefits of growth in london and the wider south east will spill over to the rest of the uk 4 low levels of investment which result in underresourced programmes of action create a competitive projectbased culture and hold back ambition 5 constant change in policies and delivery agencies which does not allow sufficient time for any programme of action to have real impact and 6 narrow shortterm measures of success that do not take account of longerterm generational and wellbeing impacts clearly these are issues not just for the uk but also for many other countries this is highlighted by a recent oecd report the report makes the case for decentralization and devolution in regional policies covering the transfer of powers and responsibilities from central to lower level authorities in three dimensions political administrative and fiscal the report shows a positive correlation at the country level between gdp per capita public investments and education outcomes on the one hand and the extent of decentralization on the other it also argues that decentralization can promote local democracy and citizen engagement reduce corruption stimulate efficient public service delivery and improve regional development therefore it could be a powerful instrument for reducing the geography of discontent however echoing some of the points made by the uk 2070 commission the oecd also emphasizes that decentralization is not a guaranteed recipe for regional growth and development because the positive impact is very much conditional on the design and implementation of the decentralization policies themselves motivated by such concerns the oecd records the risks associated with decentralization first there is the risk of insufficient administrative technical or strategic capacities at the subnational levels building these capacities takes time and requires longterm commitment from central and subnational government then there is the risk of lack of sufficient resourceunfunded or underfunded mandates as the oecd puts it de groot illustrates this for the netherlands where municipalities are faced with growing responsibilities as a result of the countrys decentralization strategy but with hardly any ability to increase financial resources due to small local tax bases furthermore governmental bodies at different levels may have overlapping responsibilities and powers which can cause lack of clarity conflict and a democratic deficit finally decentralization may lead to the loss of economies of scale and fragmented public policies policies that initially may look successful can reveal perverse consequences if the full picture is taken into account the dutch legislation on work and assistance in 2004 intended to provide activation and employment services that were better tailored to both the needs of the local labour market and the unemployed by decentralizing services from central government to municipalities this implied more autonomy in the design and delivery of services to cope with local and regional circumstances and policies but also implied a transfer of financial responsibility for the social assistance scheme a lower enrolment in social assistance was the consequence of municipalities being incentivized to be more prudent in its allocation this may have led to underprovision of municipal services for the unemployed unequal treatment of individuals in similar circumstances across municipalities and a rapidly increasing inflow of people into the centrally administered disability insurance scheme furthermore if the emphasis of new policy is a region pursuing its comparative advantage then this presumes that the region has a potential comparative advantage in something for some localities it may be difficult to uncover exactly what this might be it will be difficult to break out of the low incomelow productivity equilibrium logan et al make the case for the selfreinforcing nature of regional problems in the us they write when comparing regions in the united states a set of steadystate initial conditions in large part shaped by the nations pattern of economic development and its legacy of slavery and racial exclusion continues to shape modernday economic and policy outcomes helping to reinforce observable regional inequality today nor can it be taken for granted that there is sufficient local political and administrative competence even if there is collier and tuckett argue that it may be insufficient if there is no conviction narrative at the same time even if strategy is sensible and public funding appears sufficient it may fail because of weak local institutions as mayer et al contend as far as the provision of private finance is concerned the fundamental problem is that low productivitylow income regions are experiencing systems failure in these circumstances attempts to improve one aspect of local performance may flounder because the other unfavourable characteristics of the locality may act like a magnet and drag it back to the original equilibrium indeed it may be that a benignly intended policy has perverse effects in the uk for instance the highspeed rail project is designed to cut travel times from london to the midlands and north of the country it is meant to stimulate these regional economies but there is the possibility that it will simply enable more skilled workers to commute to london and further centralize economic activity despite increased activism in policy regional disparities have generally widened in europe in the last 40 years the balance of academic research suggests that this is mainly the consequence of the impact of globalization and changes in the sectoral composition of economies we can be confident that this widening would have been greater but for the intervention of regional policies this gives some reason for cautious optimism in the face of deepseated but not necessarily intractable problems in many countries covid19 has had a disproportionately harmful impact on poorer areas and this may well increase the focus of governments on the underlying problems of these areas furthermore it is encouraging that there is some evidence for the benefits of placebased policies that build particularly on infrastructure expenditure as well as on higher education and university support nevertheless we still need to learn more about the longterm redistributive and heterogenous effects of these types of intervention we also need to know much more about the strengths and weaknesses of devolved regional strategies more generallyabout what works and what does not work

significant regional inequalities of income and wealth exist in every western european country and in north america but their extent varies from country to country in both europe and the us it is generally thought that they tended to narrow from the early 1900s until about 1980 since when they have widened this widening has become associated with the rise of populism while the covid19 crisis has thrown regional disadvantage into sharp relief this article discusses measurement issues traces developments over time and explores the social and economic consequences of regional disparities it describes the evolution of regional policy and in particular the move to more localized approaches in europe analysing their strengths and weaknesses

introduction in the course of engaging with womens stories and affects while exploring memories dreams and associations on the subject of delayed motherhood two analytical ideasjungs mythopoetic tension between symbolism and enactments with the feminine and freuds 1 repudiation of the feminine attracted my attention to the realm of womanhood as a social problem in particular the way in which themes of psychic bisexuality produced a feminine that is thereby displaced from its forced equivalence to the object and from its inevitable localization in the woman what kept coming up as both privation and deprivation across affective behavior and narrative among eight participants was the existence of a male sibling who had more privilege encouragement and engagement with mother than the daughter i realized these participants were demonstrating the very bones of this research distinguishing the making of a complex between personal experience cultural and collective contexts the affects before me at micro level were emerging into a macro view of how feminism emerged when the feminine could no longer quietly accept being thwarted to favor the masculine like the sumerian goddess inanna participants had taken their procreative desire underground until the clamor of midlife beckoned them to reclaim the right to enjoy an ordinary life my aim in this paper is to examine the plural definition and uses of the feminine in analytical psychology and psychoanalysis in particular against western culture at large in order to define a feminist ethos for this research though jungian by qualification and perspective i must include my own reflexivity on theoretical problems such as the anima and animus in analytical psychology so that i do not unconsciously analyze the subjectivity of participants to jungian or freudian grand narratives on what it means for a woman to desire and experience motherhood in the fourth decade but more so not only does it appear the first analytical fathers offered us a useful theory of patriarchy 3 along with other documented effects of the mind doctors on women 45 their androcentric frames of feminine reference becomes an important epistemology for delayed motherhood female diseases such as depression promiscuity paranoia eating disorders selfmutilation panic attacks and suicide attempts whether reportedtreated or not are all female role rituals to which id like to add one more the expectation of fertility after forty years of age discovery process what is determined to be masculine and feminine behavior expression and choices continues in post jungian psychotherapies as a question regarding development even when these are attached to archetypes 67 the biological difference in women with an implied imperative to reproduce opens the depth question of a womans unconscious use of her body as a means of separation individuation and psychic growth delayed motherhood in a biotechnological age may be yet another form of power and control 9 10 11 to consider late motherhood in a technological age begins with a review of jungs 12 early working through his ideas on the contrasexual other of anima and animus drawing from his real world experience of what a lack of procreativity means for a woman …then you get into a special kind of hell…for a woman there is no longer any way out if she cannot does not have children escape into pregnancy she falls into hellfire…she discovers that she is not only a woman she is a man too before the myths and terms of feminine and femininity are unpacked there is something very important to register about the finding of a favored male sibling in this research across all participants stories deep wounds to do with early gender learning of the superior value placed on the masculine in a brother whether or not he was younger or older while the good things of the feminine in the daughter were difficult to see by parental caretakers were present in effect these women had been groomed to feel inferior to the masculine by being less considered desired and entitled resulting in a view they might be less capable in life than a male that most of the eight participants enjoyed engagement in the world long past many of their peers due to onset of pregnancy around the fourth decade goes some way to suggesting how their choice of delaying motherhood resonates at minimum with having to prove something to themselves and others regarding the very definition of what embodying the feminine is about normative predictive generative identity via motherhood was not going to be enough the difference in a mothers reaction to the birth of a son or daughter shows that the old factor of lack of a penis has even now not lost its strength a mother is only brought unlimited satisfaction by her relation to a son this is altogether the most perfect the most free from ambivalence of all human relationships a mother can transfer to her son the ambition which she has been obliged to suppress in herself and she can expect from him the satisfaction of all that has been left over in her of her masculinity complex the feminine principle equating to female inferiority by the founders of both analytical psychology and psychoanalysis appears along a continuum ranging from freuds perspective of causation for example his penis envycastration theory was grounds for hysteria based on a phallocentricity 2 to jungs invisible realm of the collective unconscious through the use of mythopoetics as if to rationalize logos as the sole propriety of men and eros to women as a universal structuring element of psyche conceptualized as animus and anima respectively jungian analyst polly youngeisendrath 13 frames these ideas as androcentric in their ignorance of the womans experience her social context and the nature of her female gender identity in context to traditional sex roles without conscious feminine experience an anxious middleaged woman identified with the idea that she is inferior intellectually may be called animusridden by a jungian psychotherapist because she speaks in an opinionated and insistent manner about a general or vague idea feminine riddles into myths image emotion enactments projection rituals and fantasies emerging as beliefs in early psychoanalytical theories reify mental phenomena blurring the lines between illusion and reality jung and freud appear as early social scientists looking to explain the split between matter and mind once freuds descendents opened the gate to allow for the impact of culture on phenomena observed by the analytical founding fathers the groundwork was laid for feminist inspired psychoanalysis to evolve into psychosocial research including embodied subjectivity for example for lacan the oedipus complex becomes not simply the exclusion of the child from the motherinfant dyad and parental couple which is thought by freudians to be crucial for developing personality but more a depiction of the beginning of the acculturated individualthat is the entry into and the reproduction of culture itself repeated in the development of each human being culture reproducing itself also extends to mothering 15 what follows is the effect these analytical ideas can have on society …some psychoanalytic concepts have taken on the quality of myths i define myths as symbolic representations of cultural ideologies reflecting unconscious dynamics as with individuals sometimes stale and outgrown myths persist sustained by inherent societal forces even beyond their point of usefulness resistant to change and often obstructing growth and creativity most psychoanalytic concepts originate as explanatory hypotheses however once formulated and disseminated they become rooted both in theory and in society acquiring an explanatory force generating selffulfilling prophesies and remaining unchanged as long as the myth serves a purpose…even when there have been changes in phenomena upon which the initial observations were made the original hypothesis reified and elevated to the proportion of a myth remains immutable sustained for the social economic political or psychological purpose it now serves though freud is credited with asking the question what do women want he never found an answer to the riddle of femininity 16 and neither did jung except through personal foibles 17 the favoring of jungian psychology i had intended for this research was discovered to be insufficient to reflect on an emerging cultural problem with the feminine there was danger of falling into jungs earliest reifications of gender on archetypal and functional levels underpinned by his interest in alchemical processes of the solar king meeting the lunar queen jungs identification of two kinds of thinking along gender lines of masculine and feminine classified as direct and indirect thinking is a case in point where early psychological typology function is confused with gender function indirect thinking was deemed to be intuitive irrational pictorial diffuse and symbolic jung assumed it was the foundation of feminine psychology under the principle heading of eros to include psychic relatedness love and soul which also put women under pressure to perform as such in the activities of wife consort and mother direct thinking logical goal oriented rational differentiated and spoken skills gathered together under the principle of logos became the expectation of the masculine principle and ergo for men jung assigned words like judgment discrimination and insight as well as spirit to maleness my sense of jung is that he read into the reproduction of gender performance and culture as if his identification of its contents was fact confusing fears and fantasies with real women 13 not all postjungians read gender the way he did but of those women clinicians presenting themselves as jungian feminists such as cowan 17 douglas 6 kulkarni 21 and anthony el saffar 22 few other than youngeisendrath 23 are known and published within the larger context of psychoanalytically inspired feminism i believe because she draws from social constructivism to assert the feminine archetype which is a product of patriarchy 24 yet kulkarni 21 was among the first to lay down a paradigm for a research that marries jungs respect for psyche with feminisms insistence on context an ethos this research on late motherhood endeavors to achieve in addition two academics demaris wehr 25 and susan rowland 72627 have made breakthrough and remarkable contributions in particular is rowlands view of jungs connection to feminism through his concept of the subtle body a union of mind and body in his alchemical writings which includes the abject and excluded body to reveal it as the constituting boundary of heterosexuality that must be renegotiated in a parallel but different language de beauvoirs one is not born but becomes a woman was a favoring of lived experience which inspired emerging feminism to make the distinction between sex and gender an idea meant to secure internalization of contrasting patterns of behavior… thus to displace the role of biology in determining masculinity and femininity psychoanalytical theorists have gone further than freuds ideas of the feminine contributing to and developing feminist theory aligned with clinical and social psychology theorists raphaelleffs 30 inquiry into femininity the unconscious gender and generative identity in a biotechno age argues that a basis of psychoanalytic theory in place throughout freuds life was the limitation of femininity and masculinity on original bisexuality the perception of freuds bisexual fluidity concept was ultimately eroded by occluding reification of bodybased dichotomies leading to multilayered views of fantasiesrelational configurationsidentifications proffered by harris 31 dimen 32 benjamin 33 and sweetnam 34 allowing raphaelleff 30 to frame freuds notion of bisexuality as the dichotomy of conscious unity twinned with unconscious diversity attributable to person 35 based on goldners 36 notion of culture as authorizing agent thus raphaelleffs synthesis of sex as an accommodation between chromosomes present at birth and gender as a self categorizing psychosocial construct produces new categories for gender role and sexual orientation embodiment gender representation and desire can jungian feminist literature ever be on par with the impact psychoanalysis has had on mainstream feminism jungs dichotomous idealization of the feminine as a mans anima while denigrating the masculine in a woman as a character flaw at first blush creates a problematic for the researcher who wishes to use analytical psychology as the theoretical basis for emergent feminine feminist psychosocial dilemmas until we shortly come to discussing his alchemical works jungs mythopoetical views theories imaginations foibles and proclivities regarding the feminine along with freuds fluid notions of bisexuality are both offered as evidence acceptance of the feminine as different but equal remains a long standing difficulty for both genders inspiring perhaps the intrapsychic and intersubjective cultural phenomena of a pregnant pause 37 on the way to late motherhood to revision the feminine out of patriarchal paradigms the feminine and feminism by emphasizing the feminine within feminism i am including ways of incorporating agency and nurturing through the holistic union of jungs two kinds of thinking 19 in addition to feminist concerns of equality with men such that procreative identity does not become equated to essentialist gender norms nor to performance in male terms holding on to the feminine within feminism allows for sexual difference and keeps in mind the ways the feminine has long been suppressed in culture 22 her wound the subject of myths and fairy tales without this view it would be all too easy to see women who fell into delayed motherhood as fathers daughters who abandoned the archetypal feminine to pursue career rather than respect the body marion woodman 39 likens to the mother in us what happens to women who like inanna must go underground with their procreativity is far more complicated than being fathers daughter late motherhood does not appear as a sin against the feminine by the woman who has delayed but as a repudiation of the feminine preceding adult choices necessitating a late search for the mother within hence feminism and the feminine as great mother is a vital link to rebalancing humankind while aspects of analytical psychology are relevant to this study feminist inspired psychoanalytic perspectives help to make two halves of analytic history a whole view of psyches discontent with patriarchal views of the feminine analytical psychology has a proud history of finding truth in the cosmos through archetype and image rooted in the unconscious as transcendent of knowledge while swartz reminds us that feminism has a proud history of interrogating the truth claims of psychiatric science and of foregrounding the ways in which the machinery of psychiatric diagnosis and treatment has been used to obscure or amplify the psychological effects of patriarchies for which she credits chesler 5 smith 40 and ussher 41 in particular in reviewing psychiatric diagnosis from a feminist perspective swartz gives credit to jessica benjamins 33 work concerning the long history of patriarchal domination where feminists have challenged freudian psychoanalytic diagnostic premises and opened up new ideas on the formation of female identity such that experience as mother sister wife or daughter can no longer be automatically synonymous with a lack of agency my purpose is not a rapprochement between jungian and freudian theorists and clinicians but observation early views of jung and freud on the feminine provide grounded evidence their theories continue to reflect a problem for and with women given the nature of this study to explore delayed motherhood and its connection to individual and collective complexes and the long history of women being diagnosed as prone to depression it is important to clearly differentiate the identification of a complex from a diagnosis in a diagnosis the root of the disorder is placed within an individual while social cultural political and collective contexts remain as background or in ignorance 9 delayed motherhood in the 21st century begins to appear more as an emerging epidemic with plural longitudinal gender roots between the sexes 37 rather than a disorder identifying a complex through the study of affective behaviors provides a way to see into emotional rupture as phenomena which does not originate in the individual alone but through a network of associations involved in memories with others these others do not only contribute to personal complexes as they may be unknown to the individual because they occupy a place in the social through the cultural unconscious 4243 when these impersonal contexts are included in what happens when a woman is unconscious toward her body we must consider the feminine in context to patriarchy and by extension feminist ideas it must also be noted that patriarchy does not always have a penis nor do feminists always come with a vagina and shortly i will elaborate on this further defining problems both analytical psychology and psychoanalysis have framed woman as subject object abject mother other caregiver mirror animus ridden anima woman receptive castrated empathic relationally oriented envious of a penis a uroboros for renewal and imaged as the contrasexual unconscious when the female is not referred to as part object and part symbol we find a purpose for her existence as another subject whose independent center must be outside her child if she is to grant him the recognition he exists the use and relationship to the feminine in all its variations including femininity emerged as the last straw turning freud and jung from sparring partners on universal principles to warring opposites both men were caught in the prejudices of patriarchal culture to do with rights roles and conduct of women in relation to men pleasure and becoming a mother until the motherson incest taboo provided grounds for their ultimate parting of ways 22 pp 46 47 the difference between sparring over the existence of an underlying universal principle and the motherson incest taboo may seem to be intellectually far apart until we discover how each of these men interpreted their necessity for jung motherson incest functioned as a mythopoetic in intrapsychic life it was seen as an enactment within his countertransference dynamics with patients such as spielrein while his wife emma and consort toni wolff and collection of female colleagues known as the jungfrauen all allowed him to be convinced that the fathers law against incest is regularly broken on the symbolic level and that regression to the womb is also part of the heros journey to rebirth 22 whereas in freuds 1 thinking a girls cure for narcissism is not only founded on the discovery she does not have a penis but on the move from mother to father to husband where her triumph and cure is the production of a son with whom she can transfer to her son all the ambitions she has been obliged to suppress in herself… freuds thinking is a natural wellspring for feminism while jungs psychology continues to entice women into believing they could be a mans muse and inspiratrice just as echo helped narcissus to continue looking at his image believing it to speak to him in his favor 45 one of the first jungian analysts to question the masculine psychologies of jung and freud james hillman finds in freud a definition of the conditions under which an analysis may end based upon the achievement of feminine inferiority finding it to be the root of repression and neurosis… bringing about both our psychic disorders and method of analysis aimed at these disorders 46 …one reaches the bedrock the place where analysis could be said to end when the repudiation of femininity both in a man and a woman has been successfully met in a woman the repudiation of femininity is manifested in her intractable penis envy in a man his repudiation does not allow him to submit and be passive to other men thus for hillman 46 freuds 47 repudiation of femininity is biologically founded and part of the natural psychical world in contrast with his own view the end of analysis coincides with the acceptance of femininity here hillman takes on misogyny by undermining freuds basis as biologically given and thus bedrock to the psychical field finding instead a psychological basis of apollonism as the bedrock of the firstadamtheneve perspective this apollonic archetype seeks physical form through an objective and detached selfhood a heroic course of… quest and search… above all the egoself as its carrier and analysis as its instrument with freud we must put aside the feeling and relational aspect of the feminine biology rules recreation of the myth firstadamtheneve appeared in the earliest memories of research participants in the triangulation with parents and male siblings as young women they purposely chose to use their minds and make nonuterine choices tending to put them more in the world of men such that the structure of their lives begins to suggest an extended apollonic phase from just this small glimpse into freuds thinking of the feminine through one of his last writings in vienna it may be possible to see the necessity of feminist thought to salvage psychoanalysis from freuds complaint psychology cannot solve the riddle of femininity for jung the analytic process reaches its ultimate goal in conscious bisexuality through the alchemical image of the coniunctiothe conjunction 464849 rowland 7 redeems jung for feminists in analyzing his work as a whole and in particular on alchemy where there is recognition of the limitations of heterosexual opposition… what is cast out what is structured as an abject body must be reconfigured within this is the maddening aspect of jung saddling analytical psychology with his biases of appropriating the feminine as a hidden virtue of men with the anima concept only to find him projecting onto women the worst attributes of the masculine with the concept of animus opposite and not equal yet destined for bilateral unity what is required here is a slow careful reading of jung as a trickster 27 writer to be read for multiplicity as an evolving narrative rather than authority 26 jungs writings are characterized by an entwined dual purpose in which an acknowledgement of the roots of his ideas in his individual experience work with and against a drive to universalize and construct a comprehensive psychological scheme nowhere is this more evident than in his move from the oppositional neurotic on gender to alchemys subtle body and external reality to social discourses samuels 50 questioned whether jungs concept of anima and animusfemininity and masculinity entwined in the syzygy to endure the alchemical processes of differentiation in an effort to reunite as an androgynous pair of opposites was a bonafide work on gender jung often spoke as if he were unaware of the distinction between gender and sex which is by contrast biologically determined the feminine as an aspect of men and the masculine as an aspect of women became tangled up in jungs reflections between biological bodies the embodiment of archetype and effects of culture and the collective unconscious this is no different to what happens to anyone when the principle of masculine and feminine is concretized as first adam then eve a false adaptation to compensate for psychic wounds to sexual identity aroused by conformity to cultural stereotypes can sublimate the feminine such that men find they want babies and women are afraid to have them 49 when the feminine in either gender is denigrated things go wrong a link to the alchemical subtle body becoming physically and psychically blackened precipitating a sulfuric decay to rise so that the problem as it is felt can dissolve 49 in feminist inspired psychoanalytical literature longitudinal consideration has been given to selfimages of feminine and masculine internalized through separationindividuation rituals within family as part of an evolving acquisition of genderrole identity commencing with differential permutations of motherfatherboygirl interactions with the feminine situated in the historical fact primary caregivers were invariably women raphaelleff 30 offers the observation of mother frustrating dependency thus becoming the confusing feared and desired catalyst for counter denigration of all that is designated female 51 in rapahelleffs view it is the mother that carries reproduction of the patriarchal social order of inferior social position through unconscious samesex identification with their daughters 30 this identification can be seen later in threats to reproductive body integrity 52 preferred female relatedness 53 and an ego with porous boundaries like a mother 54 compelling a daughter to give into resign herself to the patriarchal social order 355 confounding gender it is essential to return now to amplification of jungs alchemical opus as a psychic process which involved extracting the gold and liquefying the dung within primal matter including elevating the opposites to the regal status of sol king and luna queen appearing in every culture these motifs were intuitively drawn over millennia to signify psychic renewal forecasting how dominant factors in the psyche undergo processes of decomposition and clarification by fire out of which emerges the new king or new consciousness 49 this alchemical process may also serve as a paradigm for developmental processes within the pregnant pause of midlife 37 the emergent new conscious of desire for a baby becomes the new king after years of licking the wounds inflicted upon the feminine within procreative possibility due to modern cultural conditioning to favor the masculine over the feminine for economic performance thus womens lives take on the appearance of a twopart structure first adam then eve this is perhaps the basis of jungs division between the logos of a monotheistic god whose essential separation from nature sponsors rationality as dependent upon a division from matter and body and the need of eros to be connected and related as the mother earth 28 jungs early disposition for gendering opposites with varying degrees of denigration and idealization though evidence of extraordinary early work on identifying contradictions in nature seeking reconciliation 49 similarly to freud appears to be reinforced by the mythopoetics of misogyny and female inferiority in the collective unconscious jungs entire project i am suggesting is in mythical terms an attempt to rebalance modernity that has been brought to crisis by an overvaluing of logos at the expense of erosrelating…by essentializing the creation myths he is able to stabilize the masculine signifying he wants to retain it while insisting upon its reformation to include the feminine which remains marginal queer and the feminine hero queer theory emerges in personal identification and political organization as nonnormative performance in a range of experiences of being and doing inspiration for intrapsychic unions where achieving and nurturing penetrating and receiving are unassigned to gendered bodies but coexist in any body 49 citing queer theorists elizabeth freeman and judith halberstam emanuela bianchi 57 presents a movement from feminine time to queerfeminist time to notice how temporality in queer strays from the normative unaccountable and dilated time arguing that pregnancy and mothering both participate in temporal counternormativity when viewed as a formulation of womens time with womens characteristic capacity to be interrupted by the demands of family by pregnancy… we take into account the necessity for protecting against hostile and unwanted interruptions as well as promoting a liberatory transvaluation of interrupted time… to strange new queer formations of kinship gender and social life when gender performance enacts a great leap of faith outside of predictive maternal identity as biological destiny late motherhood as i have found in participants case studies is the struggle to achieve and nurture penetrate and receive a modern developmental task for the feminine hero theoretically the androgyne a union of masculine and feminine which cannot be defined as either resisting normative gender identity is the essence of queer understood this way queer is in effect the conclusion of jungs alchemical opus the philosophers stone 49 the assumption of heterosexuality and gender certainty is a problematic of classical jungian canon despite my and other jungian analysts criticisms of gender certain contrasexual opposites the archetypes of anima and animus continue to appear in dreams to reveal shadow aspects those parts of the self that are unknown unwanted and unintegrated as principles of both agentic and allowing energies seeking conscious integration in men and women to dismantle gender performance from procreative identity and sexual desire was a prerequisite for analyzing the embodied feminine as she coursed her way through intrapsychic association networks and intersubjective affects aroused by the methodologies used in this study recognizing the effect of the patriarchal animus on generations of women jungian analyst claire douglas examined the outmoded aspects of jungs theories including the ephemeral contaminated and biased to find what would free women and the feminine from patriarchal precepts she proposes a reexamination of the words and ideas within jungs map rather than conforming to concretized descriptions as normative the feminine ego needs to learn how to connect without being engulfed and how to differentiate without severing or splitting off where douglas thinking can be most readily applied is to the idea that the masculine as animus must reside solely in the internal world of the woman and for men the feminine anima must stay safely locked inside while i do not question the psychic reality of these figures identification of what is anima and animus has an unfortunate link to opposite sex gender in a straightjacket of inferiority anima and animus need each other in dialogue taking turns as sources of authority gray 58 set out to examine in philosophical terms jungs individuation idea next to the subject of the feminine by drawing from irigarays work individuation i claim is the telos of luce irigarays ideal of a femininefeminine symbolicimaginary or system of meanings and significances that arises out of sexgendered embodiment and collective responses to it…lest this reading of jung be interpreted as reinscribing masculine notions of the feminine i take a new look at the idea of essentialism which has plagued jungs own theoretical construction of the feminine and woman…and also irigarays approach to the woman question jung perhaps explains his gender biases best in describing his view of opposites in male and female terms followed by problems when the opposites are not in their right order …womans conscious is characterized more by the connective quality of eros than by the discrimination and cognition associated by logos in men eros… is usually less developed than logos in women on the other hand eros is an expression of their true nature while their logos is often a regrettable accident …instances to the contrary leap to the eye men who care nothing for discrimination judgment and insight and women who display an almost excessively masculine proficiency in this respect… wherever this exists we find a forcible intrusion of the unconscious a corresponding exclusion of the consciousness specific to either sex a predominance of the shadow and of contrasexuality in her chapter on the feminine hero in the presence of the feminine in film jane alexander stewart 60 analyzes the role of clarice starling in the silence of the lambs 61 as a new heroic journey of the feminine clarices story in the film begins with her lifting herself out of a chasm to stand at the top of the hill prepared to go forward stewart makes meaning of the scene in that clarice begins her story where classic stories of the heroines journey end at the return to ordinary life after the descent… from a metaphorical feminine center…a heroine making a return from the deep process of self examination and affirmation though the context of her meaning making resides in the modern american landscape where unseen killers await her real message is not so much based on geography but an endemic fear of psychological and physical denigration of the feminine not only do they fear mens attacks on their bodies but also they face denigrating social systems that reinforce a secondclass status and devalue what it means to live through a feminine point of view these dangers horrors and defilements have been described and examined by both kristeva 62 and douglas 63 within a frame of prohibitions leading to abjection on a platform of incomprehensible fear for the dangers facing the feminine if it is not pure with clarice starling we get a character who succeeds because she manages to claim and hold fast to her feelings what alexander stewart refers to as a set of feminine ethics… to … create hope for the safety of a feminine presence in our society clarice defies conventional wisdom on what is safe for a woman in a mans world by not behaving like a man who fears for his survival instead clarice chooses to trust what the feminine has to offer her inner forces traits that invoke fear for her and of her a greater threat to her survival than hannibal lecter himself including searches for meaning from the way his actions make her feel citing barbara walkers 64 the womans encyclopedia of myth and secrets alexander stewart offers an image not only of the filmic style of demmes lambs to evince the underground underwater underposition of starlings journey but an insight into the journey toward motherhood in the fourth decade of life students in mythology find that when the feminine principle is subjected to sustained attack it often quietly submerges under the water it swims through the subconscious of the dominant male society occasionally bobbing to the surface to offer a glimpse of the rejected harmony discussion the feminine hero may be different from the heroine in my observations the heroine comes up in life believing it is safe to be female because her nurturing early environment made it so throughout her development she does not cower at real life challenges even those threatening her with domination and sublimation rituals 44 whereas the feminine hero has had to learn how to have a relationship to her body the root of having what jung called a self but as the feminine body can be interrupted through punctuations of menstruation penetrative intercourse becoming pregnant and breast feeding rhythms resonating with vulnerability it can take time to make or find a self if it has not been installed in early childhood through conducive social interactions 65 altering the lived experience of temporality an unconscious relationship to her body difference from the masculine counterpart including her vagina womb breasts and ovaries may indicate her feelings are as an unknown aspect of self therefore making her unavailable for relationship or procreative identity until how she appears to others how she fears she will be usednot used no longer betrays her loss of integrity through some kind of violation 66 even one of abjection but emerges in synthesis toward the primary task of finding integrity within herself the dichotomous struggle to achieve equality in political social and economic fields between the sexes only to abandon the struggle in the sexual realm confuses the need to uphold sexual difference in this dichotomous state lay the ingredients for an individuation process psychicphysical tension with the potential for a union of opposites creativity springs from the resolution and the reconciliation of opposing psychic forces within an individual this creativity is at the heart of the conclusion of the fairy tale youngeisendrath draws from in considering the story of sir gawain and the lady ragnell regarding what women really want sovereignty over their own life here then lies the ethical methodological junction where feminist inspired psychoanalytic and feminist leaning analytical psychology join up to write an ethos for the use of intrapsychic and intersubjectivity in research with female participants the tension we are considering is when the body matters and when it does not a complex… results from the blend of an archetypal core… and human experience particularly in the early years of life it is both these complex processes of psychic development this research seeks to bring togetheris delayed motherhood a revolt against domination of the biological imperative to reproduce in uncertain relationship to patriarchy this is an ethical question to do with nonnormative sexual behavior the place where queer theory began its linguistic life before moving into gay and lesbian caucuses feminist politics upward to academic institutions in parallel to rising awareness of aids 70 before turning on gender itself as an encasement of an oppressive system of classificationboth heterosexuality and homosexuality …as artificial categories queer is evasive just what queer signifies or includes or refers to is by no means easy to say queer is a relation of resistance to whatever constitutes the normal the open mesh of… excesses of meaning where the constituent elements of anyones gender anyones sexuality arent made to signify monolithically queer as a theoretical and nonpredictiveperformative condition may be emerging as a new signifier of normative behavior in this way queer undermines notions of feminine masculine and eclipses both the conflict and union of opposites 49 something jagose 70 describes as holding open a space whose potential can never be known in the present yet the conceptual slippage in butlers theorizing of subject formation has resulted in a lack of clarity… regarding the capacity for action held by subjects relative to the power that enables their existence in the first place the use of queer theory and consideration of judith butlers later elucidation of a third way between voluntarism and determinism is as much about reconceiving agency 7677 as it is about holding an ethical position against pathologizing women who discover the need for motherhood and partnership later in life thus late motherhood is turning upside down jungs views of individuation in midlife for women as a time of integrating the repressed masculine a shift from an identity centered upon dependence and nurturer of others to one of agentic embrace of ones own development the task of procreative identity at midlife appears as a new definition of a union of opposites following the paradigm of first adam then eve unwittingly biotechnology has challenged even rearranged jungs life stages for women though not the essence of his observation of the midlife calling to integrate what has been overlooked in the first half of life concluding thoughts i did not enter into the research topic of a midlife pregnant pause 37 leading to late motherhood with feminist intentions rather i had a jungian perspective that cultural and collective complexes with hooks into personal complexes were getting in the way of the developmental aspect of achieving motherhood due to difficulties between the sexes delayed motherhood did not emerge as a feminist issue until particular themes in regard to men in the form of absent or wayward fathers overtly privileged brothers and betraying mothers began to surface i came to see women as having to struggle with indigenous cultural assumptions about their bodies being ordained for motherhood extending a long period of adolescence while striving for accomplishment in the masculine world coming to motherhood was a reparative process the closer in age they came to embodying the stage of life known as an older woman in looking more closely at psychoanalytically informed feminist literature mainly written by women i also discovered in freud and jung similar problems with the feminine at different points in their professional development these problems mirrored the problems participants were implying with real male others regarding their own relationship with the feminine and integration of the masculine in feminist inspired analytic literature i found the body of the woman who had lost time during her most fertile years as context for the messages from the unconscious in short i came to see jung and freud as reproducing what has been long standing in civilization a feminine split between denigration and idealization and have used their words as evidence of patriarchal privilege the screen through which each man analyzed female patients it is my belief their work was the beginning of a longer work on the reproduction of misogynistic culture with late motherhood appearing as a protection against androcentric interruption therefore an ethical position to mutable and evolving expression and repression of the feminine necessitates indepth understanding of these ingredients as alchemical products of intrapsychic and intersubjective primal material rather than constructing pathologies for nonparticipation in essentialist notions of feminine performance unconscious processes of the embodied feminine achieving late motherhood in midlife emerged as a feminist issue of power control defense separation and repair from this a new union of epistemology and ethos has become impossible to ignore in part because what is emerging in late motherhood is a different kind of mothering on which rests the future of a different relationship to patriarchy conflicts of interest the author declares no conflict of interest

while conducting doctoral research in social science on late motherhood two analytical engagements with the feminine came to my attention as evidence of a patriarchal bias toward the realm of womanhood jungs mythopoetic tension between symbolism and enactments with the feminine and freuds supposition that a denial of the feminine was necessary for psychological and emotional development appeared to be perpetuating a social problem continuing in current times across affective behavior and narrative within stories of late procreative desire dream journals and word association tests of eight participants was the memory of a male sibling who had enjoyed primacy of place in the parental home over the daughter the female body with a voice was missing in the onesided perspectives of analytical psychology and psychoanalysis on the subject of the feminine until a whole view of psyches discontents in feminist inspired psychoanalytic theories from both schools on the female body were included freud and jungs views became evidence of patriarchy as background while extension of feminist inspired psychoanalytical thinking queer theories and creation myth allowed new meanings of the embodied feminine to emerge through a recapitulation of a union of opposites as a union of epistemology and ethos the essence of jungs midlife theories altered by modernity and eclipsed by female advancement remains replicatable and paradigmatic outside of essentialist gender performance

management queensland tuberculosis full article context mycobacterium tuberculosis is one of the most ancient bacteria to infect humans and those without treatment of active infection have a 5year survival of less than 50 tuberculosis remains one of the primary causes of mortality in developing countries tb diagnosis and treatment are unfamiliar to most urban australian health practitioners this disease virtually eradicated from the australian medical lexicon by the 1980s of contemporary cases in australia 90 occur in those born overseas the remaining 10 of cases occur predominantly in indigenous populations at a rate six times that of nonindigenous australians indigenous people living in cape york and on the torres strait islands have historically higher rates of tb than people in other parts of australia proximity to papua new guinea which has a tb prevalence among one of the highest in the world and the social and biological factors increasing risk of transmission continues to put these communities at risk of this communicable disease public health guidelines recommend antitb treatment commence within 3 days of diagnosis of active disease to mitigate the risk of transmission with medication delivered as directly observed therapy in daily or three times weekly dosing the treatment cure rate for indigenous people in australia in recent years has been approximately 10 less than for nonindigenous groups one primary contributor to treatment failure is nonadherence to medication increasing the potential for the evolution of multidrug resistant tb an increasingly global concern a study published in 2015 reported 13 of cultured tb in australia was drug resistant to first line antitb agents challenges to medication adherence are multifactorial and include structural factors such as organisation of treatment and care for patients and individualpatient factors such as patient interpretations of illness and wellness knowledge attitudes and beliefs about treatment personal characteristics and adherence behaviour influence of side effects on treatment adherence and family community and household influences there are considerable challenges for health professionals who treat patients with tb as they attempt to balance public health concerns and the maintenance of patient autonomy and quality of life the remote environment and the cultural complexities of providing health care to indigenous australians compound these challenges indigenous people demonstrate lower tb cure rates than other populations with increased vulnerability of remote indigenous communities to disease outbreaks there is a considerable body of literature exploring these issues in developing countries but little documentation of these complexities in the australian remote indigenous context this case report will explore the challenges of diagnosis and coordination of treatment of tb in a very remote indigenous community and the impact this process had on the physical social and emotional wellbeing of an individual the patient has provided written consent for the publication of this case report issue the index case is a middleaged aboriginal woman residing in a remote cape york indigenous community she initially presented to the local primary healthcare centre with cough and fever at which time a local outpatient chest radiograph demonstrated a novel apical lung lesion multiple serial radiographs were obtained over a few months with nonresolution of the lesion with a ct radiograph recommended for definitive diagnosis a service that requires transfer to the closest tertiary hospital more than 800 km away the patient did not attend for this scan and was lost to followup the patient represented to the phcc 3 years later and a ct chest radiograph with findings suggestive of tb was completed sputum sample smears confirmed mycobacterium tuberculosis 3 months postct although at this stage she was asymptomatic these results confirmed what appeared to be an autochthonous case of active pulmonary tb from an unknown source as per guidelines and under the remote supervision of the stateled tb control unit the patient was admitted to the local remote hospital to commence the first 2 weeks of drug treatment attempts at isolating her in hospital for induction treatment proved unsuccessful as the patient selfdischarged the patient continued to engage with the health staff in the community although her adherence to medical treatment and appointments was inconsistent to reduce the public health risk the tb unit advised the patient to cease her welfaregovernment supported employment at the local childcare centre the loss of her work role appeared to precipitate an increase in alcohol and cannabis use resulting in chaotic social interactions and loss of routine this complicated the medical management of this patient with the health service eventually using a modified directly observed therapy approach to optimise medication adherence treatment strategies following the initial failed hospital admission dot was trialled in the community initially a clinical nurse consultant with support from an indigenous health worker delivered medication monday to friday with weekend medication left with the patient on a friday this resulted in suboptimal adherence as locating the patient was problematic the period directly after diagnosis and subsequent withdrawal from work was the most chaotic for the patient the patients loss of a consistent daily structure that would ordinarily support treatment adherence significantly affected the delivery of treatment in the first few months alternative treatment regimens were trialled including three times weekly treatment and provision of takehome medications for weekends however there remained uncertainty with adherence when selfadministering finally in consultation with the patient the use of a prepacked medication system was employed initially the registered nurse and an ihw observed selfadministration of medications from the websterpak daily as the use of the websterpak did not require a registered nurse to administer medication the case management of the patient care was able to be transferred to the ihw who was able to build a relationship with the patient to facilitate more reliable treatment adherence visits were short but daily through building a medication routine acceptable to the patient the ihw could gradually reduce the level of support provided to the patient to ensure medication adherence this shortterm intensive support to develop a medication routine had positive unintended consequences such as improving the consistency of the patients daily routine reducing alcohol and improving her nutritional intake the patient also reengaged with her employment provider she ceased medication after 14 months of therapy and thus far is considered cured of tb for ongoing surveillance lessons learned this case report describes the diagnosis of tb in an aboriginal person residing in a remote community in cape york and the treatment strategies that resulted in successful disease eradication although the desired outcome of cure was achieved limited access to timely and appropriate health services and the lack of engagement with the patient outside of their immediate medical needs resulted in delayed diagnosis extended treatment requirements and significant disruption to the patients work and social roles two interrelated categories can be used as a framework for exploring the challenges faced by the patient and health service in treating this case the health service and environmental factors and individual personal and lifestyle factors health service and environmental factors several health service factors were identified through this case study as impacting on the provision of best practice for the patient these included staff unfamiliar with diagnosis and treatment of tb poor access to diagnostic tools such as ct scan paperbased records restricting timely communication between local hospital and primary health care staff and a lack of multidisciplinary involvement to reduce the burden of the disease on the patients social and occupational roles both patient delay in seeking health care and health systems delay contribute to delayed diagnosis and treatment potentially increasing morbidity and public health risk as in this case previous research has reported indigenous australians have been less likely to experience a delay in diagnosis than other groups when this patient initially presented with cough and fever and radiographical evidence of an apical lung lesion the index of suspicion for tb should have been higher with unfamiliarity and the relative rarity of this illness in cape york possibly contributing to this delayed diagnosis access to ct imaging for all residents in torres strait and cape york involve air travel to cairns and at least one overnight stay this can be a significant burden for patients who are responsible for caring for others or have other family or community responsibilities and navigating the complexities of tertiary level services and location has previously been demonstrated to present a barrier to accessing services for remote indigenous residents initiation of treatment was also compromised by distance as medications took time to arrive from cairns and did not arrive prior to the patients selfdischarge resulting in further delays to continuation of treatment and an associated increase in public health risk in australia following the diagnosis of active tb treatment is recommended to commence within 72 hours with a 2week hospitalisation recommended at the initiation of treatment these protocols exist out of context to this patients remote community setting and hospital service and in this case the execution of the tb protocol was not well considered from an organisational perspective due to unfamiliarity health service staff experienced reduced comfort levels with respect to managing this patient this resulted in staff focusing on the biomedical and risk management of this infectious disease without considering how to best support someone who felt relatively well to stay in hospital for 2 weeks two attempts at hospitalisation resulted in selfdischarge despite the patients willingness to treat the tb and agreeing to the admissions in hindsight this was unsurprising as there was no discussion with the patient or health staff about how the patient would spend their time in hospital there was no referral to social work for input and at the time the health service did not have an occupational therapy service that could support this patient to maintain occupational roles during the treatment process the combination of dot and a case management model better served the needs of this patient and ensured her care was maintained within the complicated context of this remote health service strategies used by the case manager involved raising issues regarding patient engagement at the daily primary care staff meetings and weekly multidisciplinary team meetings the success of case management models in the treatment of tb especially when used in conjunction with dot has been reported within the literature and this model certainly reduced fragmentation of communication in this case a lack of shared electronic medical records and electronic patient recall system meant that there was a heavy reliance on verbal and email communications which were not always filed in a timely manner or sent to all relevant parties involved in patient care this not only resulted in disjointed provision of service and missed opportunities for patient review but also occasionally put staff at risk who were not aware that this patient who presented sporadically to the emergency department required airborne precautions for tb it has been suggested that a common electronic platform of communication can improve management of tb especially with respect to the complicated drug regimens in multidrug resistant tb and this certainly would have been helpful in this case individual personal and lifestyle factors individual and cultural factors affect the adherence to treatment in tb in this case the patient was agreeable to treatment attended medical appointments and was open to discussions about her illness and the treatment regimen regardless of this cooperation it became quickly obvious that competing needs of cultural and personal priorities and the adherence to the intensity of the treatment were going to place the patient at risk of treatment failure and development of multidrug resistant tb the health priorities for many patients with chronic conditions are not that of disease control and eradication but the maintenance of daily social activities stigma from the community can limit willingness to engage in treatment and a shame factor was identified in this case as a significant barrier to daily dot with the patient embarrassed by being singled out by the health service in front of her family as observed in this case with the transition of case management to the indigenous health worker the provision of a culturally competent health service inconjunction with medication adherence strategies can improve treatment outcomes in indigenous patients due to the perceived public health risk in this case the patient was advised to withdraw from her role as a childcare worker resulting in disrupted interaction with others and a degree of social isolation with no redress for this offered by the health service in patients with tb as with many diseases unemployment and low socioeconomic status are associated with a lower baseline healthrelated quality of life and the psychosocial burden can sometimes be greater than the physical burden the advice to cease employment was provided without the support of a social worker or occupational therapist if the public health risk requires patients to restrict work or other social roles efforts should be made to ensure this is implemented in consultation with relevant stakeholders and to enlist support of a multidisciplinary team to mitigate the financial and psychosocial losses to the patient in some cases it may be possible to negotiate alternative employment or social roles which may have been helpful in this case conclusion this

context tuberculosis tb is a serious infectious disease with high rates of morbidity and mortality if left untreated in australia tb has been virtually eradicated in nonindigenous australianborn populations but in remote aboriginal andor torres strait islander communities tb presents a rare but significant public health issue remote health services are most likely to encounter patients with suspected and confirmed tb diagnosis but may be unprepared for supporting someone with this disease and the complexities of balancing public health risk with patient autonomy

introduction o utofhours primary care services are intended for acute but nonlifethreatening healthcare needs that cannot wait to be attended in daytime general practice 1 timely access to an opcs is pivotal for adequate delivery of primary healthcare and prevention of unplanned hospital visits 23 for patients with multiple health problems the acute health problem focused approach of opcss could however be disadvantageous continuity of care is hampered by limited or lack of knowledge about the patients medical history at the opcs the general practitioner on duty generally is not ones regular gp and patient information exchange between the patients dgp and opcs is challenging 3 4 5 information exchange is crucial in both directions since subsequent to an opcs contact patients often have followup contacts in dgp 6 additionally quality of care is challenged by scarcity of time and high workload in an acute care setting 7 people with a low socioeconomic position were found to use more acute and unplanned healthcare services than high sep individuals 8 whereas they would particularly benefit from continuity of care in a primary care setting individuals with low sep more often experience worse health with higher prevalence of chronic diseases and multimorbidity and at younger age than more prosperous individuals 9 moreover disadvantageous circumstances such as unfavourable health behaviours and financial strain more often accumulate among low sep individuals 10 consequently their healthcare need is often more complex socioeconomically vulnerable individuals thus would benefit from the continuity of care and familiarity with the patients background in dgp 21112 however there lies a paradox in the needs of low sep patients with their generally more complex health problems and the generally limited resources available to them to put these needs into adequate action and benefit from healthcare the complexity imposed by multimorbidity necessitates skills that low sep individuals often lack 13 moreover the inverse care law dictates poorer availability of good quality healthcare for the people who need it the most particularly in strong market competition of healthcare providers 10 although the strong primary healthcare system of the netherlands does not represent a strong market competition and fosters equity in healthcare accessibility 11 low sep is related to more fragmented and inappropriate use of health and social services 2 suboptimal healthcare use may be reflected in higher rates of opcs use by low sep individuals in a previous study we found that opcs use was higher in each lower level of neighbourhood socioeconomic status 1415 it is unknown whether higher opcs use of socioeconomically vulnerable individuals reflects worse health and resembles equal care for equal need 16 the aim of this study was to determine whether a patients sep was associated with opcs use taking their health status into account in addition we aimed to determine whether the associations were stronger for patients with a chronic disease to put the use of an acute care service in perspective of a regular healthcare provider we compared opcs use with dgp use we used electronic health record data from a large number of dgps linked to opcs ehr data 17 including healthcare use and health status of almost a million dutch residents enlisted in dgps methods setting every citizen in the netherlands is enlisted in a dgp the dgp has a gatekeeping role for specialist care and therefore is the first point of contact with the healthcare system consequently the dgp ehrs represent the patients most comprehensive medical record 1819 acute primary healthcare out of office hours is provided by opcss with 50250 affiliated gps patients generally contact the opcs by phone after which a triage nurse assesses the level of urgency paired to action the use of healthcare in dgp and opcss is fully covered by the national basic health insurance scheme and does not require any outofpocket payments 1 patient involvement and ethics approval patients were not directly involved in this study this study does not fall within the scope of the medical research involving human subjects act and therefore does not require ethical approval general practices and primary care cooperatives that participate in nivel primary care database are contractually obliged to inform their patients about their participation in nivel primary care database and to inform patients about the option to optout if patients object to inclusion of their data in the database 42 dutch law allows the use of ehrs data for research purposes under certain conditions according to dutch legislation and under certain conditions neither obtaining informed consent nor approval by a medical ethics committee is obligatory for this kind of observational studies dutch civil law article 7458 lawcomcivilcodebook077htm medical research involving human subject act and general data protection regulation article 24 this study has been approved by the applicable governance bodies of nivel primary care database under no nzr00317017 study population data concerning dgp and opcs use in 2017 were derived from routine ehrs from dgps and opcss participating in nivel primary care database 20 251 dgps were included with 1 013 687 listed patients located in the catchment areas of 27 opcss dgps in strongly urbanized regions were slightly overrepresented we linked dgp enlisted patients with opcs contact records dgp enlistment was recorded per quarter of the year the majority of patients was enlisted the entire year data of patients enlisted only part of the year were linked to opcs data for the corresponding part of the year newborns in 2017 were excluded from the study population since they were not yet included in the population registry data that was used the patient sample was linked to population registry data from statistics netherlands 21 and included household income migration background and household composition patients were excluded from the analyses if they could not be linked to the sociodemographic data measures outcome measures opcs use included claimed opcs contacts of dgp enlisted patients in the year 2017 outcome measures included number of contacts and dichotomized measures reflecting whether the patient had a contact or not during the yearpart of the year and whether the patient contacted an opcs twice or more assessed urgency was included as at least one highurgency contact and at least one lowurgency contact additionally contacts for acute health problems and contacts for longlasting and chronic health problems in opcs reflected the category of symptoms or diagnoses recorded according to the international classification of primary care1 code 1822 dgp use included the annual number of contacts and a dichotomous measure indicating whether an enlisted patient had at least one dgp contact in the yearpart of the year 2017 independent variables patient socioeconomic status was measured by net disposable household income standardized for size and household composition patient income was categorized in quintiles ranging from 1 to 5 following from standardized percentiles based on the total dutch population 23 potential confounders patient characteristics included age sex living alone and nonwestern migration background nonwestern migration background included patients with one or two parents born in morocco turkey suriname the netherlands antilles or other nonwestern countries chronic diseasesmultimorbidity included the number of chronic irreversible illnesses 24 on 1 january 2017 or on the first day in the quarter of the year the patient was enlisted in general practice the presence of a chronic disease was derived from the ehr data using a method described elsewhere 18 stratification variables data on icpccoded chronic diseases from the ehrs of general practices were used to define four subgroups of patients diabetes mellitus chronic obstructive pulmonary disease and asthma cardiovascular disease and other chronic disease 1820 statistical analyses to assess the probability of opcs and dgp use according to the patients income group we conducted logistic regression analyses to control for clustering of patients within practices we applied twolevel hierarchical models including patients nested within dgps we adjusted the analyses for patient characteristics eg age and sex and number of chronic diseases on patientlevel we additionally conducted stratified analyses for four chronic disease determined groups we reported age and sex standardized probabilities to evaluate the extent of the reported odds ratios in terms of effect size all confidence intervals were set at 95 and analyses were conducted using the statistical software package stata version 151 25 additionally we calculated population attributable fractions to determine the proportion of opcs and dgp use in the study population attributable to having a lower household income when compared with the most favourable income group the paf was calculated according to the equation below 26 paf ¼ pðrr à 1þ p rr à 1 ð þþ 1 where p is the proportion of the population exposed to a level of income and rr is the relative risk of dgpopcs use summed for the four income groups with income levels 14 results characteristics of our study population are presented in table 1 regarding age sex and household income our population closely resembled the general dutch population 23 individuals with a nonwestern immigration background were overrepresented more people were using healthcare in both opcs and dgp for each subsequent lower income group with each lower stratum of income a higher proportion of individuals suffered from three or more chronic diseases and from at least one of the specified chronic diseases the second lowest income had the highest proportion of patients with multimorbidity and cvd for other chronic diseases prevalence rates increased with each higher income group healthcare use in opcs and dgp followed a similar pattern with higher use rates for each lower income group in the second lowest income group the mean number of yearly dgp contacts was considerably higher compared with the lowest income group regarding opcs contacts inequalities were observed across all types of contacts particularly contacts for a chronic health problem and lowurgency contacts in table 3 we quantify the size of socioeconomic inequalities in the probability of having had at least one opcs contact individuals from the lowest income group had a 48 higher probability of at least one opcs contact than those in the highest income group the extent of the inequalities was nearly similar for highand lowurgency contacts and for contacts for an acute health problem inequalities were largest for the probability of two or more opcs contacts in a year and for contacts for a chronic health problem inequalities between income groups were substantially smaller for the probability of dgp contact in 2017 compared with the highest income group individuals with the lowest income had a 17 higher probability the probability of contacting an opcs at least once a year attributable to not being part of the highest income group was reflected in a paf of 22 the largest paf was observed for having had two or more opcs contacts with 41 of opcs use attributable to being part of a lower income group in comparison a marginal paf of 4 was observed for dgp use income inequalities in opcs use were larger within patient groups with a chronic disease compared with the total study population mainly due to larger inequalities between the lowest and the second lowest income groups in table 4 we compare opcs use with dgp use for patient groups with a chronic disease income inequalities regarding dgp use were much smaller than for opcs use for these patient groups compared with the total study population income inequalities in dgp use were somewhat larger for patients with copdasthma and for patients with diabetes in the group of patients with cvd inequalities were smaller compared with the total study population the probability of an opcs contact due to not being part of the highest income group was larger for patients with cvd and patients with diabetes compared with the total study population for dgp use the paf for patients with a chronic disease was somewhat smaller compared with the total study population discussion key findings we observed inequalities in both opcs and dgp use reflected in higher use rates within every lower stratum of household income inequalities for opcs use were considerably larger than for dgp use these inequalities persisted when taking the patients health status into account among patient groups with copdasthma cvd or diabetes income inequalities for opcs use were larger than in the total population the extent of inequalities in dgp use between income groups were quite similar for patients with a chronic disease and the total study population study strengths and limitations the use of routinely recorded ehr data enabled us to study a large nationally representative patient sample the recorded chronic diseases were either diagnosed by the gp or a specialist and are therefore more reliable indicators than selfreported diseases 19 our study results may have been biased due to limitations of the data and the applied methods first the use of household income as indicator for socioeconomic status provided us with a robust measure that was routinely registered by tax registries the use of income however adequately classifies groups in the productive age bands and may be less adequate for people of younger and older age due to their loose attachment to the labour market different measures of sep each have their advantages and disadvantages for instance wealth is a more appropriate measure for older age groups 27 however less so for younger age groups 28 the use of household income in this study consequently suboptimally classified both younger and older people secondly health status was measured by the number and nature of chronic diseases as recorded in dgp nevertheless we were unable to quantify the severity of the generally more complex health problems of socioeconomically vulnerable patients our operationalization of health status therefore likely underestimated the healthcare need of low sep individuals and the extent to which this could account for the observed inequalities in opcs and dgp use interpretation of key findings our results showed that socioeconomic inequalities in opcs use could not be explained by differences in health status and that these were larger than inequalities in dgp use a previous study also indicated that attendance of opcs was higher in low sep patients after adjusting for health status 29 the larger income inequalities for opcs use compared with dgp use likely ensue from factors additional to and interacting with the patients health status for instance limited health literacy need for reassurance perceptions of illness and doctorpatient communication likely contribute to inequalities in usepatterns between sep groups 3031 limited health literacy for example may inhibit finding the way through the healthcare system 32 whereas poorer doctorpatient communication leads to misinterpretation of the patients care need 31 moreover people with low ses may experience more difficulty in waiting for an appointment in dgp the next working day and turn to an opcs for immediate relief of their worries 5 the larger income inequalities for opcs use among patients with a chronic disease suggest a different healthcare need among chronically ill patients with low sep due to the clustering of health and social problems and more severe comorbidity 1233 care coordination and continuity of care for these patients in dgp is more challenging 10121334 their care needs likely demand more time than dgps are able to spend on their patients 3334 additionally these patients may have difficulty obtaining other healthcare and social services and therefore may experience unmet needs 23536 the higher opcs use therefore may be a reflection of the inverse care law as a result of impeded access of dgp for low sep individuals 5101337 implications for research and practice the results suggest that opcss fill a void in healthcare needs for socioeconomically vulnerable patients particularly among the chronically ill as such opcss contribute to equity in healthcare access by providing low threshold care on the other hand using opcs services comes with downsides of acute healthcare such as lack of continuity 4 ideally from a continuity of care perspective dgp may be even more sensitive to the more complex care needs of vulnerable patients to prevent them from care seeking in opcss 3538 additionally coordination and continuity of care between dgp and opcs should be improved by better information exchange and close involvement of the patient 36 to more adequately address the patients needs resources and skills the higher opcs use within lower income groups as reflected in the paf appears to be additional to dgp use therefore overall healthcare use and the workload of gps increases since opcss increasingly experience difficulties in fulfilling vacancies and voids in work schedules the sustainability of accessible ooh primary care is at stake 7 how to relief the high workload of both opcs and dgp should be subject of further study for instance by studying the effect on workload by scalingup opcs healthcare professional staff by employing nurse practitioners 39 and integration of social support services 38 we found substantial incomerelated inequalities in opcs use the more so when compared with inequalities in dgp use particularly among patients with a chronic disease these inequalities suggest that opcs meets a healthcare need of vulnerable groups additional to healthcare provided by dgp particularly among individuals with low sep and chronic disease optimization of care sb standardized probability by direct standardization for age and sex or odds ratios from multilevel logistic regression analyses ci confidence intervals icc the intraclass correlation between daytime general practices the relative contribution due to clustering of patients in dgp to the variation unexplained by characteristics related to the patientlevel paf population attributable fraction for income groups 14 vs the highest income group models adjusted for agegroups sex living alone nonwestern immigrant background number of chronic disease episodes and random effect of dgp level key points • sep is related to worse health generally following a gradient with less favourable outcomes for each lower level of sep • low sep is associated with higher healthcare use rates of opcss • incomerelated inequalities in opcs appeared to be only partly related to health status • incomerelated inequalities in opcs use were particularly large for patients with a chronic disease and they were larger than inequalities in dgp use • these findings suggest that opcss address an additional healthcare need of socioeconomically vulnerable patients particularly among patients with low income and chronic diseases data sharing statement results are based on calculations by the researchers of this paper using nonpublic microdata from statistics netherlands under certain conditions these microdata are accessible for statistical and scientific research for further information the unpublished statistical code and raw data files excluding the microdata of statistics netherlands are available upon reasonable request from the authors coordination in dgp and between dgp and opcs should be considered to address the generally more complex care needs of socioeconomically vulnerable patients and preferably reduce opcs use supplementary data supplementary data are available at eurpub online conflicts of interest none declared

background low socioeconomic position sep is related to higher healthcare use in outofhours primary care services opcss we aimed to determine whether inequalities persist when taking the generally poorer health status of socioeconomically vulnerable individuals into account to put opcs use in perspective this was compared with healthcare use in daytime general practice dgp methods electronic health record ehr data of 988 040 patients in 2017 251 dgps 27 opcss from nivel primary care database were linked to sociodemographic data statistics the netherlands we analyzed associations of opcs and dgp use with sep operationalized as patient household income using multilevel logistic regression we controlled for demographic characteristics and the presence of chronic diseases we additionally stratified for chronic disease groups results an income gradient was observed for opcs use with higher probabilities within each lower income group lowest income reference highest income group odds ratio or ¼ 148 95 confidence interval ci 145151 income inequalities in dgp use were considerably smaller lowest income or ¼ 117 95 ci 115119 inequalities in opcs were more substantial among patients with chronic diseases eg cardiovascular disease lowest income or ¼ 160 95 ci 153167 the inequalities in dgp use among patients with chronic diseases were similar to the inequalities in the total population conclusions higher opcs use suggests that chronically ill patients with lower income had additional healthcare needs that have not been met elsewhere our findings fuel the debate how to facilitate adequate primary healthcare in dgp and prevent vulnerable patients from opcs use

introduction papadopoulos contends that every epoch has its brain and that the concept of brain plasticity occupies the brainbody imaginary of the contemporary epoch 1 the idea that the capacity of the brain is not fixed that it is an organ with the potential to adapt and change underpins and finds expression in the current scientific research and wider public interest in pharmacological cognitive enhancement the possibility of increasing brain power through pharmaceuticals sometimes referred to colloquially as smart drugs has gained considerable prominence in popular culture science magazines and the wider media as well as in policy debates 2 for example in recent mainstream bigbudget films such as lucy and limitless drugs with potent powers of enhancement enable the central characters to overcome the limitations of the normal human brain and thereby exert their influence on the world around them in a more modest vein media reports have discussed normal people taking drugs believed to enhance cognition in the context of employment including speculation about how smart drugs and cybernetics could create a superhuman workforce at the same time a number of prominent policyorientated reports have discussed the possible economic and social benefits of cognitive enhancement drugs notwithstanding the distortions of the scientific concept of brain plasticity within its popular manifestations in the media and popular culture the idea that drugs have the power to enhance the brain or unlock its potential is consistent with a general turn to pharmaceuticals to solve a whole range of problems and achieve desirable ends for individuals and society a pill for every ill 3 this tendency has been described as pharmaceuticalization it is also expressive of the prevalent view of brain functioning as essentially constituted by neurochemical processes and interactions which themselves can be adjusted and readjusted through the use of pharmaceuticals this psychopharmacological imaginary appears to hold out the promise to help people manage not only specific diseases of brain function but also importantly aspects of ordinary everyday life but at the same time as greater control seems to be available through pharmacology rose argues that the more we see ourselves in terms of brain chemistry the more we become subject to neurochemical evaluation and intervention discussion of cognitive enhancement falls broadly into two areas bioethical debate and sociological studies ethical discussions centre on two key issues first coercion versus free choice whether individuals might seek to enhance themselves out of their own volition or because they may be required to enhance or might feel pressured to do so due to working conditions or to keep up with others in education and the labour market the pressures for productivity or profitability the impetus to reduce the costs of labour and the current move towards more casualized employment conditions are some of the main drivers that could lead to coercion to enhance ethical debates tend to problematize coercion but do not question what is assumed to be its opposite free choice analysing the context of the contemporary labour market and employment relations enables an understanding of the conditions under which this choice comes to be seen by individual employees or students as possible or desirable second there is the question of fairnessequity in the access to such drugs and their outcomes whether consumption of enhancement drugs might give an unfair advantage to some people who can afford them over others who cannot sociologically orientated work on cognitive enhancement has tended to use it to develop explorations of the concepts of medicalization biomedicalization and pharmaceuticalization although this is not the focus of these studies they have made some points on specific political economic aspects of cognitive enhancement in particular this has been discussed in relation to the management of sleep and how the customisation and even potential optionalisation of sleep provides opportunities for greater productivity especially in the light of shift work other research has considered enhancement drugs in relation to the pressures associated with the characteristics of contemporary employment including increasing demands for flexible labour precarity extreme forms of working long working hours 247 availability and so on whilst acknowledging the importance of the issues addressed in such literature here we seek to situate cognitive enhancement as part of a broader relationship between cultural understandings of the bodybrain and the political economy it is the body of the worker that forms the intersection of this relationship and through which it comes to be enacted and experienced through our analysis below we argue that the use of pharmaceuticals has come to be seen not only as a way to manage our brains but through this as a means to manage our productive selves and thereby to better manage the economy more specifically in this article we investigate the imaginaries that both inform and are reproduced by representations of pharmacological cognitive enhancement drawing on cultural sources such as newspaper articles and films as well as policy documents and pharmaceutical marketing material to illustrate our argument previous studies have analysed media reporting on drugs such as modafinil or the portrayal of a range of enhancement technologies in science fiction however in this article we analyse a range of cultural sources arguing that despite their differences they also encapsulate a commonality in their construction of images of minds and brains and their potential for enhancement as the basis for our analysis we contend that prevalent representations of cognitive enhancement are inextricably intertwined with the contemporary social context as hogle argues the work that goes into both identifying and amplifying certain characteristics as being amenable to change and constructing certain traits as desirable does more than essentialize them as preferred human traits rather it forms a circuit of enterprise biology medicine and culture in complex relations to each other in this sense the traits being enhanced are not inherently natural but cultural we contend that the cognitive traits that are associated with pharmacological enhancement are predominantly concerned with making the body more productive and thus linked to particular characteristics that are seen as having economic worth and thereby connected to the broader political economic context enhancement for the purposes of improving work rates is not new historical examples of pharmacological modification of cognition include the military deployment of amphetamines and methamphetamine to improve attention and wakefulness during the second world war we can see this as part and parcel of the longstanding relationship between the economy and the body this is captured in foucaults remark that in fact the two processes the accumulation of men and the accumulation of capital cannot be separated whilst the human body is the primary instrument of labour it is also a significant limitation on it for some time now the economy has demanded flexibility on the part of the labouring body and in the current era of brain plasticity this translates into the idea of enhancing cognitive powers cognitive enhancement may thus be seen as a form of work on the body an accumulation strategy that aims to reshape it to fit the particular demands of the economy indeed it is very noticeable that discussions in the news media of the potential for cognitive enhancement through the use of smart drugs frequently focus on how this might improve various working or studying practices modafinil a stimulant synthesized in the 1970s in the context of brain research and sleep is medically prescribed for conditions such as narcolepsy however it has been deployed by various military forces and subsequently taken up within wider society as a cognitive enhancer a smart drug for example in 2011 reuters health reported on research into whether the sleepfighting medication modafinil may boost the brain power of weary surgeons similarly other coverage suggests that enhancement drugs might improve driver performance and safety in this guise modafinil has also proved particularly popular amongst students and others in highpressure occupations even though its efficacy remains a subject of scientific debate along with concerns about its known side effects paid work is multifaceted it is about more than production or making a living in capitalist economies paid work is a source of social status social interaction and social identity formation it has been argued that more and more social relations come to be viewed through the lens of economic worth such that being productive is socially valued and validated whilst there is a concomitant demonizing of those who are unproductive more recently conditions of employment have become framed within the language of what constitutes neoliberalism mindful of the ubiquitous but often illdefined use of the term we limit our reference to neoliberalism specifically to the forms of governmentality articulated by foucault in his lectures of 19789 here he elucidates the development of ideas and institutions that promulgate the generalization of the economic form of the marketthroughout the social body foucault analyses neoliberal developments in relation to biopolitics the ways in which life itself is put to work in this conception where each individual might be seen as a microenterprise investing in themselves to gain the best return on their own self as human capital it becomes more comprehensible why some people might choose to or feel they need to turn to smart drugs and other technological interventions in order to succeed compete or even just survive in this enterprise society with the growth of neoliberal economics the focus has shifted to the responsibility of the individual to work on their own body and we would add their brain this then becomes part of an individual project of selfconstruction an ethic of personal selfcare and responsibility linked to modifying the body whilst remaining tied to the wider political economy it is in this context that we would note there is a continuity between students taking cognitive enhancement drugs as a study aid and employees taking them to perform better at work as one prominent headline put it students used to take drugs to get high now they take them to get higher grades within the context of neoliberal biopolitics articulated by foucault there is a subtle shift where education becomes one of the means by which individuals can improve and actualize their human capital postponing earning opportunities in the present in order to invest in their future employability and earnings potential in the light of this the consumption of pharmaceuticals for cognitive enhancement can be seen as a potential tool for the worker acting as an entrepreneur of the self one example of pharmacological enhancement that perhaps particularly well illustrates its interrelationship with contemporary employment is the renewed interest in lysergic acid diethylamide used in very small quantities as a potential spur to creativity especially in the context of occupations such as software engineering in conditions of uncertainty and competition over jobs even for those in the professions including the muchdiscussed replacement of human workers with robots and ai and the casualization of workers contracts and rights in the socalled gig economy workers seek for the means to reduce their precarity and increase their competitive edge in contemporary knowledgebased economies it is the gold in workers heads that is particularly valued including such skills as creativity and innovation thus it is not surprising to find enhancement practices focused on these traits in summary cognitive enhancement resonates with the prevailing political economic order in particular its valuation of productive performance and the associated expectations on individuals to take responsibility for realizing their own potential in order to achieve this we contend that this ethos produces a commonality that runs through the seemingly diverse representations of cognitive enhancement that we analyse in this paper ranging from fantasies based upon the acquisition of superhuman skills through cognitive enhancement to more mundane pharmaceutical interventions aimed at managing cognitive functions such as alertness and attentiveness as well as attempts to attain greater focus and improved memory imaginaries of cognitive enhancement in order to further explore how cognitive enhancement is represented and understood in everyday life we deploy the analytical term imaginaries as a means of highlighting the connection between ideas imagery and context imaginaries relate in part to the cultural images and ideas that circulate as well as to the various ways in which people relate to them by interpretation incorporation and rejection often contradictorily sometimes explicitly and sometimes without intention or conscious deliberation therefore we purposefully refer to imaginaries in the plural not the singular the imaginaries we explore express contestations and struggles surrounding cognitive enhancement we do not consider here how these imaginaries of enhancement are received it is enough to note that we do not see them as deterministic or predictable instead we aim to elaborate specific aspects of the social cultural and economic context from which they emerge and which they in turn help reproduce the imaginaries of cognitive enhancement that are explored in this paper are not passively derived from current dominant images in society nor are they simply abstract fantasies of how society might be different they stand in the interstices between such images and those future states imaginaries have material effects they are intrinsic to the possibilities of action because they hold out the prospect of a future path for the individual and thus motivate desire and choices dawneys development of the concept of imaginaries as material embodied and affective takes this further ideas and imaginings do not cause practice they are practices in other words to position the imagination in the realm of ideas alone runs the risk of excluding a consideration of the immediate sensate and embodied modes through which imaginaries come to be experienced and felt however imaginaries have a material effect not only for individuals but also through how they come to frame future possibilities through cultural and scientific understandings for example in 1628 william harvey described the circulation of the blood through the pumping motion of the heart since then the major imaginary of the heart as a functional organ has treated it as if it is a pump even though this ignores important aspects of its electrobiochemical characteristics in the 20th century doctors worked out how to replace a faulty heart with a device that was indeed very like an electrical pump our analysis below shows that the contemporary imaginaries of cognitive enhancement present in a diversity of sources are significantly embedded in cultural constructions of what might be described as the productive body that body which is made fit for work and employment however beyond the immediate demands of the working body these imaginaries express aspirations for performance that are characterized by an increased emphasis on achievement personal development and realizing ones potential the article draws upon a variety of englishlanguage sources of material that refer to pharmacological cognitive enhancement deriving from the period 1997 to 2017 the selection of a range of sources was shaped to a certain degree by our awareness of the interplay or crossreferencing between them along with the growing media coverage and public discourse surrounding the topic of cognitive enhancement and with its manifestation in popular culture through films such as limitless and lucy it was interesting to observe that the latter became drawn upon in those media reports as a means of narrating the topic to their audience furthermore informed by other research on drugs and the brain that examined the role of industry advertisements we too chose to consider the marketing materials for the drug modafinil we view our sources as related cultural or social manifestations of the notion of brain plasticity in general and the imaginaries of cognitive enhancement in particular in short we regard our chosen sources as public fragments of social consciousness that work in concert encouraging people to reason know and fashion their worlds in particular ways accepting this commonality it is nonetheless useful to distinguish the particular characteristics of the sources as they each have different relations with the portrayal of the enhanced or modified brain in everyday life the first category of sources comprises portrayals of cognitive enhancement in popular culture specifically the recent films limitless and lucy although explicitly fictionalized narratives expressing fantasies far from everyday experience and current possibilities they invoke distorted or exaggerated scientific ideas about the brain and the possibilities of pharmacological enhancement and in doing so tap into some key desires and anxieties about its implications second we draw upon international englishlanguage media reports of pharmacological cognitive enhancement particularly newspaper articles whilst at one level some news coverage purports to present factual accounts of scientific developments in brain science neuroenhancement or the use of smart drugs amongst particular groups in society it is also involved in the construction of particular imaginaries about such matters indeed since there are currently no drugs that are licensed to be prescribed or marketed as cognitive enhancers these reports are inherently involved with the formation of narratives of what these smart drugs are and how they are used such accounts typically refer to the offlabel use of prescription drugs such as modafinil and ritalin usually associated with diagnoses such as narcolepsy and attention deficit hyperactivity disorder respectively but consumed by people who have not been given these diagnoses with the aim of improving cognitive function scientific studies are mixed in their conclusions as to whether brain functioning is improved and in any case laboratory studies are hardly representative of everyday work life overall the drugs predominantly promote wakefulness rather than increase cognitive ability nevertheless many media accounts relate the improvement in brain ability to the possibilities of or at least desire for increased performance such as in study or at work and thus the pursuit of selfdevelopment promoted by neoliberal discourse for instance taking a snapshot of coverage in uk national newspapers in 2016 revealed 20 unique reports on the topic of modafinil or smart drugs and the brain of which 18 referred to enhancement in the context of performance in study or at work 4 we contend that such examples draw upon particular ideas and social values imaginaries surrounding selfrealization employment and the social valuation of productive effort but at the same time offer imaginaries of cognitive enhancement that in turn reproduce those ideas and values the third category we draw upon is marketing material for the drug modafinil we chose to concentrate on modafinil rather than other substances that are discussed as enhancers for several reasons first it is the most common substance referred to in media reports second there has already been a more formal crossover of the drug into work environments it has been used in the military and discussed in relation to longdistance driving as a potential aid to safety and experiments with it taken place in the medical and surgical field third there was a metaanalysis of scientific studies of modafinil in 2015 which led to its being labelled the worlds first safe smart drug in newspaper reports thereby increasing its visibility and fourth the advertisements for modafinil specifically relate its use to employment official promotional material from the pharmaceutical industry does not represent cognitive enhancement as such since it is not allowed to market drugs for anything other than their licensed uses 5 however we contend that the adverts nonetheless offer imaginaries about the relationship between the brain and potential pharmaceutical interventions in its functioning for instance in terms of restoring alertness attention or wakefulness in sleepdeprived individuals the imaginaries typically deployed in promoting a drug refer to both its power to transform an individuals condition and the future self that they hope to become one of the ways in which industry seeks to convey product information to consumers is through the use of narrative devices and associated imagery centred on clearly recognizable as well as believable characters individuals that one can identify with in this regard the promotional material for pharmacological drugs is often no different such material and its associated imaginaries present possible identities that the observer can try on to see if they would fit into the imagined future that is portrayed therein the envisaged use of the product that is being promoted may thus become thinkable as a first step towards its actually being acquired moreover imagined futures have an emotional component and this is exploited in a number of advertising campaigns for various pharmaceutical drugs there is also unofficial unregulated marketing material from online retailers who overtly promote the supposed cognitive enhancement potential of these drugs with some making an explicit link to the limitless film offering the real smart drug this material includes narratives that are presented as the experiences of those who have tried the drugs it also includes online discussions between users and other information that is presented as factual about the drugs fourth we draw upon two policy reports that have been published in the uk on the use of drugs for the purposes of enhancement the academy of medical sciences 2012 report on human enhancement and the future of work and the british medical associations 2007 publication boosting your brainpower ethical aspects of cognitive enhancement these are relevant because they bring in discussions that cut across the scientific and policy communities and seek to construct futureorientated activity especially with regard to the economy as we have already noted despite the seeming diversity of these materials it is the strands of commonality between them that enable us to better understand the ways in which the associated representations of the brain relate to the cultural context out of which imaginaries of enhancement emerge as immanent potentialities this can be shown by briefly illustrating the interrelationships between the different sources for example newspaper reports pick up on scientific and policy discussions that they then represent in a popular digestible form similarly references to the real life limitless drug can be found in newspaper headlines and online pharmacies for modafinil and reviews of the film claim that it was based upon modafinil 6 our main argument in what follows is structured according to three analytical themes followed by a concluding discussion in the first of these mind over matter we explore the commonplace imagery of the brain that is deployed in popular coverage of enhancement the second theme valuing productivity and performance examines the connection between imaginaries of enhancement and the social valuing of productivity and performance especially in paid employment the third theme enhancing the economy considers how management of the self is but a microcosm of broader managerial efforts to organize the world noting wolfmeyers point about the need to understand the economy as an always embodied practice we illustrate this theme by reference to efforts to exercise pharmacological control over alertness wakefulness and sleep mind over matter in the film lucy we see portrayed a fantasy of total control in which the mindbrain has power not just over the individuals body but the external world too for example lucy is instantly able to accomplish complex tasks involving adept physical coordination by the sheer power of thoughtknowledge at the beginning of the film she is unable to drive but once the drug has enhanced her brain she transforms into someone who can skilfully weave a car through fast oncoming traffic similarly through the power of the drug lucy can immediately understand languages that she could not previously speak and is able to wield a gun like a professional the embodied nature of human skill acquisition and practice is ignored her new abilities are derived internally as it were directly from her brain power she just knows what to do and is able to do it this portrayal of the possibilities of cognitive enhancement sidesteps any understanding of how learning comes from embodied interaction with the world moreover as lucys powers develop she becomes able to exercise telekinetic and other powers over matter itself everything becomes subject to her will which can be perfectly enacted because of the realization of the full potential of her brain although easily dismissed as science fiction fantasy lucy may be better understood as the extension of current lines of thinking pushed to their limits this imaginary of cognitive enhancement shows both connection with and contrast to the current dominant materialist view of the mindbrain where mind is understood as a property of the brain which is an organ of the body here on the one hand we see the brain as an organ of the body whose biological capacity can be extended through pharmaceutical substances on the other hand it is seen as capable of being enhanced as if it was autonomous and almost separate from the body in a way that is suggestive of a power of mind that goes beyond its biological nature this evokes images of an enhanced brain which is now able to pull along a body that can be perceived as a constraining factor due to its biological limits lucys body before it is enhanced is weak and deficient she is not able to resist those who forcibly turn her into a drugs mule once she is at the full extent of her extraordinary pharmaceutical enhancement however her brain becomes allpowerful indeed so much so that the biological body is no longer able to contain it and she becomes a supercomputer before dissolving and leaving her superior knowledge behind on a flash drive in this strange sequence we see the dream of overcoming and even entirely transcending the physical body a fantasy that resonates with a long history of denial and degradation of the body we suggest that there is a residual cartesianism in this imaginary which coexists and is in tension with the prevalent materialist view within more mundane everyday examples of imaginaries around cognitive enhancement we can see similar themes newspaper reports about the use of smart drugs emphasize how they provide a means to transcend biological limits headlines include in the city that never sleepstraders stay up on smart drugs public servants used drug modafinil to stay awake to complete the federal budget on time drugtaking think what wed achieve if we never slept a wink and smart drug helps you to sleep less and think more all of these examples rely on an imaginary where the limits of the tired body can be overcome by an enhanced brain the visual imagery that is often deployed next to articles such as these is also telling for example a brain with coloured lines radiating out of it and a brain with sections brightly lit up again a notable common theme with these pictures is that the brain is shown as a single selfcontained organ abstracted from the rest of the body it appears to be able to exist and function alone and independently as a disembodied agent this somewhat mechanistic view of the brain runs through much of the discussion and visual representations of cognitive enhancement the problematizing of the body is something that can also be discerned in the official adverts for provigil in the usa these directly promote the use of the drug for patients reporting symptoms of excessive sleepiness for example a dramatic transformation from sleepiness to alertness is captured explicitly in an advert for provigil that appeared in professional journals such as psychiatric news 7 under the caption cut through the fog of es with provigil we see an image of a female clinician in the foreground who is striding ahead bright and alert in the background lurk several other figures all bearing the trappings of their employment but shrouded in fog and looking tired and deadbeat from their work a series of related images in other adverts similarly portray the before and after message with the former depicting tired aching bodies and downcast eyes and the latter showing figures whoafter taking modafinil are energetic refreshed and committed to their work the suggestion that is carried through this promotional material is one that poses the chemically enhanced brain as a solution to the failing body as elliott notes enhancement technologies are usually marketed and sold by taking advantage of a persons perception that she is deficient in some way the tensions that we see in the imaginaries of cognitive enhancement illustrate the complex and continuing power of cartesianism with its mindbody dualism and hierarchical assumptions that the mind constitutes the active subject whilst the body is mere matter the brain in some ways occupies an ambiguous and ambivalent position sometimes it is equated with the power of mind and sometimes it is equated with the limitations of that biological matter furthermore despite the prevalent idea that the mind is now embodied in the brain which is another organ of the body there is an assumption that enhancing the mindbrain can be secured without risk or detriment to the passive body with side effects considerably downplayed the transformations of the bodybrain depicted in films such as limitless and lucy as well as in the adverts discussed above and in cultural representations of enhancement more generally can be further analysed in terms of sobchacks discussion of morphing this is a technique deployed in cinematic representations of radical bodily transformation these metamorphoses depict bodily changes without any of the natural biological processes involved they are about making visible incredible alterations of an unprecedented plastic and elastic human body in doing this they ignore obscure or even write out the time and pain involved in the experience of bodily change transformation without time without effort without cost for example in limitless radical cognitive enhancement is achieved through taking a fictional drug nzt48 in this case biological processes and time are doubly removed first because once a pill is consumed it moves from the outside to the inside of the body and the changes it instigates themselves become invisible and no longer consciously thought of second because the changes of enhancement are refracted through the remnants of the cartesian body thus the dominant imaginary runs these drugs produce specifically cognitive enhancement aside from the resultant powers that are bestowed by the pill the only sustained bodily changes that we see are relayed by a pronounced brightening of eddie morras irises they seem to radiate indexing cognitive prowess dramatic negative effects are visited on the body but only as a consequence of the drug wearing off the effects being quickly reversed once the drug is consumed again there is thus an asymmetry as regards bodily processes a seamless almost disembodied transition to enhanced powers through the presence of the drug and then a body rendered lumpen and dazed by its absence the plasticity that is assumed and represented in morphing techniques can be related to the dominant image of the plasticity of the brain but as sobchack notes this plasticity comes with connotations and consequences for embodiment and social relations rendering human affective states with unprecedented superficiality and literalism at the same time the plasticity of the image has overwhelmed the reality of the flesh and its limits the bodily nature of the brain with its biological time and processes its emotions and interconnections is effectively written out through this the brain becomes rendered open to commodification and instrumentalism both for the individual and within the broader political economy featherstone notes that the body in contemporary consumerist culture has become seen and experienced as plastic and hence a lifestyle accessory a thing to be sculpted shaped and stylized similarly emily martin develops this theme in flexible bodies here placing it in an economic context and arguing that flexibility is an object of desire for nearly everyones personality body and organisation in the next section we further develop our analysis by discussing how the impetus to overcome the limitations of the bodybrain through cognitive enhancement is socially and morally legitimated in relation to the imperative to be an economically active and productive subject valuing productivity and performance the potential to enhance the brain is linked to the high valuation that capitalist societies put on productivity and thus on being a productive person an article in the new yorker entitled brain gain the underground world of neuroenhancing drugs tells of a harvard graduate who as a student regularly took adderall as a study aid 8 his summing up of this productivity is a good thing another account in this article tells of someone who works with a colleague who takes modafinil and in contrast to them is seen by their boss as a problem for not being as productive a third story is of an older person experimenting with modafinil who believes he is performing a little better the moral of this particular smart drug tale is that productivity is good and hence achieving it through pharmaceutical means is also good the rhetoric of productivity and the expectation that the individual will work on their ability to be productive legitimates the use of smart drugs imaginaries of cognitive enhancement are closely entwined with cultural norms and values of productivity and performance at the level of the individual there is an expectation that in order to legitimately participate within society one has to be a productive person for example this underpins the argument of the academy of medical sciences report human enhancement and the future of work enhancement could enable more people to work at their full biological capacity and to meet necessary entry requirements for an occupation which could result in a rise in standards or potentially greater opportunity and diversity at work individuals with lower cognitive abilities tend to have less choice of occupations but enhancement may enable them to compete and thus have greater choice this articulation indicates a key shift in the contemporary relationship between the individual employee and their place in the labour market the language is that of choice and competition but in the sense that the individual in order to have greater opportunities in their working life has a choice of enhancing themselves so they can better compete with others the significance of this can be further seen in imaginaries of cognitive enhancement that find expression in popular culture one of the straplines for the film limitless is what if a pill could make you rich and powerful similarly newspaper articles and blogs are headed nootropics substances that improve mental function can these smart drugs supercharge your career 9 smart drugs are coming to the office to make you sharper strongerbetter 10 and how to use nootropics to boost productivity and performance to use nootropics 2016 it is noticeable that these headlines address the individual worker directly in this framing then there is a sense in which the worker is expected to want to make themselves more employable in order to achieve their own full potential and selfactualization from this perspective it is the worker who has to ensure that they are fit for work in other words to choose to enhance themselves and make themselves into a productive body and brain in early industrial work the worker was fitted to the job in the sense that it was recognized that different workers had different levels of skills and abilities techniques were devised to measure these and thereby sort workers into their appropriate places within the labour market however in the contemporary world for many there has been a shift of responsibility towards the individual to make themselves employable to take responsibility for their own wellbeing such that they are fit for work effectively to make of themselves a marketable asset that can be sold to the highest bidder in the employment market this elision between productivity as being something that we do at work and productivity being a characteristic that we have or are can be discerned in entries in blog discussions amongst those who take modafinilprovigil modafinil we can link these commentaries on the benefits of the drug in terms of productivity back to the earlier discussion on the need for the flexibility of workers bodies the imaginary of the plasticity of the brain harnessed through the use of cognitive enhancers becomes yoked to this impetus to continually provide potential for evergreater performance and productivity thus the speculative nature of contemporary capitalism is worked out through the possibilities of enhancement the reallife limitless pill drug helps adults learn as fast as children by making the brain more elastic here the plasticity of the brain has its counterpart in the idea of human resourcefulness the idea that human qualities can be extended and enhanced that they are not finite or fixed as are other assets the working subject is always capable of more of becoming better of learning creativity knowledge and talent beyond that which is currently performed thus the sorts of traits that are explicitly valued here in the employee are also those that are targeted through pharmaceutical enhancement enhancement drugs therefore do not solely increase the productivity of an individual in quantitative terms but also enable employees to demonstrate that they are constantly switched on present alert creative and enthused in other words employees have to not only be productive but look productive enhancement drugs aid in this because of their potential to increase focus and attention even where an employee would otherwise be demotivated or uninterested for example in one online article we are informed that lucas baker a switzerlandbased software engineer with a large tech company takes nootropics every day he says it helps him maintain focus especially on projects he might otherwise put off when i find an unpleasant task i can just power through it he says in analysing the connections between imaginaries of cognitive enhancement and the valuation of production and performance we can discern the interplay between the enhancement of the workers body and the wider political economy furthermore following foucault we can suggest that these imaginaries denote an extension of the economy to the entire social field in the next section we move from considering the individual social relations of enhancement to a broader reflection on what this means for a political economy of enhanced brains enhancing the economy as we have seen above imaginaries of cognitive enhancement are closely entwined with the cultural norms and values of productivity and performance and at the individual level there is an expectation that in order to legitimately participate within society one has to be a productive person in this section we move from considering the individual brain to look at wider aspects of enhancement in relation to hogles point about the circuit of enterprise biology medicine and culture at a collective level this means that bodiesbrains are themselves seen as the source of productivity and performance for society for example a policy discussion paper on cognitive enhancement produced by the british medical association asserts the connection between the economy and cognition an overall increase in cognitive ability in society could also lead to competitive advantages in the cut and thrust world of international trade and commerce fukuyama who vehemently opposes the use of enhancements nevertheless acknowledges that a society with higher average intelligence may be wealthier insofar as productivity correlates with intelligence this fits with a commonly reiterated view that socalled advanced or postindustrial capitalist economies are more dependent on knowledge and its associated qualities of creativity and innovation sometimes described as the knowledge economy or labelled cognitive capitalism this impetus can also be seen in the film limitless where cognitive enhancement is presented as enabling and extending a number of intellectual capacities from playing music to writing books but its particular emphasis is on becoming so smartcognitively enhanced as to be able to work in and command the world of corporate takeovers and financial markets moreover in limitless cognitive enhancement enables the mind to read everything that is going on around it making the world legible to the human brain as eddie the central character in limitless explains everything i had ever read heard seen was now organized and available to be able to read the world is to be able to understand it and thereby have control over it to predict and change it ultimately this is a form of cognitive knowledge and control that is to be put to work in relation to the economy turning from the hollywood fantasy of enhancement to its more mundane applications in everyday life a commonality can be discerned in terms of the orientation towards the economy especially in enabling the organization and management of employment although sleep may be regarded as a precondition for health and hence the ability to work it can also be seen as the absence of productive effort a lack on the part of the body accordingly scientific efforts to understand sleepwakefulness are not just aimed at offering treatments for individuals whose lives are plagued by an inability to regulate their patterns of waking sleeping but are also of increasing relevance to organizations and the demands of an economic system that is geared towards 247 operation it is in this context that williams coveney and gabe discuss the desire for the customization of sleep with the potential ultimately to make it optional as mentioned earlier the drug modafinil has become most touted as a cognitive enhancer especially since a metaanalysis of it led to its being headlined as the worlds first safe smart drug 12 however between its strictly medical use and the accounts of its enhancement properties its prevalent use is as an everyday regulator of wakefulness for example under the headline sleepless in the city the times of india carried the subtitle modafinil the latest lifestyle drug in delhi makes owls out of human nightbirdsthe flip side of working delhis graveyard shift it is developments such as this accounts of how modafinil is used to enhance the lives of those who take it enabling them to cope with the demands of work that best illustrate the political economy of pharmaceutical enhancement in 2004 the pharmaceutical company cephalon received official clearance from the us food and drug administration to promote provigil as a means of alleviating excessive sleepiness and promoting wakefulness in connection with shift work disorder a condition associated with a significant section of the workforce engaged in long working hours or nightshift work 13 in 2011 cephalon ran a new promotional campaign for nuvigil targeting prescribing clinicians as well as potential consumers suffering from excessive sleepiness associated with shift work deploying the caption supporting those of you who stay awake for the rest of us one image on its website presented a picture of four individuals a firefighter two paramedics clinicians and an emergency services worker these familiar respected and important figures in the community were presented as professionals who make sacrifices on our behalf forfeiting what the rest of us enjoy that is a normal nights sleep they stay awake responding to whatever emergency situation arises the narrative here is that the drug enables these sorts of professionals to attain a better state of alertness or wakefulness whilst on duty remaining vigilant attentive and thereby effective despite working at night or for long hours importantly then these individuals embody significant social values such as possessing authority to deal with emergency situations expertise courage duty to others and caregiving by supporting them in their nightshift work the drug is also portrayed as upholding those values moreover to the extent that drugs such as modafinil are portrayed as supporting key social values in the context of work such social values are conversely borrowed by the adverts to legitimate their usage the official nuvigil webpages and related adverts in professional journals offer a series of user narratives including that of jenn a 32yearold emergency room nurse dealing with both shift work and the need to take responsibility for her family im so tired on my shift that its hard to do my job moreover as well as the general occupational information that her presence on the page presents we are provided with some further individual background information jenn we are told sleeps approximately 65 hours during the day waking to run errands and make dinner for the family so in addition to the social values one might typically associate with an er nurse jenn not only makes a sacrifice by working at night but she also has responsibilities for others foreshortening her daytime rest to perform domestic duties the account suggests that to achieve this she needs to manage the limitations of her own body and appeals to modafinil as a solution to her problems the drug offers a means of controlling her alertnesswakefulness which in turn would allow her to do her job and manage the rest of her life and responsibilities once again we can see an emphasis on the need for individual autonomy and responsibility in this case over her performance in work and at home coupled with a contribution to the collective good 14 of course we all expect roundtheclock availability when it comes to the emergency services however notably the nuvigil advertising campaign was later to include other rather different categories of workers bartenders waitresses djs and warehouse staff indicating a much broader scope of occupations deemed appropriate for the management of wakefulness thus far from being reserved for people working in the essential or emergency services the drug was available to support people working within all the services that modern consumer society takes for granted on the one hand then the campaign reinforced the meaning and value of work in contemporary society as we explored earlier but on the other it also indicated a managerial effort to realize a world in which employees wakesleep cycles are organized according to the demands of production and the provision of services the desire to create an alwayson body in terms of imaginaries what is notable about the official promotional material for modafinil discussed here is how it contrasts with the commonplace media imagery of an enhanced brain as noted earlier instead of a brain or head in effect abstracted from the rest of the body we have depictions of reallife embodied subjects who have recourse to the drug in order to stay alert and focused on their work the material does not promise to boost intelligence but it does offer the prospect of enhancing the brains ability to cope with working extended hours or at night this is not therefore an imaginary about becoming mentally exceptional through pharmaceuticals but rather one that envisages normal working under conditions that would otherwise lead to a deterioration of cognitive abilities 15 finally another example of the negative impact on work due to the limitations of the body occurs when individuals cross different time zones namely the problems of jet lag a number of remedies have been proposed to deal with jet lag including the prescription and marketing of melatonin 16 in 2010 cephalon applied to the fda for the approval of nuvigil as a possible treatment for jet lag with business travellers being a particular target of interest from the perspective of the individual business person the drug might seem attractive if it allowed them to stay alert and thus work effectively whilst crossing time zones but from a managerialorganizational perspective this application would help maximize use of human resources in the event the approval of the fda was not forthcoming but the fact of the application remains significant when considered in terms of the broader political economy of cognitive enhancement examined here 17 in summary whether it is a matter of enhancing the potential to cope with extended working hours shift work or business travel across different time zones modafinil can be viewed as a putative contribution to the flexibility of labour offering the prospect of suppressing the disorder to the system that the limited bodybrain might otherwise precipitate and thereby supporting the sort of 247 temporalities that are scrutinized by scholars such as crary fleming williams coveney andgabe andwolfmeyer conclusion addressing the confluence of scientific ideas about the brain pharmacological interventions in cognition popular culture and everyday life we have considered imaginaries of cognitive enhancement in relation to three analytical themes first we considered the cultural representations of the brain in connection with the idea of plasticity captured most graphically in images of morphing and the representation of enhancement as a desirable inevitable and almost painless process in which the mindbrain realizes its full potential and asserts its will over matter following this we explored the social value accorded to productive employment and the contemporary ethos of working on or managing oneself particularly in respect of improving ones productive performance through cognitive enhancement in developing this we looked at the moulding of the workers productive bodybrain in relation to the demands of the economic system aiming to build upon previous sociological studies that have researched individuals motivations for and views about the decision to take cognitive enhancing drugs we have sought to connect the individual worker and their labouring bodybrain with the contemporary neoliberal biopolitical context here we briefly consider the consequences of these arguments first in relation to studies in the history of the human sciences then in relation to the use of the concept of imaginaries and especially how this relates to the remnants of cartesianism which we have analysed in imaginaries of cognitive enhancement and finally we reflect on some of the implications in relation to the neoliberal working subject the sociological approach adopted here has wider implications in terms of the history of the human sciences viewing the shaping of the human body in the context of work as an accumulation strategy calls for an examination of the configuration or problematic that interlinks research into the body and associated developments in pharmacology the pharmaceutical industry seeking to develop markets for its products and the nexus of social political and economic factors that play a role in the constitution of problems or goals for which pharmacological or other technological solutions are sought seen in broader historical terms there has of course been a long line of research endeavouring to understand the human body in order to better harness it to productive effort examples such as the 19thcentury studies of fatigue scientific management and the emergence of the field of work psychology help set current discussions of work and human enhancement in a broader perspective in this article we concentrate on the relations between the notions of brain plasticity incorporated in cognitive enhancement and how this relates to the specific conditions of contemporary employment to this end we contend that imaginaries are of key importance in terms of the imagined goals of scientific research the ways in which these ideas are represented and interpreted more broadly in society promoted and marketed and the part they play in the deliberations sensemaking and justifications whereby individuals orientate themselves in terms of their future possibilities for action accordingly in this article we have considered how the imaginaries of pharmacological cognitive enhancement reflect and reproduce a number of key aspects of the contemporary cultural socioeconomic and biopolitical landscape prevalent in a diverse array of sources imaginaries are not mere abstract fantasies but rather a key part of how individuals orientate themselves to their future possibilities in order to act upon the world individuals need to be able to imagine this action and its outcomes imaginaries are therefore performative there is thus an anticipatory and promissory aspect to contemporary imaginaries about the brain that seems to suggest that not only will we be able to better understand ourselves as humans by understanding the brain but also this knowledge and its associated techniques will enable us to govern ourselves and human affairs in general in a better way we would argue that through the use of the concept of imaginaries there is a possibility to move away from dualistic conceptions such as mindbody as well as to better understand the implications of such conceptualizations we have analysed the cartesian strand that runs through the imaginary of cognitive enhancement and splits cognition or intellect from the body one consequence is that the focus on the enhanced brain serves to distance not only the individuals body but also the collective the social body erasing the social in this way not only reinforces the individualist subject position of neoliberalism but also diverts attention away from substantive consideration of the coercive pressures stemming from the policies and conditions of employment that might drive individuals towards cognitive enhancement the cartesian strand that we perceive in imaginaries of cognitive enhancement sees technology as a means of surpassing the biological limitations of the body in order to achieve control through the exercise of the mind along with its associated knowledge and rationality both limitless and lucy trade on the idea of unlocking the brains potential through technology in the shape of a pharmacological substance in the process acquiring power to act upon and hence manage the world rendering it subject to organization and thereby control thus we might argue that the other side of the plasticity of the brain is the increased malleability of the world in this connection it is useful to note the emphasis on progress through technology that is a key trope of modern culture underlying this is a predominantly humanistic approach to technology as the product of human knowledge to harness the resources of the earth to human desires and designs moreover the liberal view of enhancing the brain as individual free choice is allied to the longstanding north atlanticoccidental notion that the human species inevitably seeks to better itself to improve on the present by embracing the future what might be seen as the ascent of man sic as depicted in limitless or even a move to a posthuman or transhuman future as represented by lucy this suggests that it is somehow natural for individuals to better themselves to realize their potential and thereby draws upon and reproduces the neoliberal view of the autonomous subject who possesses free will and in taking responsibility for their own fate acts as their own unit of enterprise however complementing this focus on the neoliberal subject we have also considered enhancement from the perspective of the broader economic system and the accumulation of human capital to argue that the productive body is an economic entity shaped in relation to other bodies and technologies and the demands that the system generates indeed organizations have long demanded flexibility on the part of the workforce to adopt patterns of working according to the demands of the systems of production in this light cognitive enhancement might appear as yet another means of proving or realizing ones flexibility to fit with the system as a way to create the alwayson body 18 it is no mere accident or contingent matter of biochemistry that the drug modafinil which is officially prescribed to keep people awake when they are meant to be focused and alert also appears attractive to those seeking or promoting cognitive enhancement preventing inadvertent sleep during the day avoiding sleepiness whilst working at night avoiding or controlling excessive daytime sleepiness or seeking to increase focus and alertness on demand all represent efforts to manage the functioning of the brain towards productive or performative ends biochemistry may be part of the equation but so too is the contemporary biopolitical ethos in which the accumulation of capital is increasingly dependent on the accumulation of flexible brains funding the authors received no financial support for the research authorship andor publication of this article orcid id karen dale notes we would like to thank the participants at the symposium on minds and brains in everyday life in edinburgh for helpful discussions tineke and susanne for their support and detailed comments on the article and the anonymous reviewers for their insightful points 1 this view of plasticity goes well beyond recognizing that the juvenile human brain goesthrough a significant process of development to emphasize the changes that take place in the brain throughout an individuals whole life course the concept encompasses the idea of an openness to influences from both within and outside the body both environmental and importantly selfdetermined including the effects of brain training various therapies harnessing neurofeedback loops and so on and includes in its effects both individual and potential epigenetic changes this then provides a view of opportunities and threats for the future that focus on the brain 2 the term smart drugs is a potentially misleading phrase for a number of reasons first in thisuse smart refers to the assumed increase in cognitive capability but promoting wakefulness or alertness is not the same as the increase of intellect second smart drugs has also been used to describe the search to develop drugs that target and treat only certain symptoms in other words the drugs themselves rather than the outcomes are smart third there are no drugs licensed to be prescribed or marketed as smart drugs where drugs are taken for their assumed cognitive effects these are drugs that are prescribed for other conditions and taken offprescription 3 and indeed an ill for every pill with the argument that illness and diseases come to beshaped such that they fit pharmacological substances that have been developed 4 the articles were identified by utilizing the nexis database of news publications our searchterms included modafinil or smart drugs coupled with brain the sample included the following uk national publications the guardian and the observer the times and the sunday times the independent the daily telegraph and the sunday telegraph the daily mail and mail on sunday the sun the mirror and the sunday mirror the daily express and sunday express the i and the daily star 5 it is a matter of public record that cephalon was reprimanded by the fda for providingproduct information reinforced by the behaviour of sales staff that promoted the drug for general symptoms of sleepiness and fatigue well beyond its official authorization in other words the pharmacological manipulation of the brain by individuals who felt tired or insufficiently alert when they wished to be alert and attentive was becoming endorsed as a matter of individual choice 6 although alan glynn the author of the original book that inspired the film is clear that it was an entirely fictional drug similarly the drug from lucy cph4 whilst itself a fictional drug is claimed by the films director luc besson to be based upon a real chemical that is produced in pregnancy to promote the growth and development of the foetus web discussions show that individuals have sought for this substance online and sometimes unscrupulous retailers will claim to sell it whilst others claim that it is modafinil that is the real source of the fictional drug 7 psychiatric news 42 15 available at pdf101176pn200742issue7 8 adderall is a mixture of amphetamine salts primarily used to treat adhd 9 nootropics are drugs supplements and nutritional products that are claimed to improveaspects of mental function the term was coined by corneliu giurgea from greek words meaning mind and to bend or turn 10 11 12 for a critical response to this study see repantis maier and heuser 13 cephalon was acquired by teva in 2011 shift work disorder is a medicalization of thedisruptions to their sleep and wake cycles that shift workers commonly experience including the inability to sleep during the day or excessive sleepiness whilst on night shift this has not been a prescribed use of the drug in europe since 2011 when the european medicines agency decided that the potential side effects of modafinil were such that shift work disorder should not be included direct marketing of pharmaceuticals to consumers is only legally permitted in the usa and new zealand the official website for nuvigil the branded version of modafinil that superseded its forerunner provigil offered information concerning a variety of conditions associated with excessive sleepiness and for which the drug might be prescribed it suggested that some 15 million americans work outside the 9 to 5 regimen of other employees and that up to 25 of them might have swd 14 checking beds ready for her own medical marketing media available at see also pharmacy today 15 of course in accordance with our earlier discussion of morphing and representations ofenhancement this is not to suggest that modafinil might counter the other deleterious impacts that shift work has on the body for which there is a growing amount of evidence rather in a sense the imaginary on offer presents the bodily consequences of shift work as merely one of excessive sleepiness thereby potentially diverting attention away from its more serious health effects 16 an example of the discussion of this can be seen in fleming 17 that said there is continued online discussion of the merits of the drug for this purpose 18 one possible further socioeconomic factor in the future potential demand and takeup ofcognitive enhancers stems from the increasing automation of work and the substitution of human jobs by technology declaration of conflicting interests the authors declared no potential conflicts of interest with respect to the research authorship and or publication of this article author biographies brian p bloomfield

this article seeks to situate pharmacological cognitive enhancement as part of a broader relationship between cultural understandings of the bodybrain and the political economy it is the body of the worker that forms the intersection of this relationship and through which it comes to be enacted and experienced in this article we investigate the imaginaries that both inform and are reproduced by representations of pharmacological cognitive enhancement drawing on cultural sources such as newspaper articles and films policy documents and pharmaceutical marketing material to illustrate our argument through analysis of these diverse cultural sources we argue that the use of pharmaceuticals has come to be seen not only as a way to manage our brains but through this as a means to manage our productive selves and thereby to better manage the economy we develop three analytical themes first we consider the cultural representations of the brain in connection with the idea of plasticity captured most graphically in images of morphing and the representation of enhancement as a desirable inevitable and almost painless process in which the mindbrain realizes its full potential and asserts its will over matter following this we explore the social value accorded to productive employment and the contemporary biopolitical ethos of working on or managing oneself particularly in respect of improving ones productive performance through cognitive enhancement developing this we elaborate a third theme by looking at the moulding of the workers productive bodybrain in relation to the demands of the economic system

introduction there was an interesting statement by kuntowijoyo about madura when he researched the northern island of java madura is unique the word unique shows a separate meaning form and type the uniqueness lies in the values culture beliefs and social structures essential in how the madurese sees the world one of the uniqueness of madura is the practice of inheriting roma toah which is the culture of the people this inheritance reflects the family system which is the philosophy of the madurese people the life philosophy of the madurese rampak naong banyan korong means shady and shady becomes the basis of behavior and attitudes in deciding the actions of the madurese people that is the attitude of nurturing and caring for each other towards family ties is the main thingpredominantly female family members the existence of disturbing behavior from outsiders toward family members is considered a disturbance to the whole family this perspective reflects in various aspects of madurese community life for example the transfer of wealth between generations in the madurese community is more like rampak naong than referring to their religion islam if in surah annisas verse 11 boys get two shares of girls while in madura a woman gets more shares than boys even in the roma toah inheritance madurese women are privileged to occupy the roma toah building the madurese seen from the shape of the tanean lanjheng house is described as a religious society the musalla in every house is not only used as a center for religious rituals but also as a place to solve various problems of daily life led by a kyai or cleric the spirit of religion is the basis of the solution to every problem in the madurese community however the madurese prefers the traditional model of transferring wealth between generations which takes precedence the form of inheritance of roma toah is the result of a combination of culture and islamic law this combination produces a collective inheritance model that is not based on individual principles as in islamic inheritance the combination between should and the practice of islamic law in society is a neverending study it is because lifes problems are constantly developing while the source of islamic law has finished its descent process ngatawi alzastrouw sees this combination as a natural model for developing indonesian islamic law even muhammad mutawalli the combination of adat and islamic law has been practiced in the legal life of indonesian society moreover studying the relationship between islamic law and human rights has a broader scope this research is interesting because it seeks to reveal the legal facts behind the romanticism of islamic law and living law by understanding the legal facts behind the phenomenon of the roma toah inheritance practice the ratio legis or model of law formation by madurese people can understand therefore in this study we focus on two main issues first how is the division of inheritance of roma toah in the traditions of the madurese people second how is the social construction of the values contained therein methods this type of research is qualitative research with a sociolegal approach the sociolegal research approach departs from the awareness that law resides in an everevolving world culture so studying social sciences becomes necessary in this research the sociolegal model is a multidisciplinary research model it means that legal research does not look at the law from its normative perspective but what is behind it that has never been shown in legal formulations this study uses social construction analysis to understand the parts that build the reality of roma toah inheritance in the dialect of the social life of the madurese people social construction theory is the development of phenomenological theory which was born as a countertheory to theories in a social paradigm especially the theory initiated by emile durkheim this phenomenological theory was originally developed by max weber although initially it was a philosophical theory that became the leading theory of philosophical thought by hegel and husserl and was continued later by schulz which was perfect by weber weber made phenomenological philosophical theory reliable in analyzing social phenomena in society social construction theory includes the functional structural social theory where this theory sees social reality more as the function of structure in each action the structuralfunctional theory assumes that individual actions result from the formation of the structure that surrounds them in their social life individual action is like a product that follows the rhythm of the structure the roma toah heritage building social construction theory is an analytical tool because it includes social facts this method determines the cultural and social elements that shape the inheritance of roma toah in the people of bangkalan regency this method generally has three processes before a social reality becomes real externalization objectification and internalization these three phases experience a positive dialectic that runs simultaneously in forming the legacy of roma toah meanwhile data related to the practice of inheriting roma toah and its actual meaning which the madurese people uphold is the primary data in this study meanwhile this studys information on islamic inheritance from books and other sources is secondary data 123 results and discussion madura culture the culture of the madurese people is inseparable from religion as the value that underlies their outlook on life according to the madurese religion is a fundamental way of life and an identity obedience to religion has become the identity of the madurese people the traditional madurese reflects clothing models such as samper kebaya burqo for women sarong and songko for men men have become a symbol of islam in the countryside even in every madurese house building there is a prayer room that not only functions as a place of worship but also as a place to solve various life problems in addition to religion as the life identity of the madurese people malo is a situation that the madurese highly avoids in simple terms malo is similar to the meaning of shame in indonesianhowever the word shame is interpreted in madurese with the word todus the difference between malo and shame todus lies in the cause of the shame feelings of fear of being reproached or afraid of being found out to have disgrace caused by other people who deny or do not recognize their capacity so that the selfesteem in question feels humiliated and feels tada ajhina causing a feeling of malo to a madurese can lead to counteractions demanding the return of the madureses ajhina the madurese people very much avoid the feeling of malo concerning the individual and the family feelings of malo in the madurese community usually involve violations against the honor of wives children especially daughters and inheritance issues violations of these three things have resulted in very harsh prosecutions from the madurese the madurese consider it a despicable act losing face dignity honor rights and selfesteem violations of fell malo is considered otang rassah repaid in full with nyerra rassa efforts to demand repayment of debts incurred to individuals and madurese families become a duty with all family members the strong kinship ties of the madurese community generate this sense of togetherness one family member gets malo so all other family members also feel the same malo the strength of family ties in the madurese community observes from the tanean lanjheng settlement model in the madurese community the housing order in the tanean lanjheng concept describes a strong and harmonious family the strong ties of the madurese community allow for mutual love and care between family members every behavior of family members directs to maintain adherence and respect for individuals who must be respected those held in high esteem by the madurese are reflected in the adegium bu pa guru rato madurese must respect their mothers fathers teachers and rulers actions that do not respect their faults are considered disrespectful of adhet manners or manners however of the three individuals the teacher is ranked first as someone madura must respect the teacher or kyai is a person who is highly obeyed and respected by the community because he is a symbol of religious authority in madura following and obeying the kyai is considered obedient to religion the position of the kyai is that the madurese family always maintains good relations with the kyai the madurese people always preserve this message to their children and grandchildren a kyaisantri bond relationship further strengthens the obedience of the madurese community to kyai ulama or kyai in madurese society are religious authorities and various problems of madurese people complain to kyai regarding religious social cultural and political issues and even naming a baby madurese often asks a kyai for blessings that is the clergy have a vital position in the life of the madurese people distribution of inheritance roma toah such sociocultural conditions of the madurese people influence their inheritance distribution model the transfer of wealth between generations in madura reflects the patterns and views of the madurese peoples lives that is a lifestyle that upholds a strong family life adegium rampak naong bringin korong became the underlying part of the property transfer in the tradition of the madurese people there are three forms of distribution of assets the first is the distribution of sangkolan inheritance second the division of inheritance of roma toah and thirdly the distribution of inheritance which refers to islamic law the distribution of inheritance in islamic law is carried out if the two divisions of sangkolan inheritance and roma toah inheritance are not carrying first when the parents are still alive the division of inheritance of roma toah which is the focus of this research is the transfer of wealth from the previous generation to the next generation the roma toah heir does not position one of the heirs as the inherited house and land owner allotments of houses and land are allocated to all heirs it means that all descendants of the inheritor have the right to use the inherited house mukminah expressed this kind of model olle ngennengin ben mabeccek keng lok olle ajuel to other people who are not heirs even though the roma toah does not assign to one of the heirs the parents appoint one of the heirs as pamolean or who occupies the roma toah the heirs who occupy the roma toah are usually daughters there are two reasons for girls to become pamoleans first girls are considered more capable of bidding on their parents second the culture of the madurese community is women who take care of household life by appointing a daughter as a pamolean other family members do not feel ashamed to be a mole visiting the pamoleans house it is as expressed by ansori sopajeh lok todus mon taretan lekek mole jalanh ngakan ka depor it is different when boys become pamolean if a son becomes an automatic polisher his wife or inlaws inherits the household this condition makes us feel embarrassed to go home often in this case women have a unique position as respect for the people of madura womenfolk in their social life the social construction of the legacy of roma toah the madurese in general have strong religious ties the practice of inheriting roma toah which some people see as contrary to islam needs to be seen by looking at their understanding of the practice of inheriting roma toah that they do because the attitude of not understanding something can lead to fatal mistakes in responding to a fact in this case a comprehensive understanding of the bangkalan peoples perspective on the practice of roma toah is required as a unique entity the madurese is a dynamic community in all its social actions sociologicalanthropological reading to analyze some of the elements that build the formation of the roma toah inheritance model is necessary to pay attention epistemological analysis of the roma toah inheritance model needs as a basis or foothold to capture meaning it can then analyze it from the point of view of islamic law thus the istimbat process is expected to produce the right legal product efforts to analyze the construction of roma toah in the realm of social action require the concept of social science to understand it the sociologicalanthropological analysis of roma toahs used to parse and understand social action to produce a causal explanation of social action in society and its consequences waris roma toah as a social action is a legal phenomenon that lives in the life of the madurese people for the public to get meaning the writer must keep his distance to not fall into individual tendencies and produce less meaningful results in order to understand how the social construction of roma toah inheritance in madurese society it is necessary to analyze the elements of this ancestral inheritance by using three processes of the formation of social reality in the concept of social construction there is a process of forming social reality externalization objectification and internalization these three phases experience a positive dialectic that runs simultaneously in shaping the inheritance of roma toah in the people of bangkalan madura externalization is the initial process of the social construction phase of social reality in certain community entities in this phase individuals adapt to their sociocultural aspects in this adaptation moment humans use language and action as a medium to adapt to socio cultural and socially adapted at this moment people sometimes do not adapt to their sociocultural situation individual acceptance and acceptance of roma toah depend on whether or not he can adapt to his sociocultural environment jurnal ilmiah the use of language in everyday life in madurese society is essential as a symbol of ones attitude towards the other person the complex character of the madurese people makes them very sensitive to the choice of words used in communication errors in word diction can cause disputes between them in this extermination moment a pamolean roma toah is required to use excellent and acceptable language to other family members the ability to communicate well and follow the context of politeness can influence the language used so that extended family members can accept it and prevent roma toah from becoming mateh obhur it means that the roma toah are no longer friendly and the other family members do not want mo to occupy the roma toah it can even lead to disputes between heirs demanding ownership rights to roma toah such conditions can cause the existence of roma toah as a mandate from parents to be threatened with disappearance it is the cause of breaking the silaturrahim rope between family members on the other hand good verbal language communication is not only imposed on pamolean other members must also use polite language so that pamolean feels comfortable being caretakers and caring often disputes are caused by one of the families not maintaining their communication pattern with the pamolean so other families will defend the pamolean as having a responsibility to look after the roma toah if this condition persists it will become the seed of division in externalizing roma toah so in conclusion at this moment all family members will adjust to the sociocultural inheritance of roma toah as a reality initiated by their ancestors or parents process failure could have occurred carried out by some family members in addition to verbal language which is the key to successful sociocultural adjustment during the externalization of the roma toah inheritance the language of action of each family member becomes something that needs to show all actions and behavior of family members are required to represent and describe an attitude of high appreciation and respect among all heirs in order to maintain such a culture all heirs must maintain communication traffic for the sake of the continuity of the roma toah to remain in harmony according to what hatija said satetanan koduh akor jek atokaran there are no privileges for the male lineage or the eldest child even though the male line still has the privilege of managing in the roma toah culture however they cannot arrange in their actions in the roma toah tradition the male lineage becomes parembugen a place to consult in all matters related to roma toah culture however language and actions must still be equivalent in describing appreciation and respect as a family bond in one descendant when part of the family returns to roma toah the attitude of being an outside family must always be adhered to prioritizing the family who are pamoleans all household matters are rights handed over to pamoleans the outrageous attitude towards siblings appointed as pamolan can cause the adaptation process to be disturbed because the family designated as pamolean must be able to maintain a neutral position and have an open heart in dealing with various characters of other family members who are the attitude of pa mappa wedding is essential for pamoleans to adapt to the socioculture they are facing failure at this moment can cause pamolean to choose to leave the mandate given to maintain and care for the existence of roma toah as a joint family inheritance alternatively conversely outside families do not want to return to roma toah so the existence and spirit of roma toah automatically disappear such conditions may become disputes because each family still has the right to roma toah the explanation above is a tool used in adaptation to the sociocultural by various parties involved in roma toah culture the adaptation moment in this phase includes two essential processes adaptation to the holy scriptures and old values that have become the culture of the bangkalan people as an entity cannot separate from the surrounding culture religion and old cultural values are essential to community life therefore adapting to these two things is critical to understand how roma toah constructed inheritance in bangkalan society first adaptation to the holy book or religious sources of the people of bangkalan community entity known for its vital religion their holy book should have been used as a guide in all actions because the existence of religion measures to what extent an action follows the religious scriptures of a particular community the holy book is a barometer used for the legitimacy of right and wrong for an act of a religious community however at the level of the bangkalan people what is meant by barometer and legitimacy of good and bad deeds does not directly refer to the alquran and hadith as their holy books but refers to the opinion of the kyai who are considered capable of translating the meaning and content of sacred religious texts as guidelines the phrase bupak babu ghuru rato cakna kaeh is a madurese expression a teaching that implies people who respect madurese culture mothers fathers teachers and the government the discussion contains other teachings namely obedience to a kiai the words cakna kaeh represent this moral message even the kyai is considered a reference book in various matters as expressed by sayuti tang ketab jiah keaeh however in madurese society in general they prefer dawuh the opinion of a kyai becomes the basis for the legitimacy of their actions this fact applies to the general public who do not have sufficient religious knowledge to take directly the primary sources of sacred texts those who have the ability sometimes still choose to consult with their teacher or kyai who have a higher level of knowledge jurnal likewise obedience to teachers has a basis for legitimacy that exists in the scientific tradition of religion for example the source of the book which is a reference for interaction procedures between teachers and students which is the curriculum in islamic boarding schools recitation imtihanan routines and madrasas in bangkalan is media socialization of these teachings so that the legitimacy of a kyai as a reference in the field of religion becomes more vital for the people of bangkalan the legitimacy of the bangkalan ulama towards the existence of the roma toah heirs reflects their opinion the opinion of some clerics is not concerned with the existence of roma toah as a transfer of wealth between generations in bangkalan society not contradicting islam as the religion adhered to by the people of bangkalan the opinion of the madurese scholars who do not question the existence of roma toah is a strong legitimacy for the survival of roma toahs inheritance in bangkalan in addition to the opinion of the bangkalan ulama who do not deny the existence of the practice of roma toah in society verbally the reality of the life of the madurese clerics also practices roma toah inheritance by becoming a gegenten a substitute as a successor to roma toah and a place for all heirs and successors of good dawah to returntaking care of pesantren and other religious matters such behavior becomes the legitimacy of the bangkalan people in maintaining the existence of roma toah as a cultural field for their extended family such conditions continue so that the reality of roma toah becomes natural for the community by hearing and witnessing it frequently in various social interactions in their social life when they visit their sons at islamic boarding schools pray to the kyai and read genealogy at haul events madurese people usually touch and hear the reality of the roma toah the saying of the people of bangkalan sapah se deddi gegenten sapa se deddih pamolean is usually asked by the community when they hear of a kyai dying a kyai besides being a reference for the community both in speech and behavior during this externalization phase the legitimacy of the scriptures for the practice of roma toah find in several social values that exist in the inheritance of roma toah that is advice to maintain silaturrahim rope as contained in the letter annisa verse 1 o people fear your lord who created you from one soul allah created his partner from himself and he multiplied men and women from both of them fear allah in whose name we ask one another and family relations verily allah is always guarding and watching over us in the friendship of the same descendants in the roma toah culture there is a process of mutual strengthening of kinship ties with the transfer of cultural values conveyed in verbal communication by the older ones to the younger ones such a process will give birth to a strong family union apart from being a characteristic of the madurese community with strong family ties the sacred texts of islam also strongly advocate for the unity of the muslim ummah and oblige its adherents to protect it so that it does not divide one another that is the behavior of the bangkalan people in the roma toah culture has a legitimacy basis from their religion the externalization phase above is a process of adjustment to the social values contained in the roma toah inheritance in addition to the values described above the determination of roma toah inheritance which carries out since the heir is still alive has a legal ratio in islam contained in the reference books of the madurese clerics in giving fatwas and deciding religious issues of the madurese people it is discussed and described in the next chapter regarding the analysis of the opinions of madurese scholars about roma toah in the realm of madurese culture the distribution of inheritance of roma toah which carry out since the parents or heirs are still alive is considered an economic strategy as well as anticipation if their offspring have a terrible life for example there is a divorce for the male heir who in the madurese tradition follows and lives at the wifes house so roma toah is the destination for settling down alternatively for example some descendants have no luck in the economic field so they do not have a place to live maka roma toah is a shelter for those who cannot be economically independent in the context of externalization parents attention to the economy of their heirs by making their house a joint inheritance gets a strong basis in islamic religious teachings because islam is very concerned about its adherents leaving their offspring in a state that is capable in all areas of life and does not become a burden for other people thus the legitimacy of the holy book the process of adjusting the individual to sociocultural through the legitimacy of the religious scriptures adopted by the people of bangkalan namely islam has a strong relevance thus the practice of inheriting roma toah is a cultural process of the bangkalan people carried out consciously and there is no compulsion to do so second adjustment to old traditional values adjustment to this old tradition has two forms acceptance and rejection of old living values the form of acceptance can play an active role in the process that applies to the distribution of roma toah the active role of family members who receive can be in the form of participating actively in carrying out and even socializing old traditions that support the existence of roma toah in the culture of the bangkalan people one form of the attitude of accepting heirs towards the existence of roma toah inheritance in the reality of bangkalan madura life is the behavior of individual adjustments to old traditions it is directly considered an effort to preserve the values in the roma toah inheritance one form of behavior is the habit of the mole to roma toah carried out on thursday afternoons or commonly called amalem jumaten this mole habit is a form of looking at parents when the parents are still alive when a parent has died like to tilik mole ka bengkoh toah the tradition of going home on friday night was carried out with families already married by bringing modest gifts the wife walked before her with a ter ater on her head at the same time her husband followed her from behind if the mole habit does not carry out the sibling who becomes pamolean will usually ask about the omission the mole on friday night carried out by people whose homes are close to roma toah however suppose the house is far away for example migrating outside the area in that case the homecoming tradition is a form of their acceptance of roma toah as a symbol of strong family ties according to the bangkalan people roma toah is not only seen as a symbol of family ties but also of deceased parents existence so that the tradition of going home on holidays is a time that migrants from bangkalan highly anticipate because they consider returning home to visit their parents as a form of devotion to their parents with the increase in the number of families already getting more significant mole and homecoming activities are usually filled with activities that illustrate efforts to preserve family ties by carrying out lir bilir ancestry preservation of genealogy is done verbally at the mole or mudik momentum for some families the family tree of the madurese people is written in a book that records the distribution of family members in several areas it is done to preserve the family tree so that it is not forgotten and at the same time to maintain friendly relations between family members in families that have excess economic capacity or families with glorified lineages for example bhuju kyai or people who are prominent figures one of the momentums to unite families in roma toah is the haul event of the parents who form the roma toah for the first time the form of family acceptance of roma toah is their active participation as shahibul hajah at the haul event 131 in addition to accepting the old tradition which is considered good in this phase some family members do not accept the old traditional values that already exist in the roma toah culture the nonacceptance of the roma toah heirs is in the form of actions promoting disharmony in family ties there are different forms of action depending on the level of rejection of the existence of roma toah for example a very extreme refusal to question and suing their rights is in roma toah this action caused the roma toah to no longer be a unifying family in addition to suing and demanding ownership rights in the roma toah the communitys attitude of rejection can be in the form of fear of occupying the roma toah feelings of worry about other family members contesting their rights in the roma toah the roma becomes empty and no one occupies it cases like this usually occur in the inheritance of the roma toah of the ancestors who do not become pamolean or those who care for the roma toah do not have children or move houses for those who refuse he will refuse to be appointed pamolean by the extended family meeting objectification of roma toahs inheritance value objectivation is the second phase in constructing the reality of roma toahs inheritance it is an individuals interaction with the sociocultural world that surrounds him this objectivation presupposes two realities between the individual as a social being with the subjectivity owned and another reality outside the individual this other reality becomes objective for the individuals selfworld and looks different so an intersubjective relationship forms between the two realities subjective and objective the relationship between the two occurs through the process of institutionalization and institutionalization the process of objectivation to the reality of the inheritance of roma toah can explain as follows first roma toah is a building and land as a place to live for people and ancestors considered to have a meaning other than property and place of residence the people of bangkalan see the roma toah as a building with a magical meaning as a legacy from their parents and bhuju because it is a legacy from their parents a particular interaction model is needed not the same as treating a home we bought ourselves treating roma toah well is believed to get sabeb for parents or bhuju who leave the house on the contrary mistreating roma toah causing disputes with other relatives and committing disobedience are believed to result in tola belet belet for a persons life can be a failure in his life for example a low economic level a family that is not harmonious has unsuccessful offspring or even suffering from an incurable disease in short people who get belet will experience a bad life the process of meaning obtains through trust in parents and land parents are considered as prince katon by madurese as explained above obedience to parents in the context of diversity has a strong basis of legitimacy from the two sources of islam the alquran and hadith the intersubjective process in roma toah inheritance has a solid logical basis in the culture of the bangkalan people who are known to be firm in upholding their religious principles when parents decide that their inherited house will be used as a roma toah all family members will hold it firmly and see it as a reality that must be maintained likewise when parents have appointed one of the families as pamolean who takes care of the existence of roma toah they will respect and obey the parents decision as a holy order that follows disobedience to the order is considered a child who is disobedient to parents the same model of interaction is also shown for the legacy of the grandmother bhuju in the form of roma toah even the remains of roma toah left by bhuju receive more sacred treatment than the legacy of their parents this treatment is because there is an assumption that a bhuju is a person who has sacredness and is considered wellih inappropriate treatment of roma toah or bhuju remains considered we bring about sparrows we believe that they come more quickly and sometimes in cash therefore treating the roma toah left by bhuju is more memorable apart from the belief that bhuju is a holy person many family members are already bound by roma toah so that they are treated more specifically for example in procuring haul as the symbol of the mole it is carried out on a larger scale it is inseparable from the number of families whose moles are getting bigger in addition to the meaning of parents and bhuju as an objective reality with a magical religious meaning so that it has a unique position in the subjective world of the bangkalan people land in the culture of the madurese people is considered to have a unique position the land is not only considered as a property that has material and economic properties more than that the land is considered an entity with a magical value so special treatment is needed in socializing in it the belief in prohibiting selling sangkolan land to the people believes that bangkalan will bring difficulties to the economy in the future in addition the bangkalan people believe that land is considered selfidentity in the culture of the bangkalan people concrete evidence of the origin of self can be found and attached to the persons birthplace in this case the roma toah is a symbol that represents this second from all the above descriptions in the context of building a reality this is known as the process of institutionalization this process is a process of building awareness into action in the context of the inheritance of roma toah the process of building awareness into action takes place in interpreting the meaning of the roma toah in the bangkalan community as a legacy from their parents and bhuju as mentioned above meaning enters the consciousness realm then manifests in action the manifestation of the actions of the bangkalan people has a legal basis from their religious source third after awareness of the inheritance of roma toah is embedded in peoples cognition and then becomes active in institutionalization or institutionalization all the values attached to roma toah become their guide in their behavior what they are aware of is what they are doing thus their actions regarding roma toah have a logical basis not a reckless act or just joining in in 133 the context of roma toah ancestral inheritance their acceptance of their parents decision preserving the roma toah inheritance with their family is a logical action and has specific goals for them however the shift in knowledge and contact with the modern world influences the logic of bangkalan society the roma toah tradition is experiencing a shift in urban areas fourth after the reality of roma toah becomes objective and peoples behavior towards roma toah has undergone a logical conceptual process then over time the action is in the form of obedience to the decisions of parents and ancestors ancestors moreover all actions that support the solid existence of roma toah automatically experience institutionalization or the concept of capitalization it means that all these actions have become part of their daily lives and are institutionalized into habits or habits in the people of bangkalan the action has become mechanical and carried out without other conceptual considerations the whole process depends on the agents role in carrying out its function in the awareness development and capitalization of the roma toah inheritance the more often this process is carried out the stronger the existence of roma toah will be it means that the value and spirit of roma toah which is in the form of a symbol of interaction between families will be carried out more frequently so that automatically instilling awareness institutionalization and capitalization will become more robust in the reality of the life of the people of bangkalan madura the agents referred to in this process are religious authority figures in bangkalan in a smaller context the agent is a kyai whose words the family refers to kyai used as a reference for his sayings usually has teacher ties with the large roma toah family moments of general recitation recitation at islamic boarding schools madrasah musalla manaqiban imtihanan yasinan isra mirajan are opportunities that clerics commonly use to discuss friendship obedience to parents respect for parental legacy blessings kualat and so on for him all of which are values contained in the spirit of roma toah in addition to the kyai as an agent in this objectification phase oreng seppo or someone featured in the roma toah environment because all his words are used as a reference for the roma toah family usually the oldest male family member this role own because in the roma toah tradition the man manages the household even though he is outside the roma toah the moment of socialization carried out by this agent is the modic moment on eid alfitr or idhul adha when all family gathers for the homecoming event this agent conveys the importance of silaturrahim abilir katoronan telling stories about their parents lives bhuju life on that occasion this agent usually mole to roma toah if he is not located in roma toah meanwhile if appointed to be pamolean then the role of the agent to preserve roma toah by transforming the cultural values that form the basis for the formation of roma toah is easier to do it means that the objectification process can occur whenever a family returns to rome toah internalization of roma toahs inheritance value after objectifying roma toah becomes an objective reality to give birth to a process of intersubjective interaction the following process is the moment of internalization at the moment the individual carries out the process of selfidentification in his sociocultural world in this phase the individual withdraws social reality which has experienced objectification into the individuals subjective world the objective social reality of roma toah includes the world of subjective reality thus the human self will be identified in the sociocultural world this phase is a moment that occurs the process of selfidentification in the sociocultural world is the withdrawal of the objective meaning of roma toah in the person of the family automatically this creates a demand to position oneself as part of the roma toah family giving rise to a real attitude when together with fellow roma toah families on the other hand when we are with other people who are not part of rome we can show a different attitude such is the tendency of human nature to tend to unite and group with fellow individuals who have something in common in the context of roma toah family ties make them have a special bond in social interaction and all aspects of life referring to the family group in roma toah adegium rampak naong banyan korong describes a strong mutually protective bond between families in one bond different attitudes when interacting with outside families outside families unrelated to a roma toah family bond that is madurese people have standards of behavior in their social interactions with other people the attitude of ajegeh tengka being careful in behavior is always put forward to maintain the good name of the extended family avoiding the family from malo will be put forward in every interaction with the jeu family and outsiders the condition of being hurt physically or to a good name by an outsider leaves a wound in the extended family if the extended family knows it limiting attitudes and being careful with other people who do not belong to the family sphere is necessary to prevent things that damage or harm the person and the family the internalization process also occurs in individuals between family members who are in a roma toah bond selfidentification arises with an attitude that presupposes being a good family it is done to embody their role in their status in roma toah for example a person appointed by parents or extended family such as pamolean will install a behavior mirror to control his interactions with other families a pamolean must be able to embrace all members of the roma toah family because an attitude that does not reflect pamolean can result in its existence as pamolean and roma toah the planning attitude to family lemes beuh andhep asor and having the attitude pa mappa pappanah geddeng it means that a pamolean is forced to have an attitude like a banana leaf he is not limp quickly changes his opinion and stance and is also not rigid in attitude this attitude is then helpful in various matters relating to roma toah for example in dealing with various characters of family members pamolean will not be easily managed by one of the furthermore vice versa a pamolean who does not have an attitude that reflects a pamolean can cause problems later in the continuity of roma toah other family members may feel uncomfortable so the coveted family atmosphere like when both parents were alive cannot be obtained families who return to roma toah feel no different from visiting other peoples homes if this condition continues for a long time it will affect the existence of the roma toah itself roma toah rarely gets visits from family members which can lead to disputes over their rights of roma toah such pamolean is said to be lok kaop dedih pamolean in addition to the process of internalizing pamoleans the roma toah culture also forces other family members to have attitudes that reflect the outside family the attitude of andhep asor taoh ajhinah dhibi and prioritizing politeness prioritize in interactions with fellow families it primarily interacts with the pamoleans the hosts at roma toah discrepancies with the value of decency in the family will receive a direct reprimand from other families especially from the oldest male family with the right to rule in the roma toah family of all the descriptions about the internalization of the reality of roma toah in the life of the bangkalan people the value of family life in one family bond is the starting point for the existence of roma toah in the extended family of the bangkalan people it can see that the harsh reality of madurese life the existence of a tradition of acts of violence among families caused by problems with inheritance makes parents make their place of residence roma toah the purpose of its formation was to protect the extended family from things that made family malos due to the description of the harsh social conditions of the madurese people the results of data mining prove this opinion the first thing madurese parents order for their children is a message about harmony caring and not conflicting with fellow families conclusion from the explanation above it can conclude that the legacy of roma toah survives based on the madurese communitys local wisdom based on two interrelated aspects maintaining family ties and the family economy by using social construction analysis in three phases externalization objectification and internalization the roma toah inheritance is built on a harmonious blend of culture social and religion through the legitimacy of traditionalist madurese ulama so that it is considered a system that does not conflict with islamic values in maintaining family and economic integrity

applying islamic law within the framework of social culture is never complete for research certain social entities understand islamic law originating from revelation to produce unique legal products roma toah inheritance in madurese society is a division of inheritance intended for all heirs without being based on the individual principle as in islamic inheritance law in general this study aims to understand the construction of social cultural and religious inheritance of roma toah in the people of west madura who are known to be firm in upholding their religious teachings this study uses a qualitative method approach using a sociolegal approach this study uses social construction analysis so that the meaning of the inheritance of roma toah can be well understood this research resulted in the following findings first the legacy of roma toah survives based on the local wisdom of the madurese community based on two aspects that align with islamic values maintaining family ties intact and family economic resilience second by using social construction analysis based on three phases externalization objectification and internalization the roma toah inheritance is built on a harmonious blend of culture social and religion through the legitimacy of traditionalist madurese ulama so that it is considered a system that does not conflict with islamic values in maintaining family and economic integrity

introduction according to a view widely held in the media and in public discourse more generally online hating is a social problem on a global scale it has been claimed to be at least partly responsible for the assassination of a wellknown politician paweł adamowicz the mayor of one of polands biggest cities for various professionals having to flee their homes in fear for their safety as well as for suicides among private individuals the negative influence of online hating seems to additionally extend even beyond those who are its direct target available data suggests that it is sufficient to merely witness online hating in order for ones levels of subjective wellbeing to significantly decrease finally online hating seems to be an integral element of the general phenomenon of posttruth and fake news much discussed in both scholarly literature and media outlets consisting in expressing unargued for negative assessments of others online hating thrives in an environment where public opinion is more influenced by fascinating emotions and subjective beliefs than by objective facts however thus far there has been little scientific literature on the subject and to our best knowledge there is even no established scholarly definition of online hating and online haters in the first place the purpose of this manuscript is to address this by proposing an operational definition of both online hating and online haters online hating and related phenomena one reason why there has been so little research dedicated specifically to online hating and online haters seems to be that online hating is often seen in academia as a mere variant of other online phenomena most importantly trolling cyberstalking and online hate speech this would explain the fact that while the public seems to see hating as a problem as serious as those three phenomena the latter have been the subject of scholarly attention far more often than the former in other words to many scholars it is not yet clear that online hating is a separate phenomenon so it is not yet clear whether a distinct definition is needed or even possible however the evidence we have obtained suggests that the terms hating and online hating are often used to denote a phenomenon that is distinct from what is usually called trolling hate speech or cyberstalking and in fact any other online phenomenon identified in scholarly literature and which is at the same time of considerable social significance so this phenomenon is definitely worth scholarly attention on its own our evidence comes from three sources scholarly articles media accounts and ethnographic interviews we conducted systematic searches of both scholarly articles and media reports through the ebsco host database we looked for scholarly articlesmedia reports published within the period of 20052021 that feature terms online haters online hating online hate speech online trolling online trolls cyberstalking and cyberstalker with any duplicates being removed automatically by the system then we conducted a review of this material taking into consideration additional articles and media reports on the above topics that we had known about from our previous work the ethnographic interviews were conducted specifically for the purpose of this study the respondents to these interviews were graduate and undergraduate students at the university of wrocław attending lectures given by one of the authors of the study the interviews were conducted during classes with the participants giving their responses anonymously on unsigned sheets of paper for the sake of both time and anonymity we abstained from asking demographic questions however the pool from which our sample was drawn allows us to estimate that most our participants must have been women and between 19 and 23 years old overall our interviewees clearly recognized hating as a distinct phenomenon were able to give its concrete examples appeared to have witnessed it firsthand and in some cases reported to have been its objects some of our participants admitted to having engaged in online hating in the past expressing various attitudes toward these actions ranging from regret to satisfaction in what follows we will use data from these interviews as well as the data we obtained from surveys of the existing scholarly literature and relevant media accounts to spell out the differences between online hating trolling hate speech and cyberstalking by comparing online hating with each of these three phenomena the purpose of this comparison however is not only to distinguish hating from those other phenomena but also to help reach a definition the comparison will be organized along the following three axes the purpose the means and the attitude for convenience from now on we will use terms online hating hating online hater and hater interchangeably the purpose of online hating first and foremost is to publicly express a negative attitude toward a given person or object as such an act of hating is considered successful even if it provokes no reaction in others whatsoever this clearly distinguishes hating from trolling hate speech and cyberstalking alike all of which do aim at provoking certain reactions in other people the purpose of trolling is to provoke a verbal reaction from the users of a certain platform engaging them in a debate hate speech aims to induce negative attitudes toward a given social group by expressing a disparaging opinion about that group the purpose of cyberstalking is to harass to cause discomfort to and hurt the interests of a given individual community or a legal entity granted hating may result in reactions such as those that hate speech trolling and cyberstalking aim at some haters may even relish those but this does not change the fact that such outcomes are neither the primary intention of haters nor the primary purpose of hating as our respondents put it hating does not require causing any reaction or discussion hating does not aim to initiate an argument it does not require causing any reactions although haters sometime do not shy away from arguments hating is just an intense expression of ones feelings and thoughts the primary purpose of hating is achieved through the means of communicating verbal messages that carry a negative attitude among the characteristic examples of hating our subject gave there are shitty song you should never sing go and kill yourself similar examples were given in an earlier study conducted in the united states this sucks go die most likely it is this feature of hating that lies behind the custom of calling that phenomenon hating in the first place referring to the common understanding of hate as extreme dislike although trolling hate speech and cyberstalking may all involve communicating such messages doing so is not necessary for engaging in these behaviors this is clear from the fact that the goals these behaviors aim at may be and often are achieved by messages that express a positive attitude or do not express any attitude at all these may be for instance statements concerning a given group that are ostensibly positive or neutral but also false in a way that hurts that persons or groups interests or provokes a heated debate or both in addition to that cyberstalking does not need to involve any verbal messages at all and is often achieved through such actions cybervandalism or identity theft finally one feature that distinguishes hating from hate speech specifically is that unlike hate speech hating does not necessarily consists in expressing a disparaging opinion about a social group and neither is it necessarily related to any political ideology it may be disparaging without in any way referring to any ideology or the social identity of a given person or object andor aiming at diminishing the social position of a group as our subjects put it hating may be purely egoistical for instance by embodying an attitude of it is bad because i do not like it defining hating and haters given the above as well as other evidence we obtained through literature surveys and our ethnographic interviews we might define online hating as the activity of posting online an explicitly negative assessment of a person or an object primarily for the purpose of expressing ones negative attitude toward that person or object independently of whether this will cause actual harm to a concrete person provoke others to respond or whether it will diminish the value of a given social group this purpose distinguishes hating not only from hate speech trolling and cyberstalking but also from those forms of expressing negative attitudes such as critical reviews that aim to provide an informed opinion about a given person or object hating does not aim to provide an informed opinion but merely to express a negative attitude this is why a typical manifestation of online hating is an explicitly negative assessment that is not argued for and therefore perceived as unconstructive this defining feature of hating was stressed by participants in an earlier study on youtube hating and by our participants as well a hater is a person who routinely engages in hating behavior and it is reasonable to assume that such persons typically possess a common set of psychological features it is also reasonable to assume that the characteristics of haters would be different than those common for people who engage in the other kinds of online behavior that were described above while haters are likely to share some features with trolls for instance they are unlikely to share all of them for instance as both hating and trolling may result in upsetting people these are unlikely to be engaged in by people with high or typical affective empathy but at the same while a troll will likely score high on cognitive empathy without this he or she will not be able to accurately predict what will provoke people this is not necessary for a hater similarly unnecessary for a hater are machiavellianism ie a tendency to strategically manipulate others and narcissism which are in turn typical for cyberbullies and those engaging in hate speech respectively unfortunately there is almost no research on the psychological features of haters and the existing literature tells us only that haters are characterized by a low sense of selfidentity selfawareness selfcontrol lack of confidence psychopathy high psychoticism mediated by cognitive distortion blaming others the present research on hating may anchor and provoke further studies which could be based on the proposed systematization discussion in this manuscript we have argued that there exists a distinct phenomenon of online hating and online haters that thus far has not been carefully discerned and therefore studied in scholarly literature we would like to add to this now that while studying that phenomenon could yield results of scholarly significance it is also difficult in methodological terms the main difficulty here is related precisely to what according to our interviews and literature review distinguishes hating from the other forms of online harm that scholarly literature focuses on that is its intention this is because that intention may often be difficult or impossible to deduce from a given utterance and the context that is accessible to the researcher some utterances on their surface may equally well qualify as hating trolling hate speech cyberbullying or some other form of discourse but such cases should not discourage one from studying online hating firstly such cases exist for any form of discourse that is defined in terms of intentions including trolling and hate speech yet many such forms including trolling and hate speech are studied despite of that secondly one may give operational criteria that allow for qualifying an utterance as online hating based solely on their content form and the context that is easily available to researchers if an utterance gives a negative assessment of a given person or object that is not backed by any reasons does not appear controversial in a given environment does not have any explicit ideological content then this is most likely an instance of hating in closing we would like to argue that despite all the methodological difficulties online hating definitely deserves to be studied this is not only because of scholarly but also practical reasons after all one might reasonably assume that online hating causes severe social harm and that preventing that harm will not be possible without understanding online hating as such and implementing measures that are designed specifically with that phenomenon in mind 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 research ethics committee at the university of wrocławs institute of psychology the participants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest 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 copyright © 2021 malecki kowal dobrowolska and sorokowski 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

according to a view widely held in the media and in public discourse more generally online hating is a social problem on a global scale however thus far there has been little scientific literature on the subject and to our best knowledge there is even no established scholarly definition of online hating and online haters in the first place the purpose of this manuscript is to provide a new perspective on online hating by first distinguishing online hating from the phenomena it is often confused with such as trolling cyberstalking and online hate speech and second by proposing an operational definition of online hating and online haters based on ethnographic interviews and surveys of the existing scholarly literature

background improving maternal and child health are critical priorities in enhancing the agenda of quality of healthcare to some of the most vulnerable groups 1 2 3 4 despite substantial progress and different strategies that have been implemented by different countries decline in maternal and child mortality remains inadequate 5 6 7 maternal and child mortality is largely preventable with current technology and it is unjustly and inequitably borne by low and middle income countries with poorly resourced health systems 8 findings from the kenya demographic health survey confirm that more effort is still needed towards reducing child mortality and improving maternal health despite the progress that has been made 9 the quality of healthcare services plays an important role in enhancing healthcare service delivery in low income countries 10 poor quality of healthcare may lead to underutilization of services and evidence shows that pregnant women are more likely to deliver in health facilities if they are content with the care that they receive at the service delivery points 1112 a study conducted in rural zimbabwe found that poor quality of services and negative attitudes of health care workers hinder pregnant women from utilizing these services 13 where poor women have access to what they perceive as high quality health care services they increasingly seek reproductive health care services and delivery in health facilities 14 overview of the output based approach reproductive health program evidence from various studies has shown that there are significant direct and indirect cost barriers in seeking reproductive and maternal health services including treatment of complications 8 furthermore high expenditures arising from birth related complications hinder many poor mothers from accessing health care and may push households further into poverty 15 two governments kenya and germany came together in 2005 to jointly support reproductive health through the output based approach program the purpose of the program is to expand utilization of selected reproductive health services among women aged 1549 years the program targets mothers who are economically disadvantaged and living in the counties of kisumu kitui kiambu and kilifi in addition to those who are in korogocho and viwandani which are informal settlements in the county of nairobi the reproductive services offered include safe motherhood which comprise antenatal care attendance caesarian section and vaginal delivery birth related complication and postnatal care upto 6 weeks after delivery additionally the program supports longterm family planning methods such as intrauterine contraceptive device implants and tubal ligation equally the program offers counselling medical examination and treatment to vulnerable mothers who encounter sexual genderbased violence as has been shown by other authors 1617 oba aims to support the impoverished population through subsidized health services 17 the program pays service providers on the basis of agreed outputs with predefined results eg facilitybased deliveries and antenatal care visits attended rather than financing the inputs 15 under the oba model vouchers for safe motherhood and longterm family planning services are sold at highly subsidized prices to prospective women is approximately 100 kenya shillings for each voucher presented to accredited health facilities services are provided and facilities reimbursed at a fixed rate 815161819 facilities are expected to use the reimbursed funds to improve infrastructure purchase some medical and nonmedical supplies and provide incentives to facility staff among other things the program directly finances the beneficiaries with highly subsidized vouchers and funding is reimbursed directly to accredited health facilities donabedian theory evaluates three categories of quality of care structure which include inputs such as equipment and personnel process which focusses on the activities carried out by the personnel and outcomes which focuses on improved patient health such as good recovery survival and client satisfaction 20 21 22 while the program has been in existence since 2005 little research has been done on aspects of patient perception of quality of reproductive healthcare for instance one study on quality of the safe motherhood voucher schemes showed enhanced quality of post birth care and a likelihood of superior quality of care for clients who opted to participate in the voucher scheme for longer 23 the study evaluated only the postnatal aspect of care and did not touch on quality issues in overall totality hence there is a paucity of data on quality of reproductive care satisfaction with oba services and the impact of such programs therefore this study evaluated perceived quality and satisfaction of the services under the oba voucher program in kenya from a womans perspective additionally we evaluated predictors of the factors that are related to perceived quality of reproductive care in oba facilities methods study area the study was conducted in kitui kilifi kiambu and kisumu counties as well as in the korogocho and viwandani slums in nairobi which are the oba program sites the services in oba sites are provided by public ngos fbos and private service providers all participating sites were offering smh services ltfp methods and a small number was providing sgbv services study design and tool this was a crosssectional study conducted in oba sites using a semistructured interview guide administered through facetoface indepth exit interviews participants receiving oba services were asked to describe their perceptions of the quality of services and reasons for satisfaction with the quality of services they had received in their current and previous visits perception was measured using a questionaire that was developed on the basis of literature review and suited for a healthcare setting 1024 the questionaire consisted of a large number of items that were found to be imperative in measuring quality of and satisfaction with care women were specifically asked how they perceived the care they received during smh visits ltfp visits and sgbv visits besides they were also asked about the information they received the conduct of the healthcare professionals and adequacy of resources and services the items were regrouped into 23 items measuring perception there were two additional questions one on whether the women were completely satisfied with the services and two on the reasons for satisfaction or dissatisfaction perceived quality of services was rated on a five point likert scale 1 being completely disagree 2 disagree 3 agree 4 completely agree and 5 do not know sampling design in selecting participants a multistage sampling technique was used to select the facilities offering oba services first all oba facilities were classified according to type of ownershippublic and private and grouped according to county classification has been described elsewhere 16 within each county a representative sample of facilities both public ngos fbos and private facilities was randomly selected in the second stage a conservative sample size was calculated to be 313 respondents in order to determine the sample size the formula developed by cochran 25 for proportion that are larger n z 2 pqd 2 where n was the number of clientsrespondents z is the critical value for standard normal distribution for the 95 confidence interval around the true population p estimated proportion utilising oba services q represented 100p and d was the degree of accuracy the number of clients were equally divided amongst the chosen facilities a simple random technique was used to select the oba clients who sought smh ltfp and sgbv care at the time of the study to randomly select the participants at the facility the researchers used stat trek random numbers generators which have been applied in other cross sectional studies 27 the method uses statistical algorithm to give random numbers and instructions on how to use it the researchers hit a calculate button and the number generator gave a random number table with five numbers between 1 and 20 subsequently the interviewers then interviewed the participants presented by these numbers on a single basis until the sample size was obtained after data collection the questionaires were then retured to the central oba program management offices in nairobi after which they were checked for completeness before inclusion into the database only fully completed questionaires with all essential details were included in the analysis and do not know response in the questionaire was treated as a neutral term for ease of interpretation data analysis the data were analysed using statistical packages for social scientists version 18 descriptive statistical analysis was carried out to describe the respondents social demographic characteristics and the time taken to reach the facility either by bus or by foot additionally descriptive statistical analysis was conducted on the women perceptions of oba services data were then subjected to exploratory factor analysis of the 23 items to break down the items into homogonous subscales coherent with the quality dimentions as proposed by donabedian 20 principal component analysis with orthogonal varimax rotation was conducted in addition the kaisermeyerolkin measure was done to evaluate the suffiency of data for efa and bartletts test of sphericity to evaluate the degree of patterned relationship between the items additionaly reliability analysis was performed to test the reliability of the scale and internal consistencies of extracted factors whereby cronbachs alpha coefficient was calculated the multivariate response model was used to study whether level of education antenatal clinic visit marital status age and county of residence were predictors of the factors related to perceived quality of reproductive care the questions on overal satisfaction and reasons for satisfaction were analysed using microsoft excel 2010 and pareto chart 28 was obtained for the level of satisfaction ethical approval the authorization to carry out the study was obtained from the ministry of healthkenya as part of routine monitoring of the process of the oba services the proposal was approved by the health research unit of the ministry of health kenya additionally permission was obtained from the county headquarters and hospital administrators to proceed with the study verbal informed consent for the study was obtained from every woman who agreed to participate the interviewers explained the purpose of the study to the mothers in their local dialect and asked them whether they were willing to participate for those who agreed the interviewer indicated a unique patient identifier and the date of the interview on the front page of the questionnaire before proceeding with the interview and data were only used for the study results the study was conducted in 65 oba accredited facilities in kiambu nairobi kilifi kisumu and kitui sociodemographic data of the respondents out of a sample of 313 respondents 254 were included for analysis making the response rate 812 fifty nine questionnaires that had no imperative details on the independent variables and where more than two attributes of quality were missing were excluded from the analysis the details were considered important to avoid bias in the multivariate response model and exploratory factor analysis as was shown in other studies 1029 there were 198 women with safe motherhood contacts 55 with long term family planning contacts and one with a sexually gender based violence contact all respondents were female most of them married with primary level of education majority of the respondents were in the age group of 24 and below followed by those in the age group 2534 years old below mean age of the respondents was 2467 years old and mean time taken to get to the facilities by foot and bus was 9395 min and 3683 min respectively additionally majority of the women had attended anc clinics three times or more women perception of services provided the overall mean score for women perception of quality of services was 343 implying that the majority perceived the quality of oba services to be high specifically women were happy with the way healthcare providers were handling birth related complications furthermore women highly rated staff as compassionate respectful able to prescribe drugs that are needed and able to examine postpartum women well however the adequacy of the number of facility staff was rated fairly low implying that some facilities did not have enough staff factor analysis results principal component analysis with orthogonal varimax rotation was conducted where the kaisermeyerolkin measure was 0893 well above 05 suggested by kaiser 1974 30 as shown in table 5 indicating that the data was sufficient for exploratory factor analysis the bartletts test of sphericity x2 2866439 p 0001 showed that there was some degree of patterned relationship between the items items that had measures of variance equal to or greater than 1 with factor loading above 04 and factors that had three or more items were retained and used for efa 29 efa used five factors which accounted for 615 of variance explained by the data after extraction these were used in defining five subscales all five factors were included in the analysis because each had more than three variables as suggested by hair et al 29 the five factors were labeled as follows f1staff conduct and practice which had five variables and explained most of the variance f2healthcare delivery which had seven variables f3physical facilities which had five variables f4adequacy of resources which had three variables and f5accessibility of care which had three variables most of the factor loading were greater than 04 and the communalities ranged from 0815 to 0499 showing that the factor solution had identified the variance associated with each factor reliability analysis results the reliability of the subscales exhibited by cronbachs alpha ranged from 0525 for f5 to 0904 for the total score the slightly lower scores for f4 and f5 can be explained by the small number of items in the group and has been explained by writers such as haddad et al 24 means of all five factors were fairly above three and they were fairly equal to median scores showing that there was no skewed distribution on the perception of the women sociodemographic predictors of quality of reproductive health services regression analyses were performed with the different subscales and the total score for perceived quality of oba services as outcome variables the b values were interpreted directly as shown in additional file 3 table s2 and additional file 4 table s3 the results of the regression analyses indicate that marital status and the number of ante natal clinic visits play insignificant roles in determining the perception of quality of oba services within different factors except for the overall perceived quality of reproductive health care however counties are a significant determinant of the level of perception of quality for instance four factors and the total score are perceived poorly by women in nairobi kitui kilifi and kisumu as compared to kiambu county the results showed that staff conduct and practice is perceived poorly by those aged 1525 years as compared to those aged 2534 and perceived poorly by those with primary education as compared to those with secondary education healthcare delivery is judged poorly by those with tertiary education as compared to women with primary education and poorly by those aged 1524 compared to those aged 2534 years old additionally physical facilities are perceived positively by those without education or with secondary education as compared to primary education those without education perceive adequacy of resources more favorably than those with primary education accessibility of care is judged negatively by individuals aged 1524 and 3444 years as compared to individuals aged 2534 years old overall the quality of oba services was judged higher by both those without education and with secondary education compared to those with primary education and those who have attended two or less anc visits compared to those who attended three times or more the variance explained by various factors is higher than 10 for staff conduct and practice healthcare delivery physical facilities and adequacy of resources in general this shows that only for perceived staff conduct and practice and for perceived adequacy of resources a substantial part of the variance is explained by sociodemographic factors overall level of satisfaction all clients were asked whether they were completely satisfied with the services provided at the oba sites ironically 889 of the clients revealed they were satisfied despite the challenges with the issues that have been addressed above satisfaction was presented using pareto chart shown in additional file 5 figure s1 where reasons cited for satisfaction included courteousness by the staff and little waiting time to be seen by medical staff other reasons included welcoming and friendly staff free service and quality service on the other hand two clients were dissatisfied with the service because of lack of transport to the facility while one client was dissatisfied because of long waiting time before being attended to by the staff discussion our results show that f1staff conduct and practice was judged relatively high this shows that components of staff conduct and practice which are honesty compassion respect openness and devotion to work of healthcare workers provided a significant influence on the perceived quality of reproductive health services our findings are congruent with results from a study in malawi which showed that women were overall satisfied with the level of maternal care at the facilities because they were respected welcomed and listened to 31 our results also support the findings of a cross sectional study in ghana of mothers who delivered vaginally in two public hospitals and revealed that they were treated with respect 32 additionally the study is consistent with a study in nicaragua where user satisfaction with vouchers was highly correlated to satisfaction with clinic reception and clarity of doctors explanations 33 from the findings we elucidate that women tend to associate the attitude of healthcare workers with the quality of care the quality of f2healthcare delivery was rated as relatively good for instance the respondents were happy with the competence of staff in the facilities who were capable of handling complications and giving enough information this is analogous to a study in malawi with respect to handling complications 34 the findings were different from a study in mulago uganda where only 38 of the mothers revealed that they had received adequate information on the symptoms and expected health problems 35 however in serbia mothers were content with the information given regarding their rights during and after delivery by the midwives 000 bold shows items that converge to form a factor which partly support our findings 34 additionally women perceived that staff had adequate knowledge in dealing with smh ltfm sgbv issues these findings suggest that strong focus on the quality of care has contributed to increased service delivery in oba sites women judged f3 physical facilities f4 adequacy of resources and f5 accessibility of care as relatively moderate most women perceived that clean drinking water availability of bathing facilities especially after delivery and privacy when being examined were essential components of a good healthcare facility in essence toilet and hand washing facilities enhanced the level of perceived quality of care moreover within oba sites perceived quality of care was linked to adequate number of staff and the supply of drugs findings were comparable to a study in india which indicated that women were happy with the readiness of primary drugs particularly during complications and availability of health workers 36 drugs are important determinants of quality of care and the absence of drugs could lead to impaired perception of the quality of services 10 our findings also reveal that women are content with majority of quality aspects despite the number of healthcare workers being low this can probably be explained by the few number of health workers going way above their abilities and the workload to ensure that the mothers receive the services they need women seem to be aware of the shortage of workers but appreciate the services they provide an important finding from this study was that the majority of respondents were young people of 24 years and below who made at least three anc visits which is comparable with the kenya demographic health survey 2014 results 9 however women needed relatively long hours to reach oba facilities which was comparable to other studies 151936 and greatly influenced women perception of the quality of care the study has revealed that area of residence played a key role in determining the level of perception of quality of care of oba services as compared to other sociodemographic characteristics however the study identified some impact of anc visit numbers level of education and age on the perception of quality which is in congruent with results from other subsaharan african studies 3237 study limitations in studies involving perception of quality and satisfaction with the level of care there is a propensity to provide favorable answers to the questions 24 thus in as much as the study is relevant it should be used with caution besides generalizing it to other countries is not warranted secondly the sampling design provided enough users of oba services to examine the research question however in some remotely located facilities we did not find the designated number of women because they experienced difficulty in accessing the facilities thirdly women were interviewed within the vicinity of the clinic or hospital and this may have influenced the way they answered the questions recommendations a health care managers can use our findings as a guide to evaluate different areas of healthcare delivery thereby improving resources and physical facilities that are crucial in elevating women level of satisfaction with the quality of care moreover healthcare workers can use the study as a guide to enhance accessibility of care so that improved levels of satisfaction can be obtained b it is imperative for future programs to inculcate transport vouchers to reduce time to get to the facilities as it is a potential determinant of perception of quality c for the program management unit the index for perceived quality and women satisfaction should be incorporated into practice using the results from this study while different facilities reacted differently to reimbursements and incentives some facilities improved their structures and were able to attract more women who are more satisfied therefore it is imperative to introduce mechanisms in the voucher strategies that can capture perceived quality and satisfaction routinely the 23 item questions that have been translated into five factors shows the key areas that the pmu need to improve conclusion conduct and practice of healthcare workers is an important determinant of womens perception of quality women take keen interest in evaluating staff attitudes healthcare workers within different areas of residence need to implement different strategies unique to the area that will pull and improve levels of satisfaction and perception of the quality of healthcare women were overall satisfied with the way they were being handled at the oba facilities a future study could also assess whether healthcare providers perception of care is different from users perception policy makers should respect women quality perceptions within oba services and work towards improving quality of care and enhancing utilization additional files additional file 1 data collection tool for rhoba clients additional file 2 table s1 reliability analysis of factors and total score additional file 3 table s2 factors related to perceived quality multivariate response model for f1 f2 and f3 additional file 4 table s3 authors contributions bo and uk were involved in the conception and design data analysis and interpretation drafted the manuscript and are accountable for all aspects of the work sk co and som were responsible for data curation formal analysis and methodology smk st nm sg bb mr jk and cn participated in the formulation of the methodology investigation and revision of the manuscript all the authors read and approved the final manuscript competing interests the authors declare that they had no competing interests when conducting the research

background this is a facilitybased study designed to assess perceived quality of care and satisfaction of reproductive health services under the outputbased approach oba services in kenya from clients perspective method an exit interview was conducted on 254 clients in public health facilities nongovernmental organizations faithbased organizations and private facilities in kitui kilifi kiambu and kisumu counties as well as in the korogocho and viwandani slums in nairobi kenya using a 23item scale questionnaire on quality of reproductive health services descriptive analysis exploratory factor analysis reliability test and subgroup analysis using linear regression were performed results clients generally had a positive view on staff conduct and healthcare delivery but were neutral on hospital physical facilities resources and access to healthcare services there was a high overall level of satisfaction among the clients with quick service good handling of complications and clean hospital stated as some of the reasons that enhanced satisfaction the county of residence was shown to impact the perception of quality greatly with other social demographic characteristics showing low impact conclusion majority of the women perceived the quality of oba services to be high and were happy with the way healthcare providers were handling birth related complications the conduct and practice of healthcare workers is an important determinant of clients perception of quality of reproductive and maternal health services findings can be used by health care managers as a guide to evaluate different areas of healthcare delivery and to improve resources and physical facilities that are crucial in elevating clients level of satisfaction

introduction healthseeking behavior is one of the major determinants of health outcomes in a community it determines how health services are used which influences population health outcomes 1 health or careseeking behavior is defined as any action undertaken by individuals who perceive themselves to have a health problem or to be ill to find an appropriate remedy 2 individual attributes the essence of the community in which a person resides and the relationship between individual and environmental factors are all linked to the healthseeking behavior of an individual 3 there has been a growing interest in research related to healthseeking behaviors over the years locally and internationally 45 studies conducted locally among the urban population found that 635 of participants used selfmedication for minor ailments 6 85 consumed overthecounter medications 7 while 67 chose to consult the physician when they experienced any health problems 8 a national study in brazil indicated that the prevalence of use of medicine via selfmedication was 183 9 another study among the rural and urban population of karachi pakistan reported that 93 of the respondents had practiced selfmedication 10 several theoretical models explain health behaviors evans and stoddart model 11 health belief model 12 grossman model of health demand 13 and andersens behavioral model 14 andersens behavioral model of health care utilization is one of the most widely used for predicting healthseeking behaviors due to the convenience of application and popularity in modeling studies involving healthcare accessibility and utilization 14 geographic location has a significant influence on the accessibility to healthcare services 1516 and access to healthcare is reported as one of the many pivotal factors contributing to the gap in health equity among the urban and rural populations 17 the malaysian health system is based on a geographically widespread healthcare delivery system designed to provide the entire population with access to public health services both in the rural and urban localities 18 an urban area in malaysia is classified as a gazetted area with a combined population of 10000 or more whereas a rural area is defined as a gazetted area with a combined population of less than 10000 19 the equitable healthcare financing and structured public healthcare system in malaysia 20 does not inherently translate to equitable access because geographical barriers exist 21 among other factors in the health sector access and utilization are interrelated concepts with access playing a critical role in the utilization of healthcare services access to health care was defined as actual use of personal health services and everything that facilitates or impedes their use 22 according to levesques conceptual framework of access to health the five dimensions of accessibility are approachability acceptability availabilityaccommodation affordability and appropriateness 23 internationally research has documented differences in access to and utilization of health care services between urban and rural populations which consequently affected their health outcomes rural patients experienced more barriers to access health care as compared to their urban counterparts 18 24 25 26 27 28 29 which resulted in having to restart the careseeking process inappropriate use of emergency departments unmet need for care or health problem exacerbation 2530 the introduction of the new economic policy in the 1970s has increased the urbanization rate from 268 in 1970 to 710 in 2010 which were expected to rise to 766 in 2020 and 880 in 2050 31 as of 2020 the malaysian public healthcare system has a distribution of 3171 clinics and 154 hospitals throughout the country which also provide mobile clinic services to remote areas there were 7988 registered clinics and a total of 250 licensed hospitals maternity homes nursing homes and hospices in the private healthcare facilities in malaysia which are mostly concentrated in the urban areas 183233 the allocation of healthcare services and resources within the public sector was uneven favoring urban clinics heavily 24 compared to rural areas urban areas have a greater density of primary care clinics and health workers per capita 24 malaysia has a dual healthcare system where the main providers of healthcare are public and private sectors 34 in ensuring efficiency through decentralization the hierarchical organization structure of the ministry of health malaysia is stratified into the federal state and district levels 35 funded through general revenue the public sector aims to provide universal access with a focus on lowcost but highbenefit health care programs to keep up with the population growth especially in urban areas the dual healthcare system has developed with the private sector serving mostly urban regions and betteroff patients with feeforservice primary and secondary care while the public sector maintains its social equity mission including primary care services for poor and rural populations 34 as an expansion of healthcare services in malaysia pharmacy practice has also evolved beyond traditional dispensing from a productoriented to patientoriented service where inhouse pharmacists provided counseling in drug safety poison information and medication understanding some community pharmacies offered other services such as blood pressure monitoring chronic disease screening 36 and weight management 3738 although the expansion of community pharmacies in malaysia means people may have more access to overthecounter medicine the moh has implemented rules about prescriptiononly medicines such as antibiotics other studies found that the causes of misuse and overuse leading to antibiotic resistance are various 39 and largely due to antibiotics dispensed without a prescription 40 national guidelines on antibiotics have also been made accessible to the public and healthcare practitioners 4142 the duality of malaysias healthcare system is further magnified with the practice of both conventional western medicine as well as traditional and complementary medicine as part of its healthcare services 184344 under the enforcement of the t cm act t cm such as herbal therapy acupuncture and traditional massages were also incorporated in some public private hospitals as supplementary treatment modalities 4345 this was in line with the world health organizations efforts to maximize the potentials of safe and quality t cm services as a complement to modern medicine among its member states to achieve holistic healthcare as part of the universal health coverage initiative 434647 understanding healthseeking behavior and its associated factors would enable health systems to review strategies to accommodate healthcare expectations in the community 48 although this knowledge is vital in the proper designing of healthcare policies very few studies have been conducted at the national level to explore the factors which influence healthseeking behavior among the adult population in the urban and rural areas in malaysia in this study we aim to determine the characteristics of respondents based on locality determine the prevalence of sick malaysian adults based on locality and determine the factors associated with the healthseeking behavior of malaysian adults who reported sickness according to locality materials and methods study design and participants the data for this study was obtained from the national health and morbidity survey 2019 a crosssectional household survey with a twostage stratified sampling method to ensure national representativeness it was conducted among the population in malaysia who were noninstitutionalized and residing in the selected households for at least 2 weeks before the data collection states and federal territories constituted the primary stratum and urban and rural areas within the states were considered the secondary stratum the sampling frame for this survey was provided by the department of statistics malaysia using the national population and housing census 2010 all 13 states and 3 federal territories were included in this survey within each state the required number of enumeration blocks from urban and rural areas were randomly chosen first stage sampling involved a random selection of 463 ebs from the total ebs in malaysia via a probability proportional to size sampling technique subsequently in each selected eb 14 living quarters were selected during the secondstage sampling all households within the selected lqs and all members in the households were invited to participate in this survey a total of 5365 lqs were successfully visited giving an lq response rate of 926 and a total of 16688 respondents were successfully interviewed giving an individual response rate of 900 the overall response rate for this communitybased survey was therefore 834 a detailed methodology and sampling design of the survey is described in the nhms 2019 official report 44 a total of 10933 malaysian adults aged 18 years and over participated in the survey only data of respondents with complete responses on potential predictors experienced acute health problems and healthseeking behaviors were included in this study in this study the proportion of missing data was 411 and the missing data proportion of less than 5 was acceptable for complete case analysis 49 when a preliminary analysis of all respondents was conducted including those with missing data no differences in results were observed data collection in nhms 2019 data were collected from july to october 2019 by trained research assistants via facetoface interviews using a validated questionnaire 5051 the questionnaire was programmed into an application and uploaded onto digital tablets as mobile data collection tools the tablets were used to collect data store and back up data in the sd cards and upload data to the central system to ensure the minimum sample size required is achieved vacant or closed houses during the first visit were revisited up to at least three times the tenets of the declaration of helsinki were followed during the study written informed consent was obtained from all participants before the interviews the medical research and ethics committee moh malaysia granted permission to carry out the national health and morbidity survey 2019 study variables 231 andersens behavioral model of health care utilization andersens behavioral model of health care utilization was adapted into this study for its convenience of application and popularity in modeling studies involving healthcare accessibility and utilization the model suggests that the healthseeking behavior of individuals is influenced by three groups of factors sociodemographic characteristics enabling and health needs sociodemographic characteristics describe the tendency to use the services enabling factors describes the resources available to use the health services and facilities and health need factors represent perceived need for healthcare services 14 dependent variables in this study there are two dependent variables included which are seeking treatment from healthcare practitioners among those who reported sickness for the last 2 weeks before the interview and selfmedication among those who reported sickness for the last 2 weeks before the interview those who reported sickness in the last 2 weeks before the interview were respondents who answered yes to the question in the last 2 weeks did you experience any of the following health problems such as fever sore throat difficulty in swallowing running nose or blocked nose cough and others those who answered yes were then asked their healthseeking behavior based on the question in the last 2 weeks did you seek treatmentmedication or advice from healthcare practitioners and in the last 2 weeks did you take medicine without advice from healthcare practitioners in this study the term seeks treatment was used to refer to seek treatmentmedication or advice from healthcare practitioners in short healthcare practitioners refer to modern healthcare practitioners including community pharmacists as well as traditional and complementary medicine practitioners selfmedication was used to refer to take medicine without advice from healthcare practitioners independent variables sociodemographic characteristics in this study sociodemographic variables included were sex ethnicity age education level and marital status divorcedseparated the age of respondents in years was grouped into 1834 3559 and 60 years based on age distribution pattern education levels were categorized into four groups no formal education primary secondary and tertiary education respondents who had never been to school to get any form of education or did not complete primary school were categorized into no formal education while those who completed standard six were categorized as primary education level secondary education level represented those with at least five years of schooling at secondary school whereas tertiary education level represented those who completed form six or received certificates diplomas or academic degrees enabling factors the enabling factors included were employment status income quintile 2 quintile 3 quintile 4 or quintile 5 calculated based on total monthly household income and then were grouped into quintiles and healthcare coverage q1 represents the poorest 20 of the population and q5 the 20 richest healthcare coverage was defined as having supplementary financial coverage for health care such as government employees health benefits pensioner cards governmentspecific health fund personal health insurance employersponsored insurance and panel clinic health need factors proxy measures for health needs included were selfrated health and presence of at least one longterm condition assessed from the questions have you ever been told by a doctor or assistant medical officer that you have diabetes have you ever been told by a doctor or assistant medical officer that you have high blood pressure and have you ever been told by a doctor or assistant medical officer that you have high cholesterol for the analysis respondents who answered at least one yes to either one of the conditions were coded as yes to presence of at least one longterm condition statistical analysis secondary data analysis was conducted using stata version 14 complex sample descriptive statistics were used to illustrate the sociodemographic enabling and health need characteristics of the respondents according to their locality sample weights and study design were taken into consideration using a complex sampling design in all data analyses the products of the inverse of the probability of sampling a nonresponse adjustment factor and a poststratification adjustment by age gender and ethnicity were used to calculate the weight used for estimation comparison of characteristics between urban and rural populations was performed using the chisquare test univariate with the chisquare test and multivariable logistic regression analysis which presented as crude odds ratios and adjusted odds ratios with 95 confidence intervals were used to predict characteristics of those who sought treatment from healthcare practitioners and those who selfmedicated stratified by urbanrural locality all variables with a pvalue 025 in the univariate analysis were considered as predictive variables and entered into multivariable regression analysis 52 the multivariable analysis was performed for urban and rural separately to examine the predictive factors for seeking treatment and selfmedication using four models while adjusting for all other potential covariates such as sociodemographic characteristics enabling and health need factors the aor with a 95 confidence interval was determined where pvalue 005 was considered statistically significant the goodness of fit model was tested using hosmerlemeshow statistics and pvalue 005 was considered as a good fit results a total of 10484 respondents representing 189 million population were included in the analysis the respondents comprised of urban population and rural population table 1 shows the sociodemographic characteristics enabling and health need factors of the respondents stratified by locality both urban and rural populations had significant differences in all factors except marital status and the presence of at least one longterm condition table 2 presents the prevalence of malaysian adults who reported sickness the overall prevalence of malaysian adults who reported sickness was 161 of these more than half sought treatment from healthcare practitioners and about a quarter selfmedicated the prevalence of malaysian adults in the rural areas who reported sickness was higher than the urban adults there were significant differences in the prevalence of those who reported sickness by different sociodemographic characteristics among the urban population a higher prevalence of selfreported sickness was seen among females among the rural population a higher prevalence of selfreported sickness was seen among nonmalays aged 60 and over those without formal education as well as a widowdivorcedseparated prevalence of selfreported sickness among those who selfrated their health as poor to very poor and those with at least one longterm condition was higher among both the urban and rural populations among those who reported sickness more than half sought treatment from healthcare practitioners and about a quarter selfmedicated table 3 displays the results of the logistic regression analysis of healthseeking behaviors with cor and aor and their cis and pvalues the model i and ii assessed the factors associated with seeking treatment among selfreported sick adults in urban and rural localities respectively the multivariable logistic regression revealed that employment status and selfrated health were significantly positively associated with seeking treatment among the urban population among urban dwellers government employees were about 2 times more likely to seek treatment than those who were selfemployed urban dwellers who rated their health as poor to very poor were about 3 times more likely to seek treatment than those who rated good to excellent whereas among the rural population selfrated health and presence of any longterm conditions were significantly positively associated with seeking treatment urban dwellers who rated their health as poor to very poor were about 4 times more likely to seek treatment than those who rated good to excellent health whereas those with at least one longterm condition were about 2 times more likely to seek treatment than those with none model iii and iv assessed the factors associated with selfmedication among selfreported sick adults in urban and rural localities respectively the regression revealed that education levels were significantly positively associated with selfmedication among urban dwellers where being without formal education significantly increased the likelihood of about 43 times to selfmedicate whereas selfrated health was significantly negatively associated with selfmedication among the urban population urban dwellers who rated their health as poor to very poor were less likely to selfmedicate than those who rated good to excellent however in terms of selfmedication among those who reported sickness in the rural locality there was no significant association found the hosmerlemeshow test showed the goodnessfit of the models thus these models were considered a good fit discussion this study aimed to determine the characteristics of respondents and prevalence of malaysian adults who reported sickness based on their urbanrural locality as well as the factors associated with their healthseeking behaviors all variables excluding marital status and the presence of at least one noncommunicable disease were substantially different between the urban and rural populations the overall prevalence of malaysian adults who reported sickness was 161 and higher among the rural population as compared to the urban population higher prevalence of selfreported sickness among those who selfrated their health as poor to very poor and those with at least one longterm condition were seen among both the urban and rural populations more than half of those who reported sickness sought treatment from healthcare practitioners while only about a quarter selfmedicated selfrated health was one of the factors associated with healthseeking behavior among malaysian adults who reported sickness from the urban and rural areas overall less than a fifth of malaysian adults reported sickness with the rural populations exhibiting a higher prevalence than those from the urban areas similarly other published studies found that illnesses were more prevalent among the rural population 27 2853 as an uppermiddleincome country malaysias population has benefited from a welldeveloped health care system together with improved access to clean water sanitation and better child nutrition which was reinforced through programmes targeted at reducing poverty increasing literacy and providing modern infrastructure 54 and these developments may have an effect on the overall population health compared to denmark 55 and hong kong 56 malaysias population had a better health status in terms of overall prevalence of reported recent illnesses however owing to variations in methodology and variables evaluated these results are not directly comparable more than half of those who reported sickness sought treatment from healthcare practitioners in the current study and the prevalence was lower among the rural population seeking treatment from healthcare practitioners was the first choice of healthseeking behavior reported by previously published studies 2957 however given our results suggest that only slightly more than half of the population sought medical attention this raises concerns about the proportion of people who did not seek appropriate treatment or care a study conducted locally reported that 49 and 54 of urban and rural participants respectively did not seek treatment when they were sick 29 low perception of illness as a major health problem 4458 low perceived need to seek care 59 work commitment 44 financial constraint 3445960 and geographical locale 61 were barriers reported in previous studies as health needs and challenges have changed over the past decade policymakers must consider the factors that influence peoples healthseeking behavior for the sustainable and equitable provision of health care to the disadvantaged and underserved groups removing barriers and integrating public and private health services are crucial 62 malaysia is among the countries that have achieved uhc with the vast majority of the population receiving comprehensive public healthcare services 63 malaysia like most other countries has a twotiered healthcare system with a highly subsidized public sector and a feeforservice private sector 64 however this study findings showed that sick rural adults were less likely than their urban counterparts to seek healthcare from a healthcare practitioner while most studies from other countries have identified sociocultural norms as determinants distance and proximity to a healthcare facility also was identified as a significant factor for this behavior 65 66 67 68 within the public sector the distribution of healthcare facilities and resources heavily favored urban areas 20 25 26 27 28 29 31 furthermore the current study found that a larger percentage of people in rural areas fall into the lower income quintiles inadequate access to health care and a lack of income are two reported factors that contribute to the rural populations poor health 65 66 67 68 as the majority of malaysians with low socioeconomic status came from rural areas 69 this calls for more efforts to promote healthcare utilization and enhance accessibility in the remote and rural areas this study found that less than a fifth of the population who reported sickness practiced selfmedication which was lower than previous populationbased studies 2728 as well as other local studies 70 71 72 but higher in study conducted in sri lanka 73 this could be because selfmedication in malaysia is more costly compared to seeking treatment from healthcare practitioners as patients are only charged minimal fee of malaysian ringgit us dollars for visits to the public health clinics 74 although selfmedication assists in the reduction of the burden on medical care it is linked to many possible risks 70 75 76 77 this issue highlights the importance of healthcare practitioners in promoting rational use of medicines including information on potential side effects ensuring informed and responsible selfmedication 77 moreover public health awareness programmes can be organized as part of larger public health efforts to help people understand disease processes and positive health behaviors according to the world health organization education is one of the key social determinants of health and addressing it appropriately is essential to promote health and reduce longstanding health inequities 78 among the urban population in our study those with no formal education were more likely to selfmedicate than those with higher education levels the influence of education level on selfmedication practice is consistent with a study in saudi arabia 79 in malaysia community pharmacies that are strategically and conveniently located in shopping malls and supermarkets 33 led to better access to otc medications especially among the urban population where amenities and infrastructure are more readily available while otc medications have been shown to be safe and appropriate for use without the supervision of a health care provider unwanted effects may result if used irresponsibly 80 inadequate health literacy among the less educated coupled with easy access to medication may result in serious consequences which prompts the need to improve health literacy particularly the negative consequences of selfmedication to ones wellbeing furthermore people with a lower degree of education usually have lower health literacy 81 thus the combined effect of easy access to the medications and the higher likelihood of selfmedication among those with the lowest educational attainment of the urban population posed a worrying situation campaigns such as know your medicines in line with malaysias national health agenda agenda nasional malaysia sihat advocate the importance of knowing your medications to improve public awareness and empower personal health 82 results from our study indicated that selfrated health to be one of the important associated factors in healthseeking behavior those who selfrated their health as poor to very poor were more likely to seek care than those who selfrated their health as good to excellent regardless of locality conversely those who selfrated poor to very poor health was also less likely to selfmedicate than those who selfrated good to excellent health among urban population published literatures highlighted the association of healthenhancing behaviors utilization of health services 8384 and selfmedication 79 among those who rated their health as poor however the reported results are mixed previous studies have established that a singleitem measure of selfrated health provides a holistic view of the populations physical and emotional wellbeing as well as the ability to predict healthseeking behavior and healthcare use 508385 in our study those who selfrated their health as poor to very poor were significantly associated with the presence of longterm condition which is consistent with another largescale study conducted in china 86 the relationship between presence of longterm condition and poorer health could explain the influence of selfrated health on healthseeking behaviors as the nature of the longterm condition itself which demands followup appointments and a formal prescription to obtain the medications that may cause this group of people used the health care services and less likely to selfmedicate among the urban population government employees were more likely to seek treatment than those who were selfemployed when they were sick the association between occupational status and treatment seeking behavior in this study result is consistent with another study conducted in china which found that selfemployed people were less likely to take remedial action and seek medical help after being ill 87 this could be attributed to the time constraints to seek treatment when they are sick and financial issues as selfemployed individuals were more likely to have irregular working hours furthermore their incomes are directly dependent on their work 88 additionally government employees are entitled to a higher number of days for paid sick leave 89 compared to those working in other than the public sector 90 rural population with at least one longterm condition were more likely to seek medical treatment than those without which concurred with previous research that found an association between the presence of chronic illnesses and seeking healthcare services 5091 twothirds of public primary care clinics in malaysia are in rural areas 24 and a national crosssectional study of randomly selected clinics found that doctors in public clinics saw more chronic diseases like hypertension and diabetes as well as followup cases whereas doctors in private clinics saw more acute and minor illnesses 92 this occurrence may largely be contributed by the heavily subsidized public healthcare services by the malaysian government that also covers the cost of lifelong medications which is more economical for patients with chronic disease as the nominal fee granted access to the entire spectrum of public healthcare services in the clinics 1821647492 this economic factor may have driven private clinics away from the rural areas 1824 perceived severity or fear of the consequences of the disease 93 might also be the reason for seeking treatment among the rural population this study discovered that gender is not associated with healthseeking behavior among malaysian adults who reported sickness although women were perceived more likely to seek treatment and utilize health services as compared to men 5 previous local studies found that in general there was no difference in terms of healthcare utilization across gender 94 95 96 in addition previous national health survey reported that there was no difference in the autonomy of decision making for healthcare between gender 28 the sample size for this study was large consisting of 10484 adults who covered both the urban and rural areas the proportion of respondents from the urban and rural areas in this survey was very close to malaysias real population in the same year 97 despite its strengths this research has a number of limitations because of the crosssectional nature of this research no causal association between healthseeking behavior and associated factors could be established seasonal change could not be measured as the data was collected at just one point in time finally since this analysis used selfreported data on previous events there is a possibility of recall bias conclusions this crosssectional study showed that sociodemographic enabling and health need characteristics were associated with healthseeking behaviors among malaysian adults who reported sickness from both urban and rural localities with education level employment status selfrated health and presence of at least one longterm condition as the associated factors this study revealed gaps in healthcare services and more rooms for improvements despite malaysia has already achieved uhc status understanding the factors which influence healthseeking behavior among the urban and rural population could close the gaps in healthcare utilization among the malaysian population future policies should move towards specific targeted approaches that focus on the rural and vulnerable population especially regarding access to healthcare services as well as their knowledge and literacy on seeking proper medical care taking care of health should be a culture a way of life it should be embedded and be a shared responsibility across all sectors in line with the sustainable development goals social services actors and organizations which administratively are not under the purview of the moh malaysia are closer to the peoples hearts as compared to governmental organizations political players are the main drivers with powers to influence the masses mainstream and social media are also key players in educating the nation regarding health matters we recommend active twoway engagements dialogues and close collaborative efforts with these parties for a shared vision of a healthy nation we also recommend further indepth studies to be conducted on factors such as perceived quality of services received which may provide a deeper understanding on the healthseeking behavior of malaysia population supplementary materials the following are available online at 103390ijerph19063193s1 table s1 logistic regression model for selfrated health as poor to very poor among malaysian adults who reported sickness informed consent statement written and informed consent was obtained from each respondent prior to the interviews and confidentiality of respondents involved was assured throughout the conduct of the nhms 2019 data availability statement to protect the privacy of the respondents the data set that supports the findings of this article is not publicly available request for data can be obtained from the head of centre for biostatistics data repository national institutes of health ministry of health malaysia on reasonable request and with the permission from the director general of health malaysia

understanding careseeking behavior among urban and rural populations can help to support the planning and implementation of appropriate measures to improve health in the community this study aims to determine the factors associated with the healthseeking behavior among malaysian adults in urban and rural areas who reported sickness this study used data of malaysian adults aged 18 years and over from the national health and morbidity survey 2019 a crosssectional national household survey that targeted all noninstitutionalized residents in malaysia respondents characteristics and healthseeking behavior were described using complex sample descriptive statistics multivariable logistic regression analysis was conducted to examine the association between potential factors sociodemographic characteristics enabling and health need and healthseeking behaviors seeking treatment from healthcare practitioners and selfmedication a total of 10484 respondents estimated to represent 189 million malaysian adults aged 18 years and over were included in the analysis prevalence of seeking treatment from healthcare practitioners and selfmedication among malaysian adults with selfreported sickness were 573 and 233 respectively selfreported sickness among both the urban and rural populations who rated their health as poor to very poor was more likely to seek treatment than those who rated good to excellent however among the urban population those who rated their health as poor to very poor were less likely to selfmedicate among the urban population government employees were more likely to seek treatment and being without formal education significantly increased the likelihood to selfmedicate among the rural population those with at least one longterm condition were more likely to seek treatment than those with none understanding the factors which influence healthseeking behavior among the urban and rural population could close the gaps in healthcare utilization among the population in malaysia

introduction since the publication of the zimbardo time perspective inventory in 1999 hundreds of studies on timeperspective research have been conducted using this tool the tp construct is conceptualized as a nonconscious process whereby the continual flows of personal and social experiences are assigned to temporal categories or time frames that help to give order coherence and meaning to those events 1 2 time perspective is understood as the unique pattern which helps us assess and categorize our life experiences and is strongly related to every possible life domain including psychological wellbeing personal and professional achievements and personality traits 3 4 5 6 7 8 taking this into consideration it is important to find out whether it is a stable personality trait or can be changed ie to improve ones life situation 9 we are familiar with the recent literature criticizing tp theory and its shortcomings 1011 the ztpi was the only inventory measuring tp in the ukrainian language available at the time of the study our study complements the enormous amount of empirical research applying the ztpi in studies in different languages and cultures 12 according to cognitive social learning theories we first learn to reflect on our past events plan for the future or assess the current situation from our parents or other significant adults 13 14 15 16 17 the important role of the family and its socioeconomic status on ones timeperspective development is well documented in research on children who grow up in the deprived environment of an orphanage or in a socioeconomically deprived family such conditions often lead to a time perspective which is more biased towards the present while the future time orientation is underdeveloped 18 19 20 the familys socioeconomic status has been shown to influence the development of a future time orientation in adolescents the subjective orientation towards the future depends on the feasibility of plans made and the level of endorsement from a certain culture with its particular characteristics 21 22 23 24 25 26 for example seginer and lens 27 discuss how the endorsement of cultural demands defines the strength of the future time orientation in the domain of education for adolescent girls in israel a comprehensive review by fieulaine and apostoloidis 28 showed that a privileged socioeconomic status in adulthood is linked to more pronounced past and future time orientations and more positive attitudes towards them compared to individuals with a lower socioeconomic status according to the authors focusing on the present orientation in individuals with a lower socioeconomic status may be an adaptive strategy to cope with disadvantageous situations during crises and insecurity when the future is uncertain 2829 these studies indicate that the individuals time perspective is strongly rooted in the social context of personal life experiences there is clear supportive evidence that the characteristics of a persons background culture and socioeconomic status shape an individuals time perspective according to situational demands and the possibility of future rewards an individuals time perspective should in principle be modifiable in line with a profile which is optimal for psychological wellbeing and effective functioning however the simple fact that the time perspective is connected to different social factors does not mean that the impact of these factors can be easily outweighed attitudes towards time and behavioral patterns learned in early childhood and practiced according to personal experience for decades are difficult to change this suggests that the time perspective may be a relatively stable individual characteristic throughout ones lifetime how stable is an individuals time perspective many studies supporting the time perspective as a stable individual characteristic have shown strong correlations between specific time orientations and different personality traits 30 31 32 the different timeperspective dimensions are linked to all of the big five personality traits as well as to locus of control optimism selfefficacy aggression impulsivity and many more 32 33 34 35 36 indicating the construct validity of the time perspective one of the first attempts to assess the stability of time perspective was made by luyckx and colleagues 37 who studied the timeperspective dynamics of freshman students over a fourmonth interval the time perspective and an individuals selfidentity formation mutually reinforced one another which led to significant changes in both constructs among those young people after a short period of time quite different results were found by earl and colleagues 38 they tested 367 retired australians all of whom completed the ztpi three times with two ninemonth intervals in between there was no strong modulation in the five ztpi scales over the course of the 18 months pointing to the stability of the time perspective construct in elderly individuals the data were collected under similar national and global economic circumstances all three times 38 indicating that there were no significant external forces that might have led to changes in the timeperspective profiles a different attempt was undertaken by wiberg and colleagues 39 who investigated the stability of the balanced time perspective the ideal combination of time orientations that enable one to flexibly switch among different time dimensions according to personal needs and situational demands 683640 seven participants were tested with the btp profile again after a year and a half four of them had a stable btp whereas the time perspective of the other three had changed one participant had increased his level of balance and the profiles of two others indicated a decrease in their levels of balance 39 although the small number of participants makes it difficult to generalize the findings this study pointed out important questions about how to measure the stability of the time perspective namely by comparing the separate time orientations over a particular time interval and by exploring the dynamics of the whole system of the time perspectives important for our study it is known that the tp is changed in people suffering from loss and migration in syrian refugees in greece an increased pastnegative and presentfatalistic and a decreased future time perspective was associated with posttraumatic stress disorder 41 these three time orientations correlate similarly with peoples general life satisfaction 42 the present study explored whether time perspectives change significantly under radical modifications in life circumstances like political and economic factors as shown in earlier studies the time perspective correlates with a persons social and economic status 2943 we also assumed that significant changes in the social and economic living conditions would provoke a change in time perspectives the time perspective of ukrainian students was observed before and during the period of profound national social economic and political crises starting in 2014 the precrisis period was characterized by relative social economic and political stability the crisis period was marked by a high level of social economic and political turbulence the national currency rapidly depreciated by a factor of three an administrative region was annexed two other administrative regions were isolated by the war line and the level of unemployment increased greatly all these factors caused huge waves of mass migration from the annexed regions to other ukrainian regions and abroad according to official numbers more than a million ukrainians left their homes during the first two years of the crisis of 2014 differences in social economic and political characteristics between the precrisis and crisis periods were sufficiently significant to expect changes in the residents time perspectives if the tp construct is actually sensitive to situational factors the tp data analyzed in the study were gathered by ukrainian researchers from early 2010 to 2018 as part of an attempt to collect norm data of the ztpi for ukraine after the beginning of the crisis a crosssectional design of the study with two time points was applied to investigate whether there were any differences in time perspectives measured under different socioeconomic circumstances in two different ukrainian regions we were unable to implement a strict longitudinal design with intraindividual measurements across two time points what happened in ukraine could not be anticipated which is why the presented study could not be planned in advance the tp data analyzed in the study were gathered by ukrainian researchers from early 2010 to 2018 materials and methods instrument the participants completed a form on their age sex and place of residence as well as the zimbardo time perspective inventory in its ukrainian or russian adaptation depending on their native language the results were calculated according to updated keys for ukrainian and russian versions of the ztpi 50 participants responded to each of the 56 items on a 5point likert scale the results were calculated in accordance with the updated keys for the ukrainian version of the ztpi 50 which slightly differs from the first version in the presentfatalistic scale the inventory itself measures five dimensions of the time perspective the pastnegative scale reflects a generally negative aversive view of ones own past due to the reconstructive character of the past such negative attitudes could reflect real experiences of negative or traumatic moments in the past a negative reconstruction of an actually notsoaversive past or a combination of both the presenthedonistic scale reflects a hedonistic risktaking attitude toward life and presupposes enjoying the present moment with little concern for the further consequences of ones behavior the future scale measures a general future orientation which suggests that behavior is dominated by the effort made to achieve the goals set and possible rewards in the future the pastpositive scale relates to fond and sentimental attitudes towards the past when past experience and times are remembered as something pleasant with a tendency towards nostalgia the presentfatalistic scale reveals a fatalistic helpless and hopeless attitude towards the future and life in general individuals with such a time orientation believe in fate and are certain that they cannot influence present or future events in their lives 1 results first we compared time orientations from the precrisis period in the western region and in the southeastern regions the students ttest showed significant differences in presenthedonistic and future time orientations between regions the hedonistic and future time orientations were more pronounced in the eastern regions in the postcrisis period southeastern regions scored significantly higher on both negative and positive past orientations and significantly higher on both hedonistic and fatalistic present orientations while showing no difference in future time orientation as compared to the western region then we applied anovas to analyze the variance in each time orientation separately across time and for region and controlled for gender western region figure 1 shows that there were no significant differences in timeorientation scores between the first and the second precrisis periods the main change in time perspective was observed in the third period which was characterized by the socioeconomic crisis the future time orientation increased during the crisis period while the scores on the presenthedonistic and pastpositive scales decreased there was a decrease in the scores on the presentfatalistic scale throughout all three periods no dynamics were observed for the pastnegative time orientation was observed in the third period which was characterized by the socioeconomic crisis the future time orientation increased during the crisis period while the scores on the presenthedonistic and pastpositive scales decreased there was a decrease in the scores on the presentfatalistic scale throughout all three periods no dynamics were observed for the pastnegative time orientation the two precrisis subgroups were united into one group of 548 participants and then again compared with the crisis group following separate anovas the future time orientation was significantly higher in the crises period as compared to the precrisis period 1088 p 0001 ηp 2 0012 the present fatalistic 1187 p 0001 ηp 2 0013 the presenthedonistic 2857 p 0001 ηp 2 0030 and the pastpositive 2746 p 0001 ηp 2 0029 orientations were lower during the crisis as compared to the precrisis period no difference for the pastnegative time orientation was found over time 018 p 0668 ηp 2 0001 the mean values for time orientations in the precrisis and crisis groups can be found in appendix a the two precrisis subgroups were united into one group of 548 participants and then again compared with the crisis group following separate anovas the future time orientation was significantly higher in the crises period as compared to the precrisis period 1088 p 0001 ηp 2 0012 the present fatalistic 1187 p 0001 ηp 2 0013 the presenthedonistic 2857 p 0001 ηp 2 0030 and the pastpositive 2746 p 0001 ηp 2 0029 orientations were lower during the crisis as compared to the precrisis period no difference for the pastnegative time orientation was found over time 018 p 0668 ηp 2 0001 the mean values for time orientations in the precrisis and crisis groups can be found in appendix a southeastern region figure 2 shows that both pastnegative and presentfatalistic time orientations were higher during the crisis period while the scores of future time orientation were lower compared to the precrisis period the mean scores for time orientations in the precrisis and crisis groups can be seen in the appendix a the variance for each time orientation was separately calculated with anovas this revealed significantly higher values in the pastnegative 1617 p 0001 ηp 2 0029 and presentfatalistic time orientation 2563 p 0001 ηp 2 0045 after the onset of the crisis as compared to before values for the future time orientation 670 p 0010 ηp 2 0012 were significantly lower during the crises than before the crises no differences for presenthedonistic and pastpositive time orientations were identified 109 p 0298 ηp 2 0002 and f 309 p 0079 ηp 2 0006 respectively was separately calculated with anovas this revealed significantly higher values in the pastnegative 1617 p 0001 ηp 2 0029 and presentfatalistic time orientation 2563 p 0001 ηp 2 0045 after the onset of the crisis as compared to before values for the future time orientation 670 p 0010 ηp 2 0012 were significantly lower during the crises than before the crises no differences for presenthedonistic and pastpositive time orientations were identified 109 p 0298 ηp 2 0002 and f 309 p 0079 ηp 2 0006 respectively discussion the present study examined variations in ukrainian youths time perspectives measured under the different socioeconomic and political conditions prevailing during the preand postcrises surrounding the year 2014 eight years before the war started in 2022 stated in longitudinal terms the time perspectives of the ukrainian youth shifted towards a decrease in the future and an increase in the pastnegative and presentfatalistic time orientations with the beginning of the socioeconomic crisis in the most unstable and closest regions to the war zone these findings coincide with the general concept of time perspective which states that the future time orientation decreases in times of material or psychological deprivation whereas the present time orientation becomes more pronounced 294351 such a change in time perspective helps to effectively adapt to the new circumstances when the distant outcomes are impossible to anticipate and novel challenges need to be dealt with 29 in the region most distant from the armed conflict in 20142015 the western ukrainian region of lviv the direction of the change in time perspective was the opposite after the crisis had started an increase in the future a discussion the present study examined variations in ukrainian youths time perspectives measured under the different socioeconomic and political conditions prevailing during the preand postcrises surrounding the year 2014 eight years before the war started in 2022 stated in longitudinal terms the time perspectives of the ukrainian youth shifted towards a decrease in the future and an increase in the pastnegative and presentfatalistic time orientations with the beginning of the socioeconomic crisis in the most unstable and closest regions to the war zone these findings coincide with the general concept of time perspective which states that the future time orientation decreases in times of material or psychological deprivation whereas the present time orientation becomes more pronounced 294351 such a change in time perspective helps to effectively adapt to the new circumstances when the distant outcomes are impossible to anticipate and novel challenges need to be dealt with 29 in the region most distant from the armed conflict in 20142015 the western ukrainian region of lviv the direction of the change in time perspective was the opposite after the crisis had started an increase in the future a decrease in the presenthedonistic and presentfatalistic time orientations was observed the pastpositive orientation also decreased apart from the size of the identified effect another argument for the validity of the findings is their consistency no difference was found between the two precrisis periods although the time interval between them was almost equal to the time interval between the second precrisis and the crisis periods the two different precrisis periods in the westernregion sample did not show a significant difference in time orientations we can conclude that not the time interval per se contributes to the differences in time perspective but the visible changes in life circumstances between different time intervals one of the functions of the time perspective is to categorize ones personal and social experience 1 if the social circumstances change enough to notably influence personal experience the time perspective adapts accordingly whereas it does not change significantly during stable conditions this conclusion coincides with the findings of luyckx et al 37 and earl et al 38 in their longitudinal study luyckx et al 37 showed that the time perspective changed significantly under the intense influences of social experience even after a comparably short interval freshman college students showed changes in time perspectives as they shifted towards an increase in the future and a decrease in the present time orientations after just four months the authors explained that the dynamics of time perspective were due to a new social role of college students who were in the process of preparing themselves for their careers and future adult lives 37 the study by earl et al 38 showed that the time perspective does not change significantly if measured under stable conditions even after a year and a half the authors conducted three measurements of the time perspectives of 367 retired individuals at ninemonth intervals each under similar global economic circumstances finding no changes over time earl et al 38 concluded that time perspectives are difficult to change we however argue that significant changes in time perspectives do occur only if visible changes in personal or social experience happen the question is why different and even opposite directions in timeperspective changes were observed in the two ukrainian regions the future orientation decreased and pastnegative and presentfatalistic time orientations increased in the southeastern regions in the western region the future time orientation increased and the presentfatalistic presenthedonistic and pastpositive time orientations decreased one possible answer lies in the economic situation people closer to the war zone in the southeastern regions might have experienced more severe consequences of the economic decline whereas almost all economic sectors in the western region remained unchanged including tourism from abroad the proximity of southeastern regions to the war zone might also have undermined the basic safety of the inhabitants this could account for the southeastern residents shift in time perspectives towards an increase in the pastnegative and presentfatalistic and a decrease in the future time orientations when life becomes endangered by forces one cannot control the time perspective adapts by increasing in fatalistic attitudes towards the present and by decreasing the future outlook which no longer makes any sense due to its total unpredictability a further influence on the time perspective may have been expectations of the political developments as mentioned in the introduction the views of the crisis and its political ramifications differed between residents in the western and the southeastern ukrainian regions the western regions were characterized by mostly positive attitudes towards the events that preceded the crisis and their political consequences expressing belief in a better future in accordance with the sociological survey 46 this corresponds to the identified increase in the future time orientation in the residents of the western region the majority of residents of the southeastern regions had mostly negative views of those events 46 which corresponds to the revealed increase in presentfatalistic and pastnegative time orientations our study shows that time perspectives change significantly due to notable changes in social economic and political processes however it is probably not the change in the situation itself but the specific combination of factors and perceptions of them that influences the time perspective among various predictors economics safety needs and political preferences played a role in the observed differences in time perspectives measured before and after the start of the socioeconomic political and military crisis the strength of this study is the large data set which allowed us to assess differences in time perspectives measured under diverse socioeconomic and political conditions over time however there are also limitations the data used in this study stemmed from different surveys with the aim to collect norm data of the ztpi for ukraine it was impossible to plan the study in advance as a result a strictly longitudinal withinsubject design was not possible therefore any causal interpretations concerning the period of testing on the time perspective should be treated with caution the changes in time perspectives due to changes in social economic and political conditions are suggestive but longitudinal withinsubject studies are still needed to complement our findings another limitation is the fact that we did not include additional information about participants subjective views of the ongoing situation we could not examine whether there really were any clearly significant correlations between time perspectives and political attitudes all we could rely on were the results of corresponding sociological surveys we referred to the average population data by assigning students time perspectives to average sociological economic and political indices in a region a future study should include questions about feelings and judgments of personal welfare safety and personal expectations as well as expectations of the countrys political future finally the study sample was comprised of students only and was characterized by a predominance of women which could have impacted the results advanced planning and including different age groups and people from different social strata would increase the credibility of the research social economic and political turmoil cannot be easily anticipated especially not for the sake of psychological studies even now in 2022 the war took most people by surprise we relied on serendipitous data which we analyzed to the best of our knowledge conclusions the article examined differences in ukrainian youths time perspectives measured under diverse socioeconomic conditions the time perspectives tested during the social economic and political crises in 20142015 significantly varied from the ones previously measured under stable circumstances the revealed differences did not fall into one pattern but they depended on the specific characteristics of the crisis and individual perceptions of it in the southeastern regions which suffered from severe consequences of the crisis the time perspectives shifted towards a decrease in future and an increase in pastnegative and presentfatalistic time orientations in the western regions where the crisis situation was characterized by a predominantly positive political attitude and was not as severely affected socioeconomically the observed shift in the time perspectives took a positive direction with a decreased emphasis on the negative present time orientation and an increase in the future orientation the results of the presented study support the time perspective as a dynamic system which adjusts to visible changes in socioeconomic and political characteristics of the living situation data availability statement the data presented in this study are available in the supplementary materials here supplementary materials the following supporting information can be downloaded at study data ztpiukrainesenyk funding this research received no external funding institutional review board statement the study was conducted in accordance with the declaration of helsinki the scientific and valueoriented principles outlined by the ukrainian catholic university lviv served as a fundamental ethical frame of reference for our study on the prevention of academic plagiarism and other types of violations of academic integrity in the educational process pedagogical and scientific activities in the institution of higher education at the time of the study the ukrainian catholic university as well as the other universities had no ethical review board which is in the process of institutionalization but it has been delayed through the covid19 pandemic and the beginning of the war informed consent statement informed consent was obtained from all subjects involved in the study through their voluntary participation in the study which consisted of filling out the ztpi questionnaire in a group setting at an appointed time at the universities appendix a

the characteristics of the individuals time perspective in relation to changes in social economic and political conditions are of major conceptual interest we assessed the time orientations of 1588 ukrainian students living in two different regions western and southeastern ukraine with the zimbardo time perspective inventory ztpi before 2010 2011 2012 2013 and during 20142016 the socioeconomic political and military crises which started in 2014 eight years before the war in 2022 we applied anovas with the ztpi dimensions as dependent variables and the period of testing precrisis postcrisis as an independent variable for the two ukrainian regions separately the time perspectives of residents in the region most distant from the war zone western who positively assessed the change in the political situation around 2014 increased in the future time orientation and decreased in the presentfatalistic pastpositive and 333 presenthedonistic time orientations the time perspectives of residents in the regions closest to the war zone southeastern decreased in the future and increased in the pastnegative and presentfatalistic time orientations reflecting their negative judgments of the events it is not the crisis itself but the specific social economic and political factors and evaluations which define the time perspectives which are flexible and adjust to changes during extreme life circumstances

introduction urban fish vending has become a critical source of livelihood for a significant population of urban dwellers particularly in rapidly growing cities like dar es salaam the rising urban population has led to increased demand for food including fish products creating a substantial market base for various commodities consequently informal fish vending has emerged as an employment opportunity for many individuals providing them with a reasonable income and contributing to the local economy tanzanias national population census conducted in 2022 indicated that 30 of the approximately 61741120 million people live in urban areas and food is highly required to supply enough food that provides nutritious products to the rapidly growing population in dar es salaam fishing and trade on fisheries products should play a major role in the livelihoods of urban dwellers this further suggests that the presence of this population is a market base of various commodities including fish and other related products in order to supply number of fish in the required quantity a reasonable number of people have seen fish vending as an employment opportunity to them and have been making a reasonable income out of this activity in addition to providing employment opportunities for a substantial number of people fish vending contributes significantly to the countrys economy 338 in dar es salaam informal fish vending has become a common activity for women providing them with opportunities for economic empowerment several initiatives have been undertaken to support and improve informal fish vending in the city despite the fact that the government grants have been extended to women vendors to provide an avenue for capital availability majority have been unable to access the credit due to bureaucratic procedures moreover fish vending kiosk has been set up to create employment opportunities to the family as well as the community in addition to that the establishment of the tanzania women fish workers association and the development of the national fisheries policies of 2015 have aimed at promoting gender mainstreaming equity in resource access and awareness in fisheries and aquaculture indeed elazzazy found that women fish vendors do face street vending challenges and opportunities in fayoum while peke elaborated challenges faced by women fish vendor in mumbai however none of these has been conducted in ferry market dar es salaam therefore this study aims at addressing this gap by attempting the following research question what are the threats experienced by women fish vendors what are coping strategies adopted by women vendors and the implications for their resilience by shedding light on the livelihood contributions of fishing activities among women and identifying barriers hindering their meaningful participation above all the study is organized as follows literature review with theoretical and empirical studies and empirical studies that shed a light on linkage between theory and practice the third part contains the information on research methodology after analysis and findings of the study conclusion and recommendations are provided literature review this part of literature includes theoretical and empirical literature it aims at discussing different studies undertaken previously by others in connection with the theory and to the topic and helps to obtain a gap for the current study theoretical and conceptual background this paper is guided by the multilayered social resilience framework which draws from various disciplines such as ecology psychology socioanthropology and sustainable livelihoods the framework emphasizes the examination of resilience building in relation to different threats and the competencies needed to address them it suggests that actors can mobilize economic social and cultural capital to increase their power and ability to cope with threats the framework also distinguished between reactive capacities which are immediate responses to threat and proactive capacities which involve anticipating and planning for threats in advance the framework highlights the importance of positive adjustment and learning in building resilience particularly in challenging livelihood conditions it recognizes different forms of capital including social economic cultural and symbolic as prerequisites for resilience building the framework prompts researchers to be explicit about the specific threat or risk being examined and whether the affected individual or groups are aware of these threats it also emphasizes the multilayered nature of resilience building involving networks at various levels from individual to international furthermore the framework takes a strengthsoriented approach focusing on support from institutions rather than a deficit approach that emphasizes risk and inability to cope it promotes a positive perspective on the ability of urban food street vendors to adjust to threats such as evictions and reallocation framework lastly the framework offers a solution oriented and mitigationfocused approach which can guide researchers and policy makers in identifying corrective measures to enhance the resilience of food street vendors in the face of evictions and reallocation empirical review threats associated with fish vending business among women fish vendors one of the threats related to urban informal fish vending is related to vendors evictions and reallocations worldwide as evidenced in asia latin america and africa these continued evictions have enormously disturbed the business of the urban street vendors in urban areas urban fish vendors have also experienced fish scarcity due to the centralization of landing centres unhealthy competition from newly entered fish merchants and the new entrance of fish vending males in domestic markets another threat has been exploitative practices at various stages of the fisheries business starting from shore to domestic market this has been coupled with the absence of infrastructure and amenities in the fish marketplaces other challenges experienced by the urbanbased women fish vendors are harassment from various authorities deflated fish prices denial of public transportation excessive rate of interest by money lenders unhygienic market conditions lack of facilities for rest and refreshment and others due to the nature of their work the fishvending women are neither able to care for their children properly nor able to lead a peaceful family life women fish vendors are faced with an additional threat stemming from the lack of legal status as they have no license or registered vendors identification cards consequently they lack secure claim to space from which to vend whether in markets or on streets another challenge is lack of access to credit through microfinance institutions or other support or services the vendors may as well be vulnerable to harassment and exploitation women involved in fish vending also face a threat of social stigma that emanates from a belief that fishing vending in some communities is mainly associated with men in line with that fish vendors also are faced with lack of knowledge about financial institutions that are relevant for small business owners which are very few most financial institution deals with creditworthy customers of which women fish vendors do not qualify for the loan inadequate education level plays a significant role in limiting women fish vendors from access to capital as well as a market for their product in most cases less support from the government impeded womens fish vendors from coping with threat research methodology study area the study was conducted in the ferry fish selling market located in the ilala district of dar es salaam city which is a wellknown centre for oceanic fishes and fish products in the area study design the study employed a qualitative design with a phenomenological inquiry strategy this approach as suggested by creswell aimed to document the experiences of women fish vendors regarding the threats they face their coping mechanisms and the resilience implications within their specific context sampling techniques and data collection convenient sampling was utilized to recruit fish vendors who were willing to share their views on the study topic indepth interviews were conducted with a total of 30 women fish vendors from the ferry fish selling market in dar es salaam probing questions were used when necessary to gather more detailed information the researchers facilitated the discussions allowing participants to contribute their ideas while research assistants recorded the proceedings ethical consideration the study adhered to ethical principles for qualitative research permission was obtained from market authorities and all responsible women fish vendors were informed about the research participants were informed about the research considerations prior to sharing their information ethical rules including the right to remain anonymous and withdraw from the study were upheld data analysis the gathered information from the interviews was transcribed and saved as text documents swahili transcriptions were then translated into english to facilitate analysis content analysis of the transcriptions was performed using maxqda 10 verbi software marburg germany the researcher read and reread the data to familiarize themselves with the collected information and capture relevant issues open coding was used to ensure that no critical issues related to the guiding framework were overlooked the researcher used the main issues derived from the framework and identified important supporting content by coding the data this information was then used to establish the main themes validity and reliability to ensure the reliability and validity of the findings researchers practiced peer debriefing this involved engaging more than one peer or qualified expert to objectively relate the obtained themes to the predetermined ones and assess the extent of agreement or divergence a qualified impartial colleague reviewed and assessed all coded segments as well as the methodology used to derive the final themes findings and discussions a fish vending business threats among the women fish vendors based on the data collected and analysed it was noted one of the threats facing the womens fish vendors was a stigma that emanated from patriarchy this is because it is believed that culturally fishing activities were typically maledominated activity and therefore women involved in fish vending were looked at with a suspicious eye moreover women found themselves in difficult work environments because the majority of the fish sellers were men who sometimes exploited women in various ways such as harassment from various parties and denial of public space and transportation another threat experienced by the women vendors was a scarcity of fish which was mainly caused by seasonality reasons as well as men and other powerful traders controlling the availability of fish in the market male and big business people bought fish in large quantities and kept on rationing it as it pleased them in this case they controlled the market and women vendors who mainly possessed little capital experienced fish scarcity previous studies have also contended that women vendors experienced fish scarcity due to seasonality factors centralization of landing centres unhealthy competition from newly entered fish merchants and the new entrance of fish vending males with moped in domestic markets women also experienced an additional threat of higher fish prices that had mainly emanated from fish scarcity indeed it was further observed from the data that during fish scarcity prices raise more than double which make it difficult for the customer to afford this threat hindered women from buying reasonable amounts of fish for sale due to their relatively small business capital most of the fish vendors have inadequate funds for business as well as a record small amount of profit a situation that further downgrades their businesses these findings corroborate well with some previous studies in tanzania which mentioned inadequate business capital as one of the acute business difficulties experienced by street vendors and notably female fish vendors face in dar es salaam furthermore women experienced a threat of inadequate business capital to expand their business one of the respondents provided a detailed explanation stating that their inability to secure loans is not solely determined by their personal networks influence on finding someone to assure for them but also by the specific loan amount required by the lender the inability to access loans from financial institutions made our business difficult to undertake so we establish a business with very small capital acquired through collateral means the threat remains that the size of capital you get does not satisfy your initial plans and this in return makes the business hard to undertake we request the government and other stakeholders support our efforts so that we can improve our business and family life as well… the various forms of genderrelated violence such as sexual harassment that the female fish vendors faced were worsened by the lack of social protection and authority support as a result women fish vendors tended to forego their business due to constant assault that they faced it was further revealed that some women vendors were sexually exploited as one of the conditions for these men either to buy fish from the women or sell fish to the women at relatively low prices more especially the time of fish scarcity characterized by higher fish prices furthermore women explained further that they lack quick response and inadequate support from the relevant authority when reporting different cases of sexual abuse in workplaces almost similar kind of threats had been observed in india by it also corroborates with another study by aswathy kalpana which maintains that informal female fish vendors constantly face sexual harassment and assault and are considered to be among the vulnerable social groups some men are always disturbing us for the purpose of seeking relationships even if you are not interested they tend to force and harass us and at the end of the day you find yourself into the trap they use a weakness we have such as low capital or threats we face like accessing fish especially during the low catch so they tend to supplement either capital or fish for us unfortunately some of us agree with the situation and establish extramarital affairs which put us in many risks such as contracting diseases marriage conflicts unexpected pregnancies that made us make abortions or bear a child with a man who is not your real husband but all of this happens as we are breadwinners and there is no hope of success if we disagree with the circumstance… moreover women fish vendors revealed additional threats related to lack of legal status that denied them business license documents or identification cards in carrying out their business in the urban setting lack of this legal status otherwise this person must be registered consequently this subjected women fish vendors to insecure space business from which to conduct their business as well as inability to access services such as access to credit through microfinance institutions or other support or services according to some earlier studies informal women fish vendors frequently operate their businesses without a license which makes them vulnerable to threats when they approach the appropriate authorities and more often than not places them in awkward situations in the course of conducting their business female fish vendors were also subjected to various types of crime such as robbery burglary theft pickpocketing kidnapping and abduction theft and pick pocketing happened at the market places are well as where they were going or returning back from the business in most cases female fish vendors must work very early in the morning and returning very late in the evening criminals take advantage of these hours due to the darkness and because there are fewer people on the road one of the vendors states as here under most of vendors reach ferry market early at 400am which made it easier for them to get affordable price in most cases price is determine by fish supply in the market therefore when getting at the market will find retailers selling fish at a higher price when we buy fish at a higher price the profit margin out of it is very little another respondent adds we are in security dangers especially early in the morning when we rush to ferry market and during the midnight when we close our businesses as many petty thieves and robbers assumes we have enough money they tend to invade and injure us to take away the money we have sometimes back we do remember that our fellows were invaded early in the morning before reaching the main road and every penny they have was taken by robbers … last but not least women vendors experienced a challenge of massive evictions and reallocations have been found to be threats faced by women fish vendors of which because of missing some important documents especially licenses and other business permits women are forced to evict their business areas of which the flow of customers is assured to where they dont know previous studies in dar es salaam tanzania have also evidenced that vendors experience evictions and reallocations that lead to the decline of their business and as a result slows down personal development we dont have vendors identity cards to conduct our business and especially in the city centre this threatens our business and its like we have no legal rights to undertake this activity……and for sure we are discouraged when the city militia invade us and harass us while risking our products the government has to consider our petty trade since we are breadwinners of our families we need financial freedom we dont want to depend on men for everything and some of us are widows and single parents…our children need to go to school they need uniforms school contributions and food…we need rent and other expenditures in short we need recognition and support from the government … b coping with fish vending threats and the capacity to cope i reactive capacity to cope with the fish vendingrelated threats accordingly women vendors managed to develop a number of reactive capacities for coping with fish vendingrelated threats as discussed here under one of the common reactive strategies developed by the women was joining small selfhelping groups popularly known as village community banking according to the vendors this strategy would help them cope with threats related to business capital inadequacy and sexual exploitation which they experienced they justified that adequate business capital would support their business prosperity thus reducing their dependence on men who had been exploiting them sexually this is a similar case to munishi on the reactive capacity of coping with the threat developed by maasai one of the women states here under we have decided to overcome the threat of acquiring capital and depending on men to guarantee us business capital through the establishment of small selfhelp groups popularly known as vicoba these groups are really supportive of our business growth because they provide us with soft loans and some business development ideas this has increased our selfconfidence when interacting with men as we no longer depend on them too much you see inadequacy business capital partly pushed into sexual exploitation and sexual harassment formation of groups as strategy for coping with both business capital inadequacy and sexual exploitation has been previously noted among the urban street vendors in dar es salaam and elsewhere in africa another reactive strategy developed by the women is seeking closely relative security support when they get out early in the morning as observed in munishi munishi this strategy was developed to cope with the crime threats and helped them be at the ferry in time and get fresh fish at a good price one of the respondents pointed it this way you see as women fish vendors we must seek security support from our family members ie husbands children and even neighbours we request them to escort us to commuter bus stations during morning hours to ensure our safety from petty robbers who are constantly threatening us in our daily endeavours ii proactive strategies to cope with the fish vending related threats securing business financing from credible and relevant institutions firstly women vendors proactively planned to secure big loans from more advanced and relevant financial institutions such as banks and social security organizations according to the vendors this longterm plan would eventually save them from inadequate business capital threat business diversification and adopting new kind of business one of the proactive strategies developed by women against the fish vending related threats was business diversification and adopting new kind of business that would guarantee them more sells and profit this strategy would help them overcome the threats related to inadequate business capital as well as avoid sexual exploitation and harassment threats that they experienced one of the respondents explains it to me i think the only reliable way to overcome business capital inadequacy is retirement from the fish vending business and consider doing more paying and decent business in this case i now need to more efforts in raising capital from various sources as well as working hard in my current business we also need to consult differ government authorities such as the local government to supporting us in setting up and supporting our future business anticipating to engage in different kind of business as a proactive strategy of coping with undesirable and less decent job was also previously captured among the maasai migrants engaged is security work in dar es salaam as well as the motorcycle taxi riders in dar es salaam who were uncomfortable with their former jobs business registration and licensing another proactive strategy developed by women fish vendors was an attempt to undertake business registration and licensing so as they could be recognized and avoid threats related to lack of legal status of their business in the urban setting this strategy aimed at overcoming the threat related to urban informal trading in the urban areas one of the women puts it this way 342 there is nothing good like being recognized as well as being respected in your business so we as women fish vendors dont have a recognition in our business we considered very local and because of that our customers value our services so we need to register and be recognised by the government in this case we shall work with the government and other authorities to obtain business identity cards formal places to run our small businesses these strategies have also been captured by in dar es salaam tanzania who noted that issues of vendor licensing and permit issuing is among the critical policy issues in the urban settings it has attracted different actors initiatives including the president himself search for and participate in education and capacity building programmes another proactive strategy anticipated by the women was searching for as well as participating in education and capacity budding programmes vendors pronounced that this strategy would help them to either improve their current business or engage in other more paying business one of the respondents puts it this way we shall consult various training institutions and local governments authorities to organise relevant training on how to expand more on our business and investment through this i am sure we shall be included in various business forums organized by the government in where we shall obtain relevant business knowledge and skills to improve our business even more another respondent adds on the importance of business education sometimes thinking about the coming old days stresses us as we dont have enough education we dont have formal employment and we lack enough capital to run big business that can support us to earn a handsome profit for investing in social schemes such as nssf we are worried as we have experienced very old fish vendors are still dealing with the business while they are physically and emotionally tired but they dont have an alternative way to run their lives its now a right time to re think on investing for our future……… engaging in business advocacy another proactive strategy developed by the women fish vendors was advocating for conducive business environment and institutions notably policies and regulations that would favour their business this would go hand in hand in ensuring recognition of their small informal business by the various relevant government authorities including the local government recognizing and joining hands to efforts women made in small business is crucial since their growth mean a lot to the government in terms of employment creation tax payment and strengthens family welfares therefore its important to initiate strategies to register and boost women investments towards realizing their efforts to sustainable livelihood a strategy of coping with inadequate business capital has been through business advocacy was earlier captured among the maasai security guards street vendors in dar es salaam and morogoro as well as the youth engaged in the motorcycles taxi riding business in dar es salaam conducive this would ensure supportive business environment and institutions notably policies and regulations that would favour their business efforts is needed by the government and other stakeholders to ensure the future investment through social security systems is well planned and seriously undertaken c factors constraining the vendors capacity to cope with the threats one of the constraints to coping capacity was lack of adequate government support women lamented that they did not receive adequate financial support from the government they acknowledge the local government business grants arrangements however they said that the amount was too little as well as marred with a number of bureaucratic procedures when it was eventually forthcoming these findings are well supported by some previous finding that maintain that majority of the women street vendors have not had adequate financial support from the local government are still eager to receive government support through local government grants which hopefully could boost them economically and with low stress moreover it was noted that local government was either unaware or not doing anything to intervene on the issues related to crime against women street vendors local authorities in streets and wards need to ensure enough security to their residents and this will enhance economic growth above all lack of knowledge about financial institutions was also noted to be a constraint it was observed that women fish vendors had inadequate knowledge about financial institutions which limit their access to soft loans that would help to increase the size of their capital conclusions the study aimed to identify and propose strategies for overcoming threats faced by urbanbased women involved in the informal fish vending business the findings revealed various threats experienced by vendors including stigma fish scarcity higher fish prices inadequate business capital genderrelated violence lack of legal status various forms of crime and evictionsreallocations the study highlighted both reactive and proactive strategies employed by vendors to cope with these threats reactive strategies included joining selfhelp groups and seeking support from family while proactive strategies involved securing financing diversifying businesses registering and licensing participating in education and capacity building programs and engaging in business advocacy the study also identified factors that hindered the vendors capacity to cope such as lack of government support and inadequate business skills in conclusion it is recommended that supporting women fish vendors to cope with the threats they face in their fishing business activities should involve addressing the identified constraints adequate government support and provision of business skills are crucial for enhancing the vendors coping abilities by addressing these factors policymakers and support organizations can contribute to empowering women fish vendors and enabling them to more effectively deal with the challenges they encounter in their businesses recommendations based on the foregoing discussion and conclusion the following recommendations are made in light of improving the women vendors increase their resilience against the various fish vending threats they experience i government should work on the issue of ensuring legal status of the of street vendors through issuing of issue identity cards to all informal traders in the urban setting including the female fish vendors ii in order to alleviate the threat related to lack of knowledge about financial institutions among the vendors there should awareness campaign on the importance of financial institutions as well as properly be linked to fish vendors this would guarantee them soft loans from banks and other financial institutions iii government should also enact proper policies that support street vending that would also facilitate provision of support to women fish vendors notably reducing bureaucratic procedures that limit women vendors from access to the loan iv on top of that the government should provide enough entrepreneurship education to the vendors through capacity building and training sessions among women vendors this would guarantee proper management of their business v on stigmatization there should be awareness campaign to the community to eradicate cultures that treat women as disregarded in the fishing business and appreciate their contribution at family levels 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 restrictions

the aim of this study is to examine threats related to informal fish vending business among urbanbased women and to propose strategies for overcoming the threats specifically the study ascertains the threats associated with the fishing business and strategies for coping and the capacity to cope based on the multilayered social resilience framework this study used a qualitative design and a sample size of 30 participants obtained both randomly and purposively the findings revealed that threats experienced by the vendors include stigma fish scarcity higher fish prices inadequate business capital various forms of genderrelated violence such as sexual harassment lack of legal status and various forms of crime including robbery theft and pickpocketing findings further indicated that vendors managed to develop both reactive and proactive strategies for coping with the threats reactive strategies include joining small selfhelping groups popularly known as village community banking vicoba and soliciting family and relative support against insecurity threats proactive strategies include securing business financing from credible institutions business diversification and adopting new kinds of business business registration and licensing searching for and participating in education and capacitybuilding programs as well as business advocacy it is recommended that government support provision of education and access to credit should be considered in supporting women fish vendors to cope with the threats in their fishing business activities

introduction populations exposed to mass conflict and persecution commonly experience extensive losses 12 experiences that are likely to provoke feelings of injustice and anger associated with symptoms of grief 3 yet there is a dearth of research investigating a possible nexus between grief and anger amongst populations living in postconflict environments we attempt to identify a subpopulation experiencing combined symptoms of grief and anger amongst survivors of prolonged persecution and conflict in timorleste and whether that putative pattern is associated with particularly high levels of traumatic loss persisting preoccupations with injustice and ongoing family conflict anger as an unwanted and commonly dysfunctional emotional reaction has been associated with feelings of injustice amongst populations that have been exploited and persecuted having ones human rights violated or economic goals systematically undermined can understandably lead to normal anger reactions however anger can also be associated with a loss of control aggression and harm to others including community members intimate partners and children 4 5 6 7 8 9 10 anger has also long been regarded as a core component of the normal grieving process 11 moreover clinical observations have suggested that a failure to resolve anger associated with a bereavement may contribute to the persistence of the grief reaction 1213 presumably because of strong feelings of grievance and injustice associated with the loss in that regard it is notable that studies examining the factorial structure of the persisting grief reaction have consistently identified anger and bitterness as core components 1415 for example a confirmatory factor analysis conducted amongst bereaved adults in the usa identified angerbitterness as one of six symptom domains of the construct of prolonged grief 14 in keeping with this and other research the constellation of angerbitterness has been included in the categories of complex bereavement disorder 16 defined as a diagnosis requiring further empirical evidence in dsm5 as well as in the proposed icd11 definition of prolonged grief disorder 17 nevertheless controversy continues about the nosological status of these categories particularly insofar as they distinguish pathological from normative forms of grief 1819 studies amongst postconflict populations exposed to repeated traumatic losses may shed further light on the role of anger in the grief response our past research in timorleste identified what appeared to be a high rate of explosive anger in response to trauma exposure explosive anger can express itself as physiological arousal and either verbal or physical aggression the response characteristically being out of proportion to environmental triggers and experienced as uncontrollable the subject reacting without immediate thought to the consequences 16 although in the aftermath of attacks the person may feel a degree of relief or vindication feelings of exhaustion remorse andor embarrassment are also common 20 a population study in a rural and an urban village of timorleste undertaken in 2004 recorded a prevalence of explosive anger of 38 based on the international threshold of at least one attack of explosive anger a month 9 in a sixyear followup study the prevalence of explosive anger remained high suggesting that at a population level the reaction had a strong tendency to persist over a prolonged period of time 21 applying the stringent dsmiv definition of intermittent explosive disorder which mandates the occurrence of acts of aggression in conjunction with anger the prevalence if explosive anger was 8 a high rate compared to other countries where the diagnosis has been studied at a population level 22 23 24 25 a consistent finding of our studies in timorleste is that women reported higher rates of explosive anger and ied than men the converse of the usual gender pattern recorded in other countries 202225 although a mixed methods study indicated that a range of experiences were associated with ied amongst women 20 these factors applied to other morbid mental health outcomes including posttraumatic stress disorder and depression suggesting that the risk factors identified to date are not specific to anger 2627 doubts remain therefore about the origins and nature of explosive anger and its high prevalence in timorleste and why it is particularly common amongst women in our endeavour to understand this phenomenon we draw on the adaptation and development after persecution and trauma model 2829 which highlights the core roles of interpersonal bond disruptions and experiences of injustice amongst other domains as major psychosocial challenges confronted by populations exposed to conflict although the model suggests that grief and anger represent the quintessential responses to disruptions in bonds and acts of injustice respectively these two experiences are likely to overlap given the interrelated nature and meaning of the traumatic events of conflict 29 specifically traumatic losses are likely to occur in settings of gross injustices thereby provoking simultaneous reactions of anger and grief other forms of adversity for example conditions of material deprivation during and in the aftermath of conflict may compound and prolong anger and grief symptoms of grief and anger in survivors of trauma may lead to ongoing conflict within families representing one of the more severe longerterm psychosocial consequence of earlier exposure to mass violence 30 the history of persecution and conflict in timorleste provided a setting to investigate possible associations between grief and anger amongst a population exposed to extensive traumatic losses the invasion and occupation of the territory by indonesia in 1975 provoked a lowgrade resistance war waged by members of the indigenous independence movement during the period of conflict which culminated in a humanitarian emergency in 1999 an estimated quarter of the indigenous population died as a consequence of atrocities warfare burning of villages murder famine and untreated illness in addition there was widespread loss of property and livelihoods and forced displacement of whole communities with kinship and family groups being dispersed some as refugees to other countries in the postconflict phase further episodes of violence occurred particularly in 20067 when a period of sustained internal conflict led to extensive injuries deaths and displacement of communities into makeshift refugee camps socioeconomic development in the newly independent country has been slow with many families confronting extreme levels of poverty and deprivation our aim was to test whether it is possible to identify a combined pattern of explosive anger and grief symptoms amongst the timorese population we hypothesized that a subpopulation with griefanger would report high levels of traumatic losses preoccupations with injustice and ongoing adversity including family conflict in the postconflict environment we also examined whether women were more likely than men to experience the putative griefanger constellation materials and methods field team and procedure the team included 18 timorese field workers with prior survey experience andor psychology public health degrees they received a twoweek training course followed by two months of field testing and piloting of survey measures under supervision pairs of interviewers were required to achieve a consistent 100 percent level of interrater reliability on the core measures one hour long interviews were conducted in participants homes or another location if preferred by respondents the procedure ensuring maximal privacy and confidentiality in villages where families live in close proximity to each other and where overcrowding is a problem we sought to ensure privacy by taking participants to garden areas or away from the household to somewhere shaded and quite we also arranged for children to be entertained by one of our colleagues if they were likely to cause a distraction to participants households were visited up to five times in order to meet potential participants ethics statement the study was approved by the ethics committee of the university of new south wales the ministry of health of timorleste and the chiefs of each village the majority of respondents gave written consent prior to commencement of interviews verbal consent was obtained in some cases where respondents were illiterate trusted witnesses cosigning the forms the procedure was endorsed by the community and received ethical approval from the university of new south wales and the ministry of health of timorleste measures our selection of constructs and the appropriate measures to assess them was based on theoretical considerations and the empirical findings in our past studies examining explosive anger in timorleste the protocol including the grief measure was iteratively field tested amongst communities geographically adjacent and similar in sociodemographic composition to the sites of the definitive survey in piloting we applied an iterative process of feedback in which responses and solicited comments by respondents in the field were analysed and considered by a committee comprising timorese of diverse backgrounds and expatriate researchers measures were reviewed and revised to ensure that the constructs were understood by the community items were readily comprehended both semantically and linguistically and response options were appropriately graduated according to the language and culture exposure to conflictrelated traumatic events the 17 conflictrelated traumatic events listed in the harvard trauma questionnaire 31 were modified to ensure their congruence with the historical context of timorleste tes were recorded for two periods the indonesian occupation and the subsequent period leading up to the study we derived four broad te domains based on their common nature and characteristics conflictrelated trauma witnessing murder and atrocities traumatic losses and extreme deprivations each te item was scored 02 the maximum score being assigned if participants endorsed a te for both time periods we then generated a summary index for each of the four te domains based on the addition of endorsed items ongoing adversity an inventory of daily adversities was developed based on extensive community consultations and refinement of items during piloting 20 all participants rated each adversity item on a five point scale the adversity items were assigned to thematic domains 1poverty 2 conflict with family and 3 conflict with community the score for each domain was based on the summary score of constituent items preoccupations with injustice respondents were asked to identify and describe the worst human rights violation or other event associated with injustice they had experienced during three defined historical periods the indonesian occupation the period of internal conflict and contemporary time ratings were assigned as 1 for assigning an unjust event 2 for experiencing preoccupations relating to the event and 3 for distress related to these preoccupations the composite index of injustice reflected the addition of scores for each of the three historical time periods symptoms of explosive anger our community measure of explosive anger was developed tested and modified serially during piloting to ensure its cultural appropriateness and comprehensibility in the local language tetum 32 the screening questions inquired whether participants had ever experienced sudden episodes or attacks of anger and if so how frequently these attacks occurred participants who endorsed attacks at a frequency of at least once a month were then asked about associated characteristics of loss of control destruction of property verbal aggression and physical aggression towards others we then applied an algorithm to derive a diagnosis of intermittent explosive disorder according to dsmiv 32 in a convergence study we compared our community index of ied with a blinded diagnosis made on the structured clinical interview for the diagnostic and statistical manual for dsmiv assigned by experienced psychologists 32 there was a high level of concordance between the two measures area under the curve 090 in the latent class analysis we included the five core items of explosive anger as defined by ied each scored categorically explosive anger attacks loss of control of anger destruction of property during attacks verbal aggression during attacks physical aggression towards others during attacks grief symptoms we inquired of all participants whether they had experienced a loss defined as an event in which someone close to the individual had died or been killed those who identified multiple losses were asked to identify the death that had the most impact on their lives then recording the cause and time of the death almost all of these identified losses were related to traumatic deaths or untreated illness occurring during periods of mass conflict based on the identified loss event participants were then asked to rate each of four grief items on a fivepoint frequency scale as experienced in the past four weeks the initial item pool was derived from the literature and contemporary criteria for assessing prolonged grief 17 the process of piloting reducing the number of symptoms to those that were widely recognised and regarded as core experiences of the timorese people the derived three symptom items were persistent yearninglonging for the deceased feelings of intense bitterness and feelings emptiness in relation to the death the fourth item assessed the level of functional impairment associated with the endorsed symptoms for the latent class analysis we assigned a score of 0 for symptoms scored not at all rarely or sometimes and 1 if rated as often or always posttraumatic stress symptoms and psychological distress posttraumatic stress disorder symptoms and general symptoms of psychological distress were assessed using the harvard trauma questionnaire and kessler10 respectively widely used measures applied in our previous studies in timorleste 26 in our aforementioned convergence study using the scid a satisfactory level of concordance was achieved for ptsd and severe distress a score of 22 for ptsd and 30 for severe psychological distress produced the best balance between specificity and sensitivity for each index cronbachs alpha for the ptsd scale was 095 and for the k10 090 all measures were translated into tetum the most widely spoken language in timorleste minor inconsistencies were addressed during piloting and the final versions were translated and backtranslated into english 33 statistical analysis we calculated intraclass correlations to assess for possible clustering within households of indices of grief psychological distress ptsd and explosive anger all correlations were low indicating negligible clustering by households we used latent class analysis to identify clusters of participants according to their pattern of symptoms of explosive anger and grief we tested sequential models examining a suite of conventional model fit indicators to assess for the best class solution the bayesian information criterion sample sizeadjusted bayesian information criterion and the akaikes information criterion 3435 lower values of these indicators indicate a better fit in comparing successive latent class models in addition we applied the vuonglomendellrubin and the lomendellrubin adjusted likelihood ratio tests both of which compare the fit of a latent class model of n classes to one with n1 classes 36 in judging the bestfitting model we took into consideration the principle of parsimony the degree of class separation homogeneity of posterior probabilities within classes and the interpretability of the classes yielded 35 we draw on conventional criteria 37 in which conditional probabilities of 060 or above indicate a high probability of endorsing a particular symptom values falling between 059 and 015 a moderate probability and a value of 015 or less a low probability after selecting the bestfitting model we examined for associations between class membership and a range of relevant predictors using multinominal logistic regression analysis the covariates included sociodemographic characteristics of gender residency in urban or rural areas educational attainment and employment traumatic domains comprising conflictrelated trauma witnessing murders and atrocities traumatic losses and extreme deprivations current adversities including indices of poverty family conflict and communal conflict and preoccupations with injustice analyses were performed in stata version 13 and mplus version 7 results sociodemographic characteristics of the 3368 respondents approached 2964 completed interviews a response rate of 836 table 1 indicates the sociodemographic characteristics of the sample the mean age was 364 years and a larger portion resided in the rural area twothirds were married the remainder being singlenever married widowed divorced or separated in relation to education 116 had completed primary 123 junior and 263 senior high school whereas 107 had received postschool education nearly half engaged in subsistence farming domestic duties or were retired 348 were occupied with paid employment and the remainder were students or unemployed prevalence of explosive anger prolonged grief ptsd and severe distress two hundred and fifty persons met criteria for explosive anger according to ied criteria a quarter endorsed one or more symptoms of explosive anger including sudden anger attacks loss of control verbal aggression destruction of property and physical aggression over half endorsed one or more symptoms of prolonged grief including persistent yearnings or longings for the deceased feelings of bitterness about the death and feelings of emptiness a third reported functional impairment associated with these symptoms a similar number met the threshold for ptsd and severe psychological distress exposure to conflictrelated traumatic events and ongoing adversity over half of participants reported experiencing one or more conflictrelated traumas including political imprisonment combat physical assault torture and trauma related to involvement in the resistance movement four out five persons reported witnessing murders and atrocities and two fifths traumatic losses including forced separations and disappearances ninety percent experienced extreme deprivations related to access to urgent health care food water and shelter ongoing adversity table 3 shows the frequency of adversity items in order povertyrelated items endorsed were shortage of electricity no access to clean water insufficient food and money problems accessing transport environmental problems lack of shelter being unable to meet traditional family obligations conflict with spouse and extended family members youth conflict and safety issues in the community preoccupations with past and present experiences of injustice distressing preoccupations with events associated with injustice were reported by 131 for the indonesian occupation 246 for the period surrounding the internal conflict and 185 in contemporary times latent class analysis serial model testing concluded after assessing a four class lca model fit indicators improved up to the threeclass model the gains then being only marginal when progressing to a four class model importantly the vlmr and the lmr adjusted likelihood ratio tests showed no statistical changes in progressing from a three to four class model given these findings and the ready interpretability of the classes we adopted the threeclass model table 5 shows the item probabilities for each class based on symptoms of grief and explosive anger in the grief class item probabilities for preoccupations and bitterness were in the high probability range and feelings of emptiness and functional impairment were in the moderate range in contrast all items of explosive anger items in this class fell into the low moderate or low probability range in the combined explosive griefanger class comprising 24 of the sample grief symptoms fell into the high or moderate ranges in contrast to class 1 explosive anger symptoms fell into the high or highmoderate probability ranges in the low symptom class comprising 51 of the sample there were low probabilities for the majority of symptoms of grief and explosive anger with only two exceptions preoccupationsyearning were in the moderate range and the generic item for explosive episodes was in the lowmoderate range comorbidity in comparison to the low symptom class both the grief and griefanger classes were associated with ptsd and severe psychological distress associations with past trauma ongoing adversity and preoccupations with injustice table 6 presents the findings of the multinomial logistic regression analysis testing for associations between the designated covariates and the lca classes in comparison to the low symptom reference class women and urban dwellers were more likely to be assigned to both the grief and griefanger classes the two te domains of witnessing murder and atrocities and traumatic losses were both associated with the grief and griefanger classes in addition however the griefanger class reported greater exposure to traumatic losses than the grief class also the griefanger class alone reported greater exposure to extreme deprivations related to conflict in comparison to the reference class in relation to ongoing adversities both the grief and griefanger classes exceeded the reference class on the index of poverty the griefanger class in turn reported higher rates of poverty than the grief class only the griefanger class reported greater levels of family conflict in comparisons with both the reference low symptom class and the grief class compared to the low symptom class both the grief and griefanger classes reported greater preoccupations with injustice for the two historical periods of conflict only the griefanger class however reported a higher level of preoccupations with injustice for contemporary times compared to the reference class discussion our analysis in postconflict timorleste identified a typology comprising three subpopulations including those experiencing grief griefanger and low symptoms the first two categories affecting a quarter of adults in the sample women and urbandwellers were more likely to be assigned to both the grief and griefanger classes compared to the low symptom reference class both the grief and griefanger classes reported greater exposure to conflictrelated murdersatrocities and traumatic losses more extreme levels of poverty and distressing preoccupations with injustice related to two successive historical periods of conflict there were important distinctions between the two morbid classes however in that the griefanger class reported greater exposure to traumatic losses greater deprivations during the period of conflict higher stress levels related to poverty ongoing family conflict and preoccupations with injustice for contemporary times prior to discussing our findings we consider the strengths and limitations of the study the sample is one of the largest in the contemporary postconflict mental health field and we achieved a high response rate although sampling was restricted to two localities the sites were identified initially as being broadly representative of the sociodemographic profile of timorleste as a whole 38 nevertheless replication of the study in other areas of timorleste and in postconflict countries worldwide will be needed to test the generalizability of our findings caution needs to be exercised in inferring causal relationships from crosssectional data of this kind longitudinal studies may assist in delineating the chronological sequencing of the relevant symptom constellations in particular whether anger precedes and thereby acts to prolong symptoms of grief recall of traumatic events can be subject to amnestic bias although there was a notable consistency in the pattern of traumas documented and the known history of timorleste a systematic approach was followed in the transcultural adaptation translation and testing of measures although the majority of losses identified as triggers of grief symptoms occurred several years earlier our measure did not record the course of grief symptoms so that judgement is reserved as to whether the reaction was prolonged or not caveats notwithstanding our findings cast new light on the high prevalence of explosive anger previously identified in community samples in timor leste 5920 a phenomenon that has yet to be fully unexplained 20 even though previous studies had shown associations between explosive anger and common stressors such as conflict poverty and injustice these factors were common to other patterns of mental distress including symptoms of ptsd and severe psychological distress yet there were reasons to suspect that explosive anger had distinctive antecedents given that the reaction appeared to be relatively independent as a construct from those of ptsd and severe psychological distress in that regard the identification of a subpopulation comprising a quarter of the sample that manifested the constellation of griefanger offers a potential explanation for the high prevalence of anger identified in this society notably although a grief class of equal size emerged there was no independent explosive anger class further accentuating the close association between anger with grief the griefanger class reported the greatest exposure to traumatic losses an important finding given that murder atrocities and death by untreated illness and famine were widespread during the prolonged period of conflict in timorleste it may be that in collectivist societies such as timorleste losses that provoke strong and enduring feelings of injustice are particularly potent in generating the identified combined pattern of griefanger to confirm this replication of our findings will be needed in other conflictaffected settings where traditional family and community values prevail importantly our regression analysis involving relevant covariates added credibility to the distinction we found between the griefanger and grief classes specifically the griefanger class stood out in reporting high levels of traumatic loss extreme deprivations during the period of conflict severe ongoing poverty and family conflict and preoccupations with injustice extending over three contiguous historical periods in relation to the latter finding we have reported a similar association between the anger component of persistent complex bereavement disorder and a sense of injustice amongst refugees from west papua a neighbouring territory that has experienced a comparable level of prolonged mass conflict under indonesian occupation 3 the finding that a half of the population experienced relatively low levels of grief and anger symptoms offers some insights into the factors that protect postconflict populations from these adverse psychological outcomes it is notable that the low symptom group reported a similar level of exposure to the general traumas of conflict indicating that they had not been sheltered from these events it was only in the te domains of witnessing murderatrocities and traumatic losses that the low symptom group reported lower exposure suggesting that protection from these salient forms of trauma may act to avert risk of developing the specific griefanger constellation being male living in a rural environment experiencing lower levels of poverty and not experiencing family conflict were other factors that appeared protective noting however that causeeffect relationships involved remain to be confirmed given the crosssectional nature of the study our findings have potential implications for the individual the family and the society as a whole not only in timorleste but in other postconflict settings worldwide in particular confirmation of a griefanger class and the social factors associated with the pattern has the potential to add support to a cycles of violence model which postulates that exposure to the traumas of past conflict may contribute to risk of subsequent family conflict in the aftermath of the violence 30 we note however that explosive anger associated with grief may be both a cause and a consequence of family conflict resulting in a complex reciprocal and interacting effect that generates a vicious cycle of instability in the household our past qualitative data indicated that timorese women with ied frequently recognized that their explosive anger led to harsh parenting behaviours which in some instances had an adverse effect on the health and wellbeing of their children 20 it is possible therefore that the griefanger pattern we have identified contributes to the transgenerational transmission of trauma in a manner that impacts adversely on the psychosocial development of the next generation in relation to ongoing adversities there appeared to be a stepwise relationship between the severity of poverty and the griefanger grief and low symptom classes respectively these observations underscore the interaction between traumarelated mental health problems and socioeconomic factors in postconflict societies poverty places stress on individuals families and communities compounding past interpersonal and material losses in generating a sense of injustice and anger in that sense apart from the immediate hardship incurred by poverty conditions of extreme material deprivations jeopardise recovery from traumarelated mental health conditions which in turn can impair functioning and reduce the capacity of survivors to engage in gainful employment or other opportunities to improve their economic wellbeing 39 conclusions our study identified a griefanger constellation comprising a quarter of the study sample in postconflict timorleste there were commonalities with the grief group in reporting greater exposure to witnessing murder traumatic losses and poverty and experiencing persisting preoccupations with injustice related to two consecutive historical periods of conflict the griefanger group was unique however in reporting extreme levels of traumatic losses exposure to material deprivations during the period of conflict preoccupations with injustice in contemporary times and ongoing family conflict it is a cruel irony that the traumatic rupture of interpersonal bonds during periods of mass conflict can generate a psychological reaction pattern in survivors which in turn may undermine the survivors capacity to achieve a stable family environment in the postconflict period all relevant data are within the paper and its supporting information files supporting information s1 dataset this is the s1 dataset performed the experiments es zdc analyzed the data akt contributed reagentsmaterialsanalysis tools akt wrote the paper sr akt ds

previous studies have identified high rates of explosive anger amongst postconflict populations including timorleste we sought to test whether explosive anger was integrally associated with symptoms of grief amongst the timorese a society that has experienced extensive conflictrelated losses in 2010 and 2011 we recruited adults n 2964 18years and older living in an urban and a rural village in timorleste we applied latent class analysis to identify subpopulations based on symptoms of explosive anger and grief the best fitting model comprised three classes grief 24 griefanger 25 and a low symptom group 51 there were more women and urban dwellers in the grief and griefanger classes compared to the reference class persons in the grief and griefanger classes experienced higher rates of witnessing murder and atrocities and traumatic losses ongoing poverty and preoccupations with injustice for the two historical periods of conflict the indonesian occupation and the later internal conflict compared to the reference class only the griefanger class reported greater exposure to extreme deprivations during the conflict ongoing family conflict and preoccupations with injustice for contemporary times and compared to the grief class greater exposure to traumatic losses poverty family conflict and preoccupations with injustice for both the internal conflict and contemporary times a substantial number of adults in this postconflict country experienced a combined constellation of grief and explosive anger associated with extensive traumatic losses deprivations and preoccupations with injustice importantly griefanger may be linked to family conflict in this postconflict environment

children with disabilities thus in most states nonattorneys albeit with special knowledge or training can support families in school disputes while the idea permits a nonattorney advocate with special knowledge to accompany and advise families during formal dispute processes the idea regulations also indicate that whether a parent may be represented by a nonattorney in these processes is a matter of state law in this way the regulations to idea provide a distinction between nonattorney advocacy and legal representation while nonattorneys do not have licenses to practice law they should have training in special education law and advocacy currently there is no professional license or certification for special education advocates even though nonattorney advocates may charge for their services nonattorney advocates can engage in a number of activities that do not constitute the practice of law including assisting with record collection organization and review developing position statements and letter writing providing parents with copies of the law and making suggestions about a childs educational program the advocate can also attend meetings as an individual with specialized knowledge of the child and may be a more economical and less adversarial alternative to legal representation to serve this need for special education advocates several models of training have recently emerged although training models share the common goal of teaching advocates necessary skills models vary widely in duration content and training activities for example one such training the special education advocacy training merged practices from three different professional communities to develop competencies and a code of ethics for nonattorney advocates supported by the office of special education programs this 230hour training was primarily used by experienced advocates to gain legitimacy as professionals another such training the volunteer advocacy project consists of 40hours of instruction about providing instrumental and affective support concerning the childs education to families of students with disabilities although less targeted toward professional special education advocates the vap training primarily focuses on special education law training topics include evaluation and eligibility the components of an individualized education program free and appropriate public education least restrictive environment discipline and functional behavior assessment assistive technology and extended school year services in addition to these topics sessions on nonadversarial advocacy and dispute resolution are presented by local experts from the state protection advocacy agency and the arc the vap training has been shown to be effective in increasing participants special education law knowledge and comfort with nonadversarial advocacy activities such as effectively participating in iep meetings although upon completion trainees are prepared to advocate for families it remains unclear how program graduates use these skills over time as part of the vap program graduates are asked to volunteer as an advocate for at least four families but the exact nature of such educational advocacy remains unclear due to differing meanings of the term itself according the council of parent attorneys and advocates which focuses on special education advocacy an advocate is defined as …someone who speaks writes in favor of supports advises or urges by argument in support of another person in the parent advocacy literature however the term advocate has been described differently in a variety of contexts approaches and activities to fulfill the postgraduation requirement of the vap training graduates may engage in a broadly defined range of advocacy activities related to the special education needs of the child with the goal of working towards provision of fape for students with disabilities however it remains unknown how these advocacy activities group together if graduates of advocacy training programs engage in the full range of these advocacy activities that support the education of students with disabilities and the wider disability community and if such activities change over time further although research examining volunteering more generally indicates that volunteer activity often continues over a relatively long period the field has only begun to identify the correlates of longterm volunteer advocacy for example balcazar et al found that future advocacy was predicted by prior experience and involvement with advocacy organizations but sustained volunteering may also be predicted by three other variables motivationfunction satisfaction and role identity the first of these variables motivationfunction concerns why people volunteer according to clary and synder six personal and social motivations are served by volunteering values expressing or acting on important values understanding seeking to learn more enhancement growing and developing psychologically through volunteer activities career gaining careerrelated experience social strengthening social relationships and protective reducing negative feelings or addressing personal problems in most studies of volunteers in the wider literature volunteers reported that the most important functions served by volunteering were values understanding and enhancement although these functions may also exist among volunteer advocates we do not know whether advocates prioritize or even share the same motivations a second of these hypothesized correlates concerns satisfaction not surprisingly those people who are more satisfied with volunteer activities show longer lengths of service and more continued volunteering motivation and satisfaction may also work together to predict sustained volunteering thus if ones motivation to volunteer aligns with the act of volunteering the degree of satisfaction may be greater because the volunteer has met these motivationsfunctions therefore volunteers who are satisfied because their motivations are met are more likely to continue volunteering in the longterm a third predictor involves role identity as a volunteer or the degree to which one identifies with and internalizes the role of becoming a volunteer that is the extent to which this role and the relationships associated with it become part of a persons selfconcept according to penner if one maintains an initial level of volunteering a volunteer role identity will develop which may in turn relate to both the number of hours of volunteering and the degree to which one intends to remain a volunteer consistent with the wider volunteer literature role identity has been proposed as one important dimension in the development of special education advocates but particularly for volunteer advocates role identity may be a broader construct which also encompasses involvement in a broader disability community that affords the opportunity for group membership and leadership this study then examines the posttraining advocacy of program graduates of a volunteer special education advocacy training to determine the correlates of sustained advocacy we surveyed six cohorts of graduates from a threeyear period to answer the following research questions what do sustained volunteer advocacy activities look like over time do existing measures of volunteering apply to volunteer advocates are greater amounts of advocacy correlated with role identity motivation and satisfaction and after completing the training are there differences between program graduates who volunteer as advocates compared to those who do not volunteer method participants respondents included 83 graduates of an advocacy training program from 20092012 participants were primarily white nonhispanic females who had at least a college degree most respondents were family members or parents of individuals with disabilities and many were nonschool service providers such as nonprofit employees or healthcare providers on average program graduates reported being very to extremely satisfied with the training on a five point scale procedure trainingall respondents attended 40 hours of training on special education law and advocacy skills in a southeastern state these sessions were provided either as twelve 3hour weekly trainings or six 6hour biweekly trainings participants either attended the sessions in person or at distance sites from which they viewed the webcast content the training was offered once every academic term with survey respondents recruited from six cohorts from fall 2009 through spring 2012 during this time period the training was run by a single coordinator with no major changes to content or mode of training delivery at the conclusion of the training graduates were asked to volunteer as an advocate for four families of students with disabilities graduates were either referred to families that contacted the vap for advocacy help or connected with families independent of the training program surveyin collaboration with past and current training program coordinators an online survey was created to better understand the advocacy activities and support needs of program graduates after feedback was obtained from the training advisory board and the survey was pilot tested by three individuals with knowledge of the training we created an online version of the survey in research electronic data capture once paper and online versions were approved by the university institutional review board redcap was used to disseminate the survey and store responses in an online secure database participants were recruited from a list of all program graduates who completed the training between 2009 and 2012 as our interest was in volunteer advocates we excluded any university students who completed the course for credit we then attempted to contact via email the remaining 169 graduates from six training cohorts six paper surveys were mailed to participants who did not have access to the internet or did not provide an email address in their contact information after multiple recruitment attempts we were unable to reach 11 graduates for whom we did not have uptodate contact information we thus received responses from 83 of the 158 graduates who we could contact and invite to complete the survey response rates were approximately equal across sites and the number of respondents was also proportional to the size of each cohort over the 3year period measures the survey consisted of four sections relating to demographic information questions about advocacy activities since completing the training motivation for volunteering and satisfaction and information about advocate role identity demographic informationrespondents provided information about their gender race ethnicity highest level of education and present occupation they also answered questions about their role including if they were parent or family member of an individual with a disability school personnel and nonschool service provider respondents could select as many roles as applied advocacyrespondents were asked if they had advocated for any families since completing the training if they answered yes they were considered posttraining volunteer advocates and were then asked how many families they had advocated for overall since completing the training program and in the last six months to learn more about the advocacy activities in which they engaged with each family respondents were then asked a series of followup questions about the frequency of specific advocacy activities as no validated scale exists of activities performed by special education advocates these questions were based upon the training curriculum along with input from special education advocates specifically if a trainee had advocated postgraduation we asked about the number of times they had advocated by writing a letter to the school or helping a family write a letter to the school communicating directly with the school on behalf of the family meeting in person with a family to discuss the special education needs of the child talking over the phone with a family to discuss the special education needs of the child completing a record review helping coordinate or speaking at a special education training helping coordinate or developing a forum or parent support group and referring a family to another advocate agency or attorney motivation and satisfactionto measure the motivation of advocates the volunteer functions inventory was modified to use language more specific to advocates the vfi measures the six personal and social functions served by volunteering which include values understanding enhancement career social and protective this measure consists of 30 items rated from 1 to 7 in addition on a scale from 1 to 5 respondents were asked to rate their satisfaction with the training and their satisfaction with volunteering as an advocate role identitya fiveitem measure of volunteer role identity was modified to apply to advocates these items were rated on a 5point likert scale from 1 to 5 items included advocacy is something i rarely think about i would feel at a loss if i had to give up advocacy i really dont have any clear feelings about volunteering as an advocate for me being an advocate means more than just advocating for individuals with disabilities and volunteering as an advocate is an important part of who i am participant identityin addition to the role identity scale respondents were asked to rate their identity through a series of questions about their involvement in the advocacy community currently in the future and as it has changed since training these items were developed based on input from special education advocates and the vap advisory board about opportunities for involvement in the local and state advocacy communities first respondents were asked about their current involvement in different types of advocacyrelated activities on a scale from 1 to 5 including involvement in disability advocacy networks such as the disability coalition on education involvement with other disability organizations such as the autism or down syndrome societies special olympics or the arc involvement in a disability advocacy social media group such as an advocacy facebook page and being in touch with other advocacy training program graduates in addition respondents were asked to rate the likelihood that one year from now they would be doing each of the following activities advocating through the vap advocating through another organization and informally working with families of individuals with disabilities they also answered the question as a result of completing the training how has your involvement in the disability field changed on a scale from 1 3 to 5 in order to compare advocates to nonadvocates participants were categorized based on their response to the question have you advocated for any families since completing the vap training those who answered yes will be referred to throughout the paper as advocates or volunteer advocates those who answered no will be referred to as nonadvocates because respondents varied in their amounts of time since graduation we calculated an average 6month advocacy rate for advocates by dividing the overall number of families helped by the number of 6month periods since graduation this variable was also calculated for each of the eight individual advocacy activities we also made several methodological decisions as 6month advocacy rates were not normally distributed for all correlations involving advocacy rates we used nonparametric statistics to understand relations among the eight types of advocacy activities we conducted a principal component analysis with varimax rotation for each factor of existing scales we calculated cronbachs alphas then each factors average item score which was used for analyses when comparing those who had advocated since completing the training we performed ttests and chisquares finally to control for multiple hypothesis testing we used a benjaminihochberg correction procedure for all analyses results sustained advocacy since completing the training 639 of trainees reported having advocated for at least one family with 361 not advocating for anyone the median of the average 6month advocacy rate for all program graduates was 050 families with a range from 0 to 200 families frequencyupon further examination of the 53 participants who advocated for families after completing the training 189 advocated for 12 families 226 for 34 families 189 for 57 families and the remaining 396 for 10 or more families for these 53 trainees who volunteered after completing the training advocacy frequency was steady across time these volunteer advocates reported helping a median of 55 families since completing the training 2 families over the last six months and an average 6month advocacy rate of 1 family all three measures were highly correlated across their time since graduation volunteer advocates were consistent in the numbers of families that they helped activitiessince completing the training volunteer advocates reported engaging in a median of six different types of advocacy activities out of the eight listed in the survey with a median of five types performed in the last six months the total number of types of advocacy activities in the last six months and since graduation were also highly correlated similarly for each of the eight advocacy activities individually the frequency over the last 6months and the average 6month rate were highly correlated all volunteer advocates reported that since completing the training they had talked to a family over the phone to discuss the special education needs of the child with almost all having met with a family in person to discuss the special education needs of the child and completed a record review the least common advocacy activity was coordinating or developing a forum or parent support group which was performed by 400 of all volunteer advocates since completing the training to understand relations among different types of advocacy activities we then performed a principal component analysis using the average 6month rate for each activity the eight advocacy activities loaded onto two factors the first factor named familyfocused explained 7209 of the variance with an eigenvalue of 577 and consisted of the following five behaviors referring a family coordinating or developing a forum or parent support group coordinating or speaking at a special education training talking over the phone with a family to discuss the special education needs of the child meeting in person with a family to discuss the special education needs of the child the second factor schoolfocused explained an additional 2014 of the variance and consisted of the three remaining advocacy activities taken together the two factors accounted for 92 of the variance volunteer scales to determine whether items grouped similarly for volunteer advocates compared to volunteers on whom measures were originally analyzed we calculated cronbachs alphas for subscales of the vfi and for the role identity scale volunteer functions inventoryfor this subsample of volunteers alphas for the six volunteer functions ranged from 79 to 90 with volunteer advocates rating most highly the functions of values understanding and social as table 3 shows these rankings are consistent with those from the wider literature both groups rated values and understanding as the most important functions for our sample of advocates 943 identified two or more important motivations from the vfi in the wider volunteering literature twothirds of volunteers reported two or more important motivations out of the six possible functions in the vfi in addition for these volunteer advocates all three of the highest rated functions were rated as some degree of important further all volunteer advocates rated values as an important motivation role identity scalevolunteer advocates had a high role identity scale score with an average of 425 out of 5 indicating agreement with role statements the five items of the role identity scale had a cronbachs alpha of 62 fourteen respondents strongly agreed with all five role identity items item 1 was rated most highly with 868 strongly disagreeing with the statement advocacy is something i rarely think about the lowest rated item i would feel at a loss if i had to give up advocacy had a mean score of 344 still signaling general agreement correlates of sustained advocacy although the amount of postgraduate advocacy was not correlated with the role identity scale vfi or satisfaction the average 6month advocacy rate for volunteer advocates did correlate with several aspects of involvement greater amounts of advocacy were positively correlated with the extent to which the individual was involved with other disability organizations and in touch with other program graduates the average 6month advocacy rate was also significantly correlated with the likelihood of advocating through another organization and informally working with families of individuals with disabilities in a year in addition the average 6month advocacy rate was related to the degree to which advocates involvement in the disability field changed as a result of completing the training comparison between advocates and nonadvocates although univariate analyses showed proportionally more parents advocating and fewer school personnel advocating graduates who did advocate after completing the training did not differ significantly on any demographic or training characteristics or on the six volunteer functions scales those who volunteered posttraining were more satisfied with volunteering as an advocate t 371 p 001 d 089 with a mean score of 433 compared to 345 on a scale from 1 to 5 role identityprogram graduates who advocated posttraining had significantly higher volunteer role identity scores t 344 p 001 d 079 these differences were also mirrored in individual items including i really dont have any clear feelings about volunteering as an advocate for me being an advocate means more than just advocating for individuals with disabilities and volunteering as an advocate is an important part of who i am comparing the number of advocates and nonadvocates who rated their role identity as highly as possible over a quarter of volunteer advocates reported this highest level of role identity compared to only 34 of those who did not advocate posttraining χ 2 699 p 008 significant differences were again noted for those items that more indirectly reflected increasing identities as a volunteer advocate through involvement since completing the training posttraining volunteer advocates reported greater change in their involvement in the disability field t 276 p 007 d 064 and one year in the future they were more likely to predict their own sustained longterm advocacy both through the training organization and through other organizations volunteer advocates also reported being more involved in disability advocacy social media groups such as advocacy facebook groups t 325 p 002 d 071 as shown by the large effect sizes the advocate role identities of graduates who volunteered posttraining were substantially larger than those of program graduates who did not volunteer as advocates discussion this study examined the posttraining advocacy activities of volunteers to understand the correlates of sustained advocacy it is important to train volunteer advocates who possess special education knowledge and advocacy skills and who use these skills to support families of students with disabilities over time this study has four main findings first this volunteer advocacy program seemed effective in producing advocates who demonstrate sustained volunteering in a variety of ways over time almost twothirds of program graduates went on to volunteer as advocates and numbers of families helped in the last 6 months in the time since the training and on average for 6month periods were all highly correlated thus advocates continued advocating at similar rates over time the types of broadlydefined advocacy activities were also stable with a median of six types of activities completed since graduation and types of advocacy activities grouping into those that were familyfocused and those that were schoolfocused such maintenance of the nature and frequency of advocacy activities over time is a key methodological issue and a challenge for many interventions in addition with almost twothirds of program graduates continuing to maintain nearconstant advocacy rates over time the cumulative number of families helped continues to grow although one might strive for higher percentages of graduates advocating post training such maintenance argues for the continued offering of special education advocacy training programs such as the vap second the established measures of volunteer motivation and role identity seemed valid for this population of volunteer advocates high cronbachs alphas were found for each of the five factors of the vfi and the motivations rated highest by volunteer advocates values and understanding were identical to the most important functions rated by volunteers more generally similarly for this sample the five role identity scale items converged on a single factor with advocates reporting high role identity overall then volunteer advocates although focused on the highly specialized area of special education were similar to volunteers in general for several major volunteering constructs third we identified important correlates of sustained advocacy the average 6month advocacy rate significantly correlated with several participant role identity involvement questions indicating that role identity may be a more complex construct for volunteer advocates than for volunteers more generally specifically those who advocated at higher rates were more involved with disability organizations and with other program graduates participants also predicted that in one years time they were more likely to be advocating informally or through another organization those who advocated more also indicated that their involvement in the disability field increased more as a result of completing the advocacy training finally postgraduate volunteer advocates rated their role identity significantly higher than did those who did not advocate in addition to mean differences between groups we also noted differences in percentages of extreme scores thus although 34 of those who did not advocate rated their role identity as highly as possible over a quarter of postgraduate volunteer advocates considered themselves at this highest possible level of role identity greater amounts of advocacy were also positively related to involvement in the wider advocacy and disability community taken together these findings highlight the importance of role identity and the potential for advocacy training programs to either change or intensify such identity indeed role identity has recently received attention throughout a variety of fields within disabilityfamily studies for example parents of children with disabilities often report positive changes in their lives their new roles as parents of children with disabilities may serve to redirect their life choices and identities even including acquiring a new vocation as a result of their parenting experiences such changes are similarly noted for identity formation in professional training in both cases a discrete experiencebecoming a parent of a child with disabilities or undergoing training in a particular fieldleads to clear changes in ones behaviors and values in other ways as well volunteer advocates experienced change thus in the professional socialization of graduate students discussion has focused on both identity formation and on intellectual communities among program graduates as well successful advocates were like parents of children with disabilities both adopting the acquired role of an advocate and discovering a community of likeminded advocates they were more involved in the disability field more likely to advocate in one years time and more likely to participate with other advocates in disability social media groups in this sense then becoming a longterm committed advocate involves both personal and interpersonal transformationsit encompasses changes or intensifications in who one is and with whom one associates implications for practice this study has several implications for practice when training volunteers who will use their skills in the community to help other families navigate the special education process programs should consider trainees motivations satisfaction and role identity as indicated by our findings graduates who were more satisfied and had a stronger identity as an advocate were more likely to advocate posttraining to foster such posttraining advocacy the role identity of advocatesintraining should be explicitly developed during training specifically advocacy training programs might develop group membership by referring to trainees based on their cohort which helps volunteers to internalize the volunteer role as part of a personal identity a training program might also have trainees sign a list with the names of past graduates at graduation or provide an advocacy related memento that is only given to program graduates at training completion a training model should work directly to foster the development of this advocate role identity which is considered one of the best predictors of sustained volunteering for those graduates who did advocate after graduation greater amounts of sustained advocacy also correlated with more involvement in the wider disability community this context for role identity demonstrates the importance of a social structure to attach meaning and expectations to identity to build on this part of role identity training programs might in the days and weeks after graduation more explicitly involve trainees in the larger disability network training programs might collaborate with existing family support agencies such as parent training and information centers protection and advocacy agencies and university centers for excellence in developmental disabilities trainers might also help to engage program graduates in disability social media support groups and social networks by forging relationships with other disability agencies and intentionally involving trainees in the larger disability network participants may feel more connected to the wider disability community thereby increasing their postgraduation advocacy activities additionally considering the distinction between familyand schoolfocused advocacy activities the trainers who direct such programs might foster in their trainees particular areas of advocacy specialization for example certain advocates might specialize in familyfocused advocacy activities learning more how to work with families on their childs special education needs and mentor families as they gradually become their own selfadvocates in the special education system trainees might also specialize in more traditionally defined schoolbased specialeducation advocacy more intensively learning to communicate with the school and attend iep meetings on behalf of families although our program graduates engaged in both types of advocacy activities by developing clearer more intensively trained areas of expertise volunteer advocates might have even greater impact on both parents and schools future research and limitations beyond replicating these findings with other programs and types of participants future studies might examine whether volunteer motivations also exist for other advocacy trainings which do not emphasize volunteerism for example the seat program does not require a volunteer component it would be interesting to see which motivations affect the posttraining advocacy rates of seat participants additional research is also needed to better understand the motivations of volunteer advocates especially given that many volunteer advocates are themselves parents or family members of an individual with disabilities are volunteer advocates predominantly motivated to help their own child or to support other families and does this self vs other balance change with program participation and identity development also for participants who are parents of students with disabilities how do their experiences in special education affect their motivations as advocates or their area of specialization in addition although the items of the role identity scale were consistent and hung together in identical ways as in the general volunteer literature the role identity construct may be more complex and varied among volunteer advocates findings from this study were also correlational and directionality of findings cannot be inferred it is unknown whether advocate role identity developed over time as program graduates engaged in formal and informal advocacy activities or if certain trainees had previously identified themselves as advocates and felt strongly about this role identity when they began the training although we measured changes over time in advocacy activities we did not measure advocacy role identity prior to training or at program graduation longitudinal research can also be used to better understand differences in the characteristics of those program graduates who go on to advocate for many families compared to those who only advocate for the four families as part of the program requirement if we are able to identify such characteristics of more active advocates we will better understand how advocacy training programs can recruit certain participants who are likely to be most active in special education advocacy through such research we can also learn how to tailor training materials to participants along this continuum of sustained advocacy beyond sustained advocacy future research is also needed to examine the outcomes of the actual volunteer advocacy process for program graduates and families for those families with whom the trainees engaged in formal schoolfocused special education advocacy what were the outcomes were the families satisfied with affective and informational support what were the procedural outcomes many unanswered questions exist regarding potential positive and negative results of using special education advocates to fill the role of attorneys at different points in the disputeresolution process the risks and benefits for the advocates themselves as well as for the child family and school district must all be considered additional limitations relate to the specifics of this study itself our study had a relatively small sample size and moderate response rate it is possible that respondents represent a particular subset of graduates from our training however respondents were proportionally distributed across cohorts and similar response rates were demonstrated across sites in addition given that only 64 of respondents reported having advocated for any families which is a requirement of the training it seems unlikely that this sample represents a selection bias further efforts were made to disseminate surveys to all graduates including those who lived in more rural areas and did not have access to the internet regardless caution must be exercised in interpreting these results which may reflect only a particular subset of volunteer advocates in addition vap graduates were primarily female white and highly educated and results cannot be generalized to a more culturally and economically diverse sample despite these limitations this study is one of few to examine the activities of volunteer advocates over time given that the need for such formal and informal supports seems unlikely to diminish we as a field need to develop a better understanding of special education advocacy and how trained advocates perform over time families face many challenges in interacting with schools and understanding complicated special education law at a time when special education policy and practice are only growing more complex programs need to successfully train advocates in special education law we need to know more aboutand to provide support forthose individuals who once trained engage in sustained volunteer advocacy for families of students with disabilities

parents of students with disabilities often receive support from special education advocates who may be trained through a variety of programs using a webbased survey this study examined the postgraduation advocacy activities of 83 graduates of one such volunteer advocacy training program in the 14 years after program graduation 638 53 of 83 of the graduates advocated for one or more families these sustained advocates reported stable rates of advocacy over time and advocates performed activities that were either familyfocused or schoolfocused for graduates who advocated posttraining amounts of advocacy were positively related to satisfaction with advocating and with higher levels of involvement with other advocates and with the broader disability community compared to those not advocating after graduating sustained advocates reported greater advocacyrole identities increased involvement in disability groups and higher likelihood to advocate in the upcoming year future research and practice implications are discussed

introduction suicide is the second leading cause of death among ages 10 to 34 and a major crisis among adolescents and young adults division of violence prevention 2015 although the causes for suicide are multifactorial most cases are linked to psychopathology and particularly to depression as depression also continues to rise among adolescents and young adults it is important to develop an understanding of factors that may contribute to or buffer against depressive symptoms andor suicide risk in order to prevent the continued acceleration of these interconnected threats social relationships with family and peers have been identified as particularly important categories of risk and protective factors but most research has examined these factors as a few independent indicators of risk rather than as a complex and interactive microsystem this method limits both theoretical understanding and applicability of findings to improvements in identification and treatment of atrisk youth therefore the current study seeks to explore unique and complex associations between family and peer factors with depressive symptoms and suicide risk in a highrisk residential sample the microsystemic social environments of adolescents and young adults have a profound effect on psychological development ecological models of development and health illustrate the influence of context on individual health and psychosocial wellbeing such models encourage the examination of both proximal and distal factors surrounding a person to understand the interrelatedness of multiple embedded systems of influence extant research suggests that there are two critical microsystems that are especially important for understanding common but pervasive mental health symptoms in adolescents the family and the peer group the quality of relationships with family and peers are particularly potent factors contributing to risk for depression and suicide close and trusting relationships with family members and peers build support facilitate coping and promote a sense of belonging the opposite is also true when adolescents and young adults experience conflict with their families and isolation from peers this contributes to stress and impacts psychosocial functioning indeed family and peer factors have been associated not only with the development of clinicallyrelevant symptoms but also with treatment trajectories and outcomes family factor research has identified several specific and potentially important risk factors that may help prevent or contribute to the development of depressive symptoms and associated suicide risk in adolescents and young adults first parental criticism can be a potent risk factor youth who perceive high levels of parental criticism are at increased risk for depression and suicidal thoughts and behaviors similarly conflict in the home is robustly associated with depressive symptoms and suicide risk furthermore a lack of perceived parental support is consistently associated with risk for developing depression as well as risk for suicide attempts finally youth who perceive less parental monitoring may be at greater risk for depression importantly longitudinal studies suggest that psychological symptoms often follow not precede these types of family factors that is family conflict and criticism may be risk factors for later development of psychological symptoms and these associations are not merely reflecting deterioration in close family relationships following the onset of symptoms positive and negative experiences with peers can also influence psychological wellbeing including risk for depressive symptoms and suicide positive experiences such as friendships have small but consistent negative associations with depressive symptoms longitudinal research suggests that highquality friendships may protect against later depression symptoms whereas lack of friendships and feelings of isolation may damage youth psychosocial health negative experiences such as bullying are also associated with depressive symptoms and suicide risk over time notably it is important to distinguish between different types of bullying such as physical and cyberbullying which may have different associations with depressive symptoms however these family and peer factors should not be understood as simply a collection of factors that may be added and subtracted to understand individual risk of depressive symptoms or suicide first much of this research has examined family and peer factors separately without accounting for possible overlap this makes it difficult to determine which factors may be the most important second and even more crucially more complex effects like interactions and nonlinear associations have been underexplored while many studies suggest direct linear relationships between family and peer factors and youth mental health others suggest that in actuality these mechanisms interact in complex ways for example one study found that supportive peer relationships were associated with lower depressive symptoms only under conditions of low family support these supportive peer relationships were associated with an increase in depressive symptoms for adolescents with a high degree of family support interestingly other studies have found the opposite supportive peer relationships were only associated with lower depressive symptoms under conditions of low family conflict some studies also suggest that family factors may have curvilinear rather than linear associations with psychological outcomes for example poor family control may be a risk factor for poor adjustment but higher levels of family control have diminishing returns therefore examining factors in isolation and excluding the possibility of nonlinear and interactive associations may lead to incorrect conclusions about the role of family and peer factors in depressive symptoms and suicide risk there is a clear need for a detailed examination of potentially unique nonlinear and interactive associations between family and peer factors with depressive symptoms and suicide risk however for this examination to be meaningful for research theory and practice it is important to account for a few additional considerations first studies suggest the effects of family and peer factors on youth mental health may be moderated not only by other social relationship factors but also by demographic factors gender appears to be a particularly salient moderator in previous research depressive symptoms are more common among girls than boys and differentiated social roles for boys and girls may result in family and peer factors affecting youth differently second the majority of the research that examines combined and complex effects of family and peer factors has only considered depressive symptoms not suicide risk as these outcomes are often linked it is critical to determine whether these family and peer factors are uniquely related to suicide or primarily through increases in depressive symptoms finally these associations are particularly important to explore in higherrisk clinical populations due both to the severity of risk and the potential for differences in how family and peer factors are associated with risk in clinical samples compared to more general youth and young adult samples current study taken together it is important to examine previouslyidentified family and peer factors with the expectation that they will each be associated with depressive symptoms andor suicide risk in adolescents and young adults furthermore based on previous research and theoretical understanding nonlinear and interactive effects are anticipated between these factors which must be understood to draw conclusions about the true effects of these family and peer factors based on previous research interactions are also anticipated with demographic factors which may shed light on which family and peer factors may be uniquely important for certain demographic groups finally given the association between depressive symptoms and suicide risk at least some associations between family and peer factors with suicide risk are expected to be mediated by depressive symptoms method procedure the deidentified data used in this current study comes from a larger quality improvement project at a privatelyowned multisite psychiatric residential treatment center which provides both outpatient and inpatient care to youth with different and cooccurring conditions data were collected from 2019 to 2020 staff administered the assessment battery at the intake meeting using the electronic bhworks platform the assessment takes approximately 15 minutes and scores are automatically computed and uploaded into patients electronic medical record system as part of their research agreement with drexel university newport institute provides drexel university with deidentified data for analysis and publication approval for use of this data for the current study was given by the treatment center and the drexel university irb deemed that this was not research activity that needed irb approval measures all variables were drawn from the behavioral health screen a tool developed by diamond et al to increase detection of behavioral health problems in medical settings questions were derived from the diagnostic and statistical manual of mental disorders fourth edition text revision criteria and other public domain psychosocial assessment tools the bhs includes 13 modules assessing demographics medical school family safety substance use sexuality depressive symptoms anxiety nutritioneating suicide psychosis and traumatic distress there are 55 core questions with an additional 38 followup items the bhs is currently used in 40 medical sites and 500 schools across pennsylvania and is being rolled out in four other states psychometric validation has supported the validity and reliability of the scales parental monitoring participants selfreported how often their parents knew their location on a threepoint likerttype scale family conflict participants selfreported frequency of arguing in the home on a threepoint likerttype scale family support participants selfreported frequency of turning to parents or other adult family members for support on a threepoint likerttype scale parental criticism participants selfreported perceived frequency of parental criticism on a fivepoint likerttype scale ranging from 1 to 5 interactions with friends participants selfreported frequency of interactions with friends on a threepoint likerttype scale verbal bullying participants selfreported frequency of being victimized by verbal bullying on a threepoint likerttype scale physical bullying participants selfreported frequency of being victimized by physical bullying on a threepoint likerttype scale cyberbullying participants selfreported frequency of being victimized by cyberbullying on a threepoint likerttype scale depressive symptoms depressive symptoms were assessed using the bhs depressive symptoms subscale this measure has shown strong reliability factor validity and criterion validity in previous studies using a threepoint likerttype scale patients rated how often the following five depressive symptoms occurred within the past 2 weeks consistent feelings of being down loss of interest in things previously enjoyed unexplained irritability or anger loneliness and feelings of failure reliability was good in this study items were averaged to produce a single score for variable selection in structural equation models items were treated as indicators of a latent construct suicide risk suicide risk was assessed using the bhs current suicide risk subscale this measure has shown strong reliability factor validity and criterion validity in previous studies patients rated whether they experienced suicidal ideation made plans to commit suicide or attempted suicide over the past two weeks reliability was acceptable in this study for variable selection a single dichotomous score was created indicating the presence or absence of any suicidal indicators in structural equation models items were treated as indicators of a latent construct results preliminary analyses mahalanobis distance test detected and removed 13 multivariate outliers means standard deviations and intercorrelations are found in table 1 approximately 723 of the sample reported current suicide ideation 473 suicide plans and 427 suicide attempts the average depressive symptom score of 214 was just below the previouslyidentified cutoff of 220 for moderate depressive symptoms approximately 524 of the sample was above this cutoff and 308 of the sample was above the cutoff for severe depressive symptoms less than 13 of participants had missing data on any of the key variables these participants were included in pairwise analyses wherever possible identifying possible main interactive and nonlinear effects sparse interaction models were estimated using hierarchical lasso in the r package hiernet the package hiernet tests all possible twoway interactions and quadratic effects and allows for weak or strong hierarchy to ensure that only meaningful secondorder terms are included in strong hierarchy interaction terms are included in the lasso only if both constituent main effects are selected for the model whereas in weak hierarchy interaction terms are allowed if at least one of the main effects is selected weak hierarchy was specified and 10fold crossvalidation was used to select the best value of λ using the lambda1se criterion a total of 132 possible terms were tested 11 main effects 110 twoway interactions and 11 quadratic effects age was continuous gender and race were dichotomized given the predominantly binarygendered and white sample of the predictors all except race parental monitoring family support and physical bullying were selected as main effects by the lasso procedure for depressive symptoms four interaction terms were selected family support x gender cyberbullying x gender interactions with friends × cyberbullying and interactions with friends × physical bullying there was also one quadratic effect for cyberbullying this was positive suggesting that the impact of cyberbullying increased with frequency as a followup analysis a lasso was tested for current suicide risk however this only indicated gender therefore nine main effects one quadratic effect and four interactions were included in all subsequent analyses interactions the two gender interactions are plotted in fig 1 using the r package sjplot the family support × gender interaction suggests that in conditions of low family support female respondents reported more depressive symptoms than did male respondents at moderate or high family support there was no difference in depressive symptoms between male and female respondents there is a similar finding for cyberbullying among those never cyberbullied female respondents have increased depressive symptoms but there is no difference among those sometimes or often cyberbullied the two interactions between bullying and friendship are plotted in fig 2 both suggest that youth often spending time with friends are at lower risk for depressive symptoms only if they are never physically or cyberbullied associations with latent depressive symptoms and suicide then a structural equation model was tested in the r package lavaan using the diagonally weighted least squares estimator wherein latent depressive symptoms were predicted by identified predictors and latent suicide by the same pool plus depressive symptoms good fit was predetermined as cfi ≥ 095 srmr ≤ 008 rmsea ≤ 006 and scale items were expected to have good loadings indirect effects on suicide through depressive symptoms were also tested standard errors were computed using 5000 bootstrap draws all candidate variables selected were then entered into a single structural equation model wherein all candidate predicted both depressive symptoms and suicide risk overall fit was good χ 2 12469 p 0072 cfi 0997 rmsea 0015 srmr 0058 all items had good loadings on their factors the lowest loading was 067 the model explained 29 of the variance in depressive symptoms and 50 of the variance in suicide standardized estimates are shown in table 2 nearly all included predictors were significant except for cyberbullying and the friendship × cyberbullying interaction taken together older age female gender family conflict parental criticism a lack of interactions with friends and the experience of verbal bullying all explained unique variance in depressive symptoms moreover as depicted in figs 1 and2 the relationship between depressive symptoms and gender was moderated by family support and cyberbullying and the relationship between depressive symptoms and lack of friendship interactions by physical bullying on the other hand outside of the sizable association between depressive symptoms and current suicide risk only age and family conflict shared unique associations with suicide risk mediation by depressive symptoms indirect effects were also tested as shown in table 2 indicating whether associations of family and peer factors with suicide risk were mediated by depressive symptoms several variables had significant indirect effects on suicide through depressive symptoms suggesting possible downstream associations the final model dropping nonsignificant paths is illustrated in fig 3 this model also fit well χ 2 12359 p 0054 cfi 0996 rmsea 0016 srmr 0057 alternate model analyses additional analyses examined the lasso model for each suicide risk indicator separately with and without the inclusion of depressive symptoms this did not select additional variables not already included by the depressive symptoms lasso discussion approaches for understanding and predicting risks for adolescent depressive symptoms and suicide are still evolving the current study used a multidimensional approach by studying the interconnected nature of family and peer influences on individual health following variable selection parental criticism family conflict verbal bullying and interactions with friends alongside demographic factors of gender and age were all found to be uniquely associated with depressive symptoms gender and frequency of interactions with friends were significantly moderated by other family and peer factors although only family conflict and age directly predicted suicide risk above and beyond depressive symptoms indirect associations through depressive symptoms were supported for other variables and should be explored further in longitudinal research there are several strengths of the current study first the study examined a highrisk clinical sample of adolescents and young adults many of whom reported severe depressive symptoms and suicide risk therefore family and peer factors that emerged as particularly salient in this sample are likely to be relevant for identifying those adolescents and young adults at greatest risk for severe outcomes although this is a crosssectional study better understanding of these factors may lead to advances in prevention intervention and treatment particularly in the era of covid19 which has greatly disrupted interpersonal relationships the robust association of interactions with friends with depressive symptoms suggests that methods for developing and maintaining these potentially protective relationships are crucial for the psychological health of adolescents and young adults finally the methodology of the current study also follows recent recommendations involving the use of datadriven approaches to examine multiple variables and complex relationships given the difficulty in predicting suicide and other severe consequences of depressive symptoms studies that examine multiple interactive risk factors are crucial for advancing understanding of how these relational processes may influence psychological wellbeing however several limitations of this study should also be noted first the sample was highly racially homogeneous although race was not selected by the lasso this may be attributed to low power and the reduced sensitivity of this dichotomous variable second only patient report with single items was used multiinformant methods could also be used to gain a better understanding of relational processes beyond the patients own report third this study utilized a crosssectional approach and conclusions about directions of effects cannot be supported previous longitudinal research suggests that family and peer risk factors often predate mental health symptoms but these associations are also likely to be bidirectional similarly indirect effects suggested potential mediating pathways of family and peer factors on suicide risk through depressive symptoms but these should not be interpreted causally finally given the complex multifactorial causes of suicide it is crucial for future research examining more proximal family and peer factors to include other categories of risk factors including genetic factors and family context which may interact with the microsystemic social environment and depressive symptoms the current findings have implications for understanding how family factors related to depressive symptoms in adolescence and young adulthood first negative family experiences including parental criticism and family conflict emerged as particularly relevant for depressive symptoms this echoes previous research but further suggests that these effects are unique that is independent of factors like family support these two types of negative family experience appear to pose distinct risks on the other hand although the association between conflict and depressive symptoms was in the expected direction family conflict appeared to share a negative association with suicide risk after accounting for depressive symptoms suggesting more complex processes worthy of further investigation second positive family factors were not robustly associated with depressive symptoms or suicide this may be due to the clinical severity of the sample the developmental stage or the specific indicators other studies have found mixed results regarding parental monitoring and it is possible that other assessments of parental involvement may be more appropriate for older adolescents or young adults family support was measured by inquiring about interactional frequency while measures of interactional frequency might indicate support in normative samples families of distressed youth may be more likely to fail to respond to supportseeking or to respond negatively therefore it is important to examine multiple dimensions of family support and cohesion in order to understand how these function among atrisk youth there are also important implications regarding how peer relationships are associated with depressive symptoms in this study interactions with friends and verbal bullying emerged as particularly salient processes for depressive symptoms the role of peers becomes increasingly more important in adolescence and young adulthood and feelings of acceptance or isolation from peers can be highly consequential for youth mental health the moderation of interactions with friends by bullying suggests youth with both frequent interactions with friends and the absence of bullying are especially unlikely to endorse depressive symptoms on the other hand the benefits of friendships were not moderated by family factors in contrast to previous research however these interactive effects have been less robust in more severe clinical samples perhaps due to the greater likelihood and severity of family dysfunction in these populations in the presence of these dysfunctional families peers may serve a particularly important role in providing support and stability to distressed youth finally only verbal bullying was directly relevant for depressive symptoms this is somewhat surprising given previous research suggesting that cyberbullying poses a particularly large risk for depression conclusion family and peer factors are known to be associated with youth depressive symptoms and suicide risk but most studies examine these factors in relative isolation and without accounting for their interdependence without acknowledging the context in which family and peer relationship factors emerge it is difficult to estimate the unique contributions of factors like support and conflict particularly when the effects are not linear or depend on the levels of another factor the current study analyzed unique interactive and nonlinear effects of several peer and family factors associated with depressive symptoms and suicide risk in a highrisk residential sample of adolescents and young adults building on previous research the current results suggest that negative family processes and verbal bullying are associated with more severe and interactions with friends less severe depressive symptoms moreover gender differences were mediated by family support and cyberbullying and interactions with friends by physical bullying suggesting that examining individual peer and family factors in isolation may produce misleading results contrary to expectations however few factors were directly associated with suicide risk but several shared possible indirect pathways through depressive symptoms these results underscore the difficulty in identifying youth with suicide risk but also provide directions for advances in identification research and treatment for highrisk adolescents and young adults negative aspects of the family environment may be likely to outweigh any positives as distressed youth may receive support primarily from their peers however the increased importance of peer relationships also has a dark side youth with a history of peer victimization may be at high risk of depressive symptoms even when they have frequent interactions with their friends in sum relational factors with implications for depression and suicide do not occur in a vacuum and it is important to understand this complex microsystem to estimate the true impact of these factors on the psychological wellbeing of adolescents and young adults supervision and resources and helped draft the manuscript all authors read and approved the final manuscript funding funding was provided by the newport institute which has been using the behavioral health screen to evaluate patient outcomes across its entire organization data sharing and declaration this manuscripts data will not be deposited compliance with ethical standards conflict of interest the behavioral health screening tool was developed by gd and colleagues but is owned by childrens hospital of philadelphia they license the tool to medical decision logic inc a health science informatics and computer science engineering company gd may receive a small royalty payment for his part in developing the tool asr and the other coauthors do not report financial interests or potential conflicts of interest ethical approval the drexel university irb deemed this research not requiring irb approval informed consent patient consent for treatment and data collection was obtained by newport institute at admission publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors contributions asr conceived of the study performed the statistical analysis and drafted the manuscript jr helped conceive in the design and interpretation of the data pw helped draft the manuscript lr designed measurement and collected data and helped draft the manuscript gd helped conceive in the design provided alannah shelby rivers is a postdoctoral researcher at the center for family intervention science drexel university her major research interests include the influence of close relationships on mental and physical health and psychometrics jody russon is an assistant professor of human development and family science at virginia polytechnic institute and state university her major research interests focus on vulnerable youth particularly lgbtq adolescents and young adults payne winstonlindeboom is a project coordinator at the center for family intervention science drexel university her major research interests are in the mental and behavioral health of adolescents and young adults especially those who have dealt with family issues or trauma linda ruaniu is a postdoctoral fellow at the center for family intervention science at drexel university her major research interests focus on crosscultural assessment psychiatric diagnosis and assessment and suicidal behavior among youth guy

close relationships are consequential for youth depressive symptoms and suicide risk but nuanced research examining intersecting factors is needed to improve identification and intervention this study examines a clinical residential sample of 939 adolescents and young adults ages 10 to 23 years old m 1584 sd 153 977 white 995 nonhispanic 55 female the final model found that family conflict parental criticism verbal bullying and interactions with friends were associated with depressive symptoms in the expected directions and there were significant interactions with family peer and demographic variables however most associations with suicide risk were indirect associations involving family factors peer factors depressive symptoms and suicide are not always straightforward and should be understood within a microsystemic context

manju kapur is an acclaimed indian writer who possesses a high rank among the contemporary women novelists of 20th century as a literary artist she is a writer with purpose as her novels reveal the fact that she deals with serious issues related to women in indian society as a woman she is conscious of the gender discrimination in society it is an accepted fact that women have been exploited and treated unequally by men for yearsthey have been the victims to the socalled traditional patriarchal society for years though india got freedom in 1947 the condition of women is unchanged as they have to struggle hard to get an individual identity in society inspite of making various efforts they are the sufferers and have to face many challenges to cross the boundary of the conservative patriarchal society as patriarchal norms do not allow a woman to think and act freely as a writer manju kapur can be put in the category of those indian writers who brought a great transformation in indian writing as she deals with the dreams aspirations struggleand problems of women in a realistic manner as a woman she believes in feminine power and presents her female characters as bold and strong her novels reflect how the women pass through a period of transition and break the confining four walls of conservative patriarchal society as a woman she is concerned with women need for self expression self fulfillment and selfrealization her protagonists fight for freedom and individuality as they are in search of their true identity in patriarchal society through her female protagonists she presents the picture of society where women are aware of gender discrimination exploitation social injustice her novels are based on the actual incidents as the story of virmati is based on the story of her own mother in an interview with jo stimpson she reveals the fact i based my first novel on her i admire her fighting spirit her generosity her capacity to endure she irritated me when she was alive but now i see these things more clearly i think of her every day she deals with real characters representing the contemporary indian society her female characters are assertive and raise voice against the social injustice and patriarchal norms her works reveal the feminist struggle against patriarchy exploitation social restrictions sufferings of women identity crisis etc they crave for self identity selffulfillment and selfautonomy the novel difficult daughters is about the struggle of a woman through tradition to modernity it is the story of virmati an indian woman craving for freedom and selfidentity through virmati the writer presents the concept of new indian woman who has a longing for love freedom and individuality as a thinking womanshe raises the questions why is a woman not free to take her own decision for her life why is she not free to live life of her own choice why is she forced to follow the patriarchal norms why is she restricted to the unjust shackles of conservative traditions has she no right to think and express her thoughts freely can she not enjoy life as an individual like a man is marriage necessary for a girl has she no existence without marriage manju kapur is a serious thinker who raises the various problems related to women liberation and their place in society simon de beauvior says one is not born but rather becomes a woman no biological psychological or economic fate determines the figure that the human female presents in society it is civilization as a whole that produce this creature difficult daughters is the story of virmati who is born in an arya samaji punjabi family in amritsar being the eldest daughter in the family she has the pressure of household works and other family responsibilities she has eleven siblings and she was sixteen years old when her mother conceived the eleventh child since childhood she remains busy in looking after her siblings and helping her mother kasturi in other household duties here kapur presents the picture of an indian family where the eldest girl child is supposed to support her mother in performing domestic duties and other household tasks and the same is the case of virmati as she is supposed to do the homely tasks and other responsibilities related to her siblings the novelist calls virmati the second mother to her siblings she has a keen desire to study and to do a job but her mother kasturi a traditional woman is of the opinion that a girl should have study only to read and write as her basic need is to learn knitting sewing and cooking and other household works as both virmati and kasturi have different opinions the rising conflict is quite obvious between the mother and the daughter virmati has a dream to be educated like her cousin shakuntala who is a progressive independent woman manju kapur accepts the fact that womens higher education makes them more confident and ambitious as educated women emerge more successful and prove their individuality shakuntala is a new woman who opposes family tradition of early marriage she has done msc in chemistry and is teaching science in a college in lahore virmati is much impressed by her dressing sense activities and modern life style through shakuntala manju kapur presents the image of an empowered woman who is leading a free life of her own choice as herr outlook is modern as a new woman she is assertive and defies the patriarchal restrictions and fights for her rights she is bold outspoken and determined and inspires virmati to study and to look outside to education freedom as time has changed virmati is so much influenced by her that she realizes that education is a grat weapon for freedom and thinks that being educated is a way to get freedom and happiness the novelist remarks shakuntalas visit planted the seeds of aspiration in virmatiit was possible to be something other than a wife images of shakuntala pehnji kept floating through her head shakuntala pehnji who having done her mscin chemistry had gone about tasting wine of freedomno she had to go to lahore even if she had to fight her mother who was so sure that her education was practically over here the novelist presents virmati as the embodiment of liberation virmati wants to study further and even she is prepared to fight her mother kasturi who opposes her idea to continue her study further kasturi believes in the anceint popular indian myth that a girl is paraya dhan and it is the destiny of every girl to get married and to follow the family traditions she doesnt like the life style of shakuntala who defies the family traditions as a mother kasturi has the responsibility of the marriage of five daughters and is worried for them to her study doesnt mean to defy or disgrace family tradition as study helps in the development of the mind for the benefit of the family so she thinks that virmati should not think like shakuntala and says leave your studies if it going to make you so bad tempered with your family you are forgetting what comes first what good are shakus degrees when she is not settled will they look after her when she is old demanded kasturi irritably at your age i was already expecting younot fighting with my mother however the novelist depicts the true picture of an indian traditional family that is against the modernization of womenthe discussion between virmati and her mother kasturi depicts the conflict between traditional and modern outlookshakuntala is the embodiment of modernity but her ways are not approved by the traditional women like kasturito whom marriage and family are more important than study and freedomkasturi is the symbol of tradition and patriarchy vera alexander remarks in the juxtaposition of marriage and education education is either described in terms of a threat or portrayed as a dead end reducing accomplished female characters to obedient wifehood and dependency rather than enabling them to make a living out of their training though virmati hopes to live a free life like shakuntala she feels herself bound to the orthodox traditional shackles of patriarchy here the writer depicts the difference between shakuntala and virmati as the former i s like a free bird while the latter is like a caged bird fluttering its wings to break the cage open soon the family finds a suitable match for her marriage and forces her to get engaged with a canal engineer inderjit but virmati does not lose her hope and shows great courage to continue her study even after her engagement as a woman of strong will she struggles hard to continue her studies and follows her own way she joins as college to do baand meets harish an oxford return married proffesor as a mother kasturi does not realise her daughters need for love as she has no time to understand or share her daughters feelings and enthusiasm and thus consequently virmati shares her feelings with harish the professor and falls in love with him at this pointshe does not realise that her affair with a married man will be a cause of her sufferings in future it is a bold step on her part that she refuses to marry inderjit and thus challenges the family custom and patriarchal norms here virmati is the prototype of liberated woman who thinks of her happiness only and takes the bold step against the wish of family though she finds herself torn between her passion and her duty towards family she refuses to marry she challenges the family tradition as she has yearning to be loved though she realises that she has failed in performing her duty as a responsible sister and has disgraced the family she rejects the idea of marriage psudhashri remarks virmati the protagonist rebels against traditionyet she is filled with selfdoubt she pleads for studying further and postponement of her marriage she attempts suicide when faced with prospect of marrying the canal engineer the family brands her to be restless sick selfishand locks her up through the portrayal of virmati the novelist presents a woman of unyielding will power who has a zeal to live a free and meaningful life and decides to break her relationship with the professor she informs the professor that she is going to lahore for further studies as she desires to be a teacher like shakuntala as an optimistshe has great hopes for her futureso she decides to end her relationship with the professor and burns all the letters he has ever sent to her she is termed as the difficult daughter to the family as she challenges the family tradition the family was against her study but they have to yield to her wish and finally she is sent to lahore for further studies here her life takes a positive turn ad she starts a new phase of her life as a strong woman she possesses the strength of mind and decides to give a new turn to her life in lahore she came under the influence of strong independent women like shakuntala and swarna lata who constantly motivate her to take part in social and political movements she is much impressed by her room mate swarna lata who is an active participant in the freedom struggle movementswarna lata a new womanis a clear headed committed activist who follows her own ideology and fights for women liberation and the upliftment of the social values through the character of swarna lata the novelist depicts an assertive dynamic modern woman who emerges as the stout champion of womanhood as a committed feminist she is firm advanced and action oriented young lady she asks virmati to join the demonstration against draft hindu code bill come and demonstrate with us against the draft hindu code bill next saturday outside the railway station men dont want family wealth to be divided among women say their sisters get dowry thats their share and the family structure will be threatened because sisters and wives will be seen as rivals instead of dependents who have to be nurtured and protected as a result women will lose their moral position in society imagine as a woman the novelist feminist concern is quite obvious here as she supports the equal rights for women in the male dominated patriarchy where men are not ready to accept women as their equals according to her it is a matter of great surprise that women who have the equal intellectual and mental capacities like men are regarded inferior to men in a patriarchal familyswarna lata may be called the mouthpiece of the novelist as through her kapur expresses her own views regarding the equality of women in patriarchal family virmati is so much influenced by her dynamic and advanced life style that she desires to be an intellectual dynamic personality like her swarna lata attends various political conferences and rallies and wants to do something beyond marriage and family her modern outlook is quite obvious in her conversation with virmati marriage is not the only thing in life viru the war the satyagraha movement because of these things women are coming out of their homes taking jobs going to jail wake up from your stale dream though virmati feels much impressed by her opinions she is unable to check her passion for the professor who comes to meet her in lahore she falls an easy prey to the professor and gets pregnant swarna lata helps her in aborting the child and motivates her to get involved in social activities of women liberation swarna lata is an advanced straight forward and mature thinker who follows her own opinions independently without any fear or doubt according to christopher rollason the pages of difficult daughters speak not only of virmati but of other difficult daughters who succeed better than she did in their parrallel struggle for independence in their lives at the centre of the narrative we are confronted with a woman who fights but falls by the wayside but at its edges as no doubt less representative but still symbolic figures we encounter as will be seen below other women whose relative success points the way to the future as a realist manju kapur has successfully presented the fact that women played an active role in the satyagraha movement and other social and political movements related to womens rights and freedom struggle virmati noticed that women are crossing the threshold of homes and coming outside to be the part of social activities she also attends many conferences and rallies with swarna lata and hears many inspiring speeches delivered by strong intellectual women like leela mehta and other women nationalists she realises that these women are fully devoted to the cause of women liberation and independence of the country she feels an inner conflict and asks herself is she an intellectual like these women who are free strong and taking part in the freedom struggle is she free the author says am i free thought virmati i came here to be free but i am not like these women they are using their minds organizing participating in conferences politically active while my time is spent being in love wasting it well not wasting timenoof course not but then how comei never have a moment for anything else however she feels great confusion in her mind as what to do there is a conflict between her passion for love and freedom struggle she blames the professor for disturbing her life in lahore she curses herself to be an easy prey to harish again she shows marvellous will power in overcoming her passion for harish and starts a job of a headmistress of a girl school at nahan it is a respectable job and now she is an independent woman living her life like a free bird without any problem her job made her economically independent and her life takes a positive turn as it is happiest period of her life she finds a suitable place to live away from her family earning her own money she is leading her life happily teaching girls at school as an educated woman she succeeds in asserting herself and establishes her individual identity in society however virmati emerges as a bold selfreliant woman who has a positive vision of life she adjusts herself in the new surroundings and shows remarkable courage and power to control her life as an educated woman she possesses the sense of selfworth and finally succeeds to find a proper place in society as a rebel she challenges the social practices and breaks the shackles confining women within the four walls of home and gets a proper identity of her own though she is happy and satisfied with her free life here she has no desire to live a lonely life as a woman she feels the need of a man in her life as she wants to fulfill her life with love unfortunately she developes her relationship with the professor again and loses her job as the school authorities come to know about her illicit relationship with the professor inspite of losing her jobshe has courage and goes to shantiniketan she decides to marry the professor and becomes his second wife but she is still a restless as she feels herself alienated in the family his family does not welcome her and the latter has to bear insults in his home virmati has married to get love happiness peace and security but it seems that her life is devoid of the desired peace and happiness though she succeeds to get the marital statusshe has to bear oppostion in the family and thus her search for identity and proper place in her laws home restarts to her the only comfort is the love of her husband harish who always wants an educated companion actually she knows it well that being the second wife she has to bear some opposition in society as her family is also against her marriage with the professor she is sure that her family will never accept her relationship with him as she has disgraced family in the past and her mother and family curse her yet she is happy with the man of her choice and promises herself a blissful marriage she accepts her marriage as her husband is everything for her thus she takes a bold step by marrying the married professor as a bold womanshe succeeds to show the society that women can defy the patriarchal dogmatism and conservative taboos in society and can bring a revolution in the society though she has to bear the hatred and curses of ganga harish first wife and his mother she tries her best to adjust in her husbands home at last she enjoys the company of her phusband at his home when the whole family shifts to kanpur due to partition riots finally she gets free space for which she has struggled hard yet sometimes she feels guilty as she becomes the cause of the sufferings of gangashe also realizes that she did not fulfill her responsibility as a daughter and sister and destroys the good name of her family through she is bold enough to overcome the social and traditional barriers she has to suffer a lot for all this she conceives and gives birth to a daughter ida np sharma remarks virmati has to fight against the power of the mother as well as the oppressive forces of patriarchy symbolised by the mother figure the rebel in virmati might have actually exchanged one kind of slavery for another but towards the end she becomes free free even from the oppressive love of her husband once she succeeds in doing that she gets her husband all by herself her child and reconciliation with her family ida virmatis daughter is also portrayed as a rebel who revolts against social conventions she is not prepared to become a puppet in the hands of her husband prabhakar who was approved by her parents for marriage she married him to please her parents as ida says because you thought prabhakar was so wonderful and i was glad that in the choice of my husband i have pleased you prabhakar denies ida maternity and forces her to have an abortion as a result ida breaks up her marriage as he does not want a baby from her as a new woman she rebels against the deep rooted family norms of male dominated society ida is the product of postindependence era she establishes herself as a new independent woman she transcends the social restrictions and fights for her identity dignity and individuality again the novelist presents the difficult relationship between mother and daughter as the very first line of the novel the one thing i had wanted was not to be like my mother depicts the complicated relationship of ida and her mother virmati ida says when i grew up i was very careful to tailor my needs to what i knew i could getthat is my female inheritancethat is what she tried to give me adjust compromise adapt assertion though difficult to establish is easy to remember regarding mother daughter conflict manju kapur herself asserts that conflict between mother and daughter is inevitable and i suppose i was a difficult daughterthe conflict carries on through generation because mothers want their daughters to be safewe want them to make right choicesright in the sense that they are socially acceptable my mother wanted me to be happily married i want my daughter to have good jobs ida is a difficult daughter to virmati as the latter was to her mother kasturi ida rebels against virmati and follows her own way ida refused to show any signs of intellectual brightness there are other things in life she told her mother like what asked virmati like living you mean living only for yourself you are disappointing your father why is it so important to please him i grew up struggling to be the model daughter pressure pressure to perform day and night she is not ready to bear pressure any more and decides to break her loveless marriage with prabhakar she is introduced to the reader as a middle aged divorcee who visits amritsar and lahore and meets her mothers relatives to know about her mothers painful past she wants to understand her mother virmatis life she relates to her mother virmati when she comes to know that virmati too had an abortion ida feels miserable as her husband and her abortion both were not chosen by her the book connects both mother and daughter as both were not different she experiences a strong bond with her as she says without her i am lost i look for ways to connect ida is strong independent woman who takes a bold step by freeing herself from the hollow relationship on the other hand virmati who is also an educated woman with her individuality and challenges the patriarchal norms but fails to show her courage in matter of love and cant think beyond her husband and marriage but ida is brave enough to end her relationship with prabhakar as he had forced her to abort the fetus idas conscious decision shows her strength of mind and heart thus it becomes clear that manju kapur is a committed writer who has firm faith in the female strengthas a feminist writer she has successfully presented the concept of new women and their struggle to freedom in patriarchal society her female characters ida shakuntala virmati swarna lata are assertive self reliant progressive women who show remarkable will power and transcend the age old social restrictionsthrough their portrayal the novelist portrays the female desires ambitions and expectationsthey are highspirited women who fight to be free from the stale social restrictions and attain freedom they are aware of gender discrimination women liberation and their empowerment and raise voice against social injustice and gender inequality and get victory over it by establishing their identity as new women they participate in social and political movements for freedom struggle they are aware strong willed self reliant beings having faith in the inner strength of womanhood works cited

the purpose of this paper is to study the evolution of feminist power and the emergence of new woman in the novel difficult daughters manju kapur is an eminent novelist who can be put in the category of those women writers who brought a remarkable transformation in the representation of women characters as a woman she is concerned with the problems of indian woman in the patriarchal family and deals with various feminist issues as gender equality freedom from discriminationright to education marriage abortion autonomy womens property rights oppression etc in the novel difficult daughters virmati is a typical daughter to her mother as she opposes the patriarchal norms for self identity women are discriminated and devoid of their basic rights in the patriarchal societyher female protagonists are educated women with independent thinking who follow their own ideology her novels present the position of women and their struggle in the contemporary indian society as a woman she successfully highlights the feminist struggle against patriarchy exploitation her female characters reveal feminist power and represent the new women who are thinking questioning and rational beings and raise a voice for basic rights self identity and survival

introduction since 2000 international branch campuses have grown to be a unique feature in the global higher education system despite this altbach and de wit have suggested many ibc struggle to provide comparable education in receiving countries as their home institutions due to differing sociopolitical and economic environments moreover complicated geopolitical environments can make running ibcs unsustainable in early 2015 altbach identified several unsustainable aspects of ibcs such as inferior education quality resulting from high turnover rates among foreign faculty limited curriculum and infrastructure the difficulty of sustaining quality applicant pools and competition with local institutions recent research has additionally raised ethical concerns regarding ibcs such as the building of western ibcs in the global south as a neocolonial practice in line with this strand of literature the current study applies colonial discourse analysis to explain how whiteness and colonial patterns embedded in ibcs continue to cause harm to local and global communities ibcs often employ the discourse of internationalization to distinguish themselves from local institutions and to attract prospective students especially wealthy ones buckner and stein have argued that although higher education institutions around the world are engaging internationalization they often lack a clear understanding of internationalization specifically ibcs often reproduce the imaginary of whiteness as futurity by positioning themselves as providers of worldclass educations in the global south contexts and presenting western knowledges and experiences as international in the past few years china has surpassed the united arab emirates and become the top host country of ibcs to understand this phenomenon it is important to understand how the concept of internationalization has been mobilized by chinese he and ibcs in particular in this article i look at how ibcs in china define and promote internationalization in he how whiteness is reproduced through the discourse of worldclass education and how whiteness as futurity is reflected and reinforced in the development and operation of ibcs i employ colonial discourse analysis to conduct a case study that analyzes publicly available branding materials on the whenzoukean university website and draw on shahjahan and edwards framework of whiteness as futurity to understand how whiteness is mobilized and reproduced through representations that uphold the western supremacy internationalization and chinese higher education in addition to the trend of globalization and many he sectors efforts on internationalization the establishment and growth of ibcs around the world is the result of several overlapping factors including reductions in public funding for he from local and national governments in the west these reductions have driven universities to instead seek international profit via ibcs importantly some have argued that there are neocolonial attitudes embedded in the expansion of ibc by western countries welcoming ibcs to be established in some of the global south nations by both local government and students were arguably an indication of coloniality of power in other words many people in nonwestern contexts also believe that western knowledges are more validated this colonial imaginary however validates western subjects at the expense of other knowledges and peoples and demonstrates how western ideals have spread to nonwestern contexts according to buckner who has argued the benefits of internationalization are localized internationalization can mean different things in different national contexts although internationalization is arguably a contested term and has multiple meanings knights definition has been widely cited according to knight internationalization is defined as the process of integrating an international intercultural or global dimension into the purpose functions or delivery of postsecondary education nevertheless de wit argued that internationalisation in higher education is at a turning point and the concept of internationalization requires an update therefore de wit and hunter modified the definition of internationalization as the intentional process of integrating an international intercultural or global dimension into the purpose functions and delivery of postsecondary education in order to enhance the quality of education and research for all students and staff and to make a meaningful contribution to society some however have questioned the ethics of internationalization stein for instance has argued that one of the most significant ethical challenges of internationalization is that it reproduces colonial patterns of knowledge and eurocentrism in a broader global context and that the existing global system is inherently violent and unsustainable stein and da silva and buckner and stein have also highlighted the importance of revising the hegemonic assumptions embedded in internationalization to instead promote the possibilities in different ways of knowing and being internationalization is also understood by universities and policymakers according to their national contexts and unique economic and political conditions for example following the the reform and openingup policy of the late 1970s china began seeking opportunities for international cooperation in he these efforts eventually resulted in the establishment of ibcs a form of transnational education that has rapidly expanded in the last 20 years since then much has been written on the internationalization of chinese universities some have referred to it as a form of westernization and argued for the dewesternization of internationalization instruments such as the requirement of english proficiency others have written on students experiences particularly those with ibcs for example li found chinese students considered four major factors when choosing ibcs namely personal reasons institution image program evaluation and city effect scholars have also studied ibc models and strategies yang et al for example identified how differences in asian and western educational cultures create gaps in expectations between instructors and students and has suggested practical changes for narrowing these gaps yet despite these scholarly advancements critical analyses of the ethics of ibcs remains a notably underexplored blind spot in the research for instance xu has argued that the work of internationalization of he in china is closer to westernizing chinese institutions through the hiring of faculty with western backgrounds the adoption of eurocentric pedagogies the use of english as the medium of instruction and the privileging of scholarship published in english journals all of these efforts are perceived as approaches to boost global university rankings and strive to become worldclass universities in this article i build on this emerging foundation of scholarship on the ethics of ibcs by applying a whiteness as futurity framework to analyze the colonial discourse of a particular ibc in china in doing so i extend extant critiques of the narrative that ibcs bring worldclass and international he to china through the examination of western ibcs a particular zone wherein whiteness and coloniality are reinforced and reproduced in chinese society in ways that diminish nonwestern peoples and knowledges theoretical framework whiteness as futurity in the context of this paper the utility of the whiteness as futurity framework necessitates a critical understanding how global imaginaries have positioned western he and ibcs as desired products in the global he market marginson has argued three key imaginaries of global he to be global capitalism competitions for status and hierarchy and networks and partnerships among global universities stein and andreotti have argued imaginaries are embedded in western supremacy as western he is dominant among topranked global universities and leads global partnerships in global he sectors however gurs are not objective instead they oriented the world in a stratified order together these imaginaries exert and reinforce a stratified national order that places western he at the top of the global he hierarchy western he is therefore considered a superior and more desirable product in the global market than nonwestern he these assumptions especially perpetuate the coloniality of power in receiving countries in the global south where western heby way of ibcshas become a highly sought after and coveted commodity in such cases ibcs are understood as useful tools for governments to grow the capacities of their he systems and brand their nations and cities as hubs of global education ibcs realize this via the building of partnerships between local universities and western universities that ostensibly increase receiving countries competitiveness through the provision of opportunities for students to pursue western degrees desired in the global market without having to leave their home countries according to ahmeds conception of whiteness as a phenomenon that orients bodies in directions that privilege white subjects shahjahan and edwards developed the whiteness as futurity framework to examine how the power of whiteness works to colonize global subjects imaginaries and reinforce the asymmetrical movements networks and untethered economies underpinning global he specifically whiteness as futurity is comprised of three interwoven pathways whiteness as aspiration whiteness as investment and whiteness as malleability whiteness as aspiration suggests white nations manipulate global imaginaries in terms of what counts as the future of he and what others should aspire to whiteness as investment which is evoked by whiteness as aspiration indicates the superstructure of whiteness compels nonwhite nations to invest in whiteness to gain social and material benefits or otherwise face harm for instance white and english language credentials are considered preferable and more competitive in national and global labor markets finally whiteness as malleability suggests whiteness and its privileges are reachable the authors argue this particular feature of whiteness is what makes whiteness as futurity possible as it claims nonwhite bodies and spaces can symbolically and materially project and gain advantages of whiteness for instance a student from a nonwhite nation can seemingly enjoy certain privileges of whiteness after obtaining a degree from a topranked university in a white nation in such cases students might exhibit whiteness as aspiration and invest in it to whiten themselves in summary the three pathways of whiteness as futurity interact with one another and colonize the international he imaginary by determining for all what worldclass educations scholars and students should look like and know whiteness as futurity is appropriate for this study because ibcs were primarily established in nonwhite nations based on the assumption that western education and whiteness are and should be desirable in nonwestern contexts as a result these assumptions have been inextricably nested in the promotion of internationalization and worldclass education by drawing on the three pathways of whiteness as futurity as a guide this study unpacks how discourses of internationalization and worldclass education are used in the branding materials of western ibcs in china and how these discourses reinforce the supremacy of western education and the desire for the state of knowing and being of whiteness a case study wenzhoukean university this paper focuses on wenzhoukean university an ibc of kean university in new jersey kean university is a public comprehensive university in new jersey that claims kean is the only american public university to offer a full campus in china with wenzhoukean university wkus website defines the university as a chineseamerican jointly established higher education institution with independent legal person status and limited liabilities and a provincestate friendship project between the zhejiang province and new jersey in the united states different from other ibcs in china that are substantially supported by funds from private enterprises in china wku was initiated and supported by local and provincial governments the current president of china xi jinping visited kean university in new jersey in 2006 while serving as the secretary of the chinese communist party in the zhejiang province to deliver a keynote speech at wkus signing ceremony the project of wku was approved by the chinese ministry of education in 2011 and officially established in 2014 besides wku gained support from local and provincial government to become an internationalized and worldclass university as of today wku is comprised of four colleges the college of business and public management the college of architecture and design the college of liberal arts and the college of science and technology it offers 17 undergraduate programs 8 masters programs and 3 doctoral programs the university imports educational resources from the usa and recruits faculty globally most of the courses taught at wku are provided by its home institution kean university and english is the medium of instruction the wku website highlights that 68 of graduates of the class of 2019 chose to attend graduate schools and 43 were admitted by top 50 universities according to qs world university rankings unlike other ibcs in china such as new york university shanghai duke kunshan university and the university of nottingham ningbo china wku is unique in that it is likely the only ibc with independent legal person status in china whose home institution is not perceived as a wellknown prestigious university in the west in terms of its gurs according to us news world report kean university tied for number 126 in regional universities north unlike researchoriented universities that are outstandingly positioned in gurs regional universities focus on providing undergraduate education and only offer a limited number of graduate programs i chose to examine a branch campus in china whose home institution is not highly ranked in the west to demonstrate the power of whiteness as futurity in colonizing the international he landscape in china methodology based on studies that have argued western ibcs in the global south reproduce neocolonial attitudes and practices the current study uses colonial discourse analysis to analyze how colonialism and whiteness drive the discourses of internationalization and worldclass education in wkus online branding materials drawing on saids argumentas inspired by foucaults assertion that history knowledge and power are intertwinedthat the orient is a myth created by the west to espouse and evidence the wests superiority young has similarly suggested colonial discourse analysis … forms the point of questioning of western knowledges categories and assumptions i employ this methodology to locate common features of colonial discourse on wkus website such as rhetoric that operates as a productive force reproduce sedimented social relations and practices and provid es opportunities for…disruption and resignification my analysis is specifically centered on wkus online branding materials for admission and graduates in the about us section there is a publish list through which branding brochures are available for download i selected five documents to review in total including the admission brochure university brochure and graduate brochures proud 2018 proud 2019 proud 2020 and proud 2021 these brochures were selected because they are publicly available online and have english versions more importantly the documents range gives a general indication of how wku represents itself using the colonial discourse of worldclass education the admissions brochure provides particular insight into the types of students wku aspires to recruit and the kind of education they promote themselves as providing while the proud graduates brochures serve as products that illustrate the success of western ibcs and the types of students the western knowledge economyvia wkuvalues and considers excellent taken together these five documents discursively illustrate how colonial discourse undergirds wkus perceptions of what counts as a worldclass education its values as a sinous joint institution and internationalization to code the data i first looked at how the wku branding materials represent and define worldclass education and how they articulate western education as something chinese students should aspire to over chinese he in reviewing the university brochure i paid particularly close attention to what wku highlights as features of americanstyle education for the proud graduates brochures i looked at how colonial criteria are used to define proud graduates by examining who wku presented as proud graduates and what work these students did during college that wku considered international i then draw from colonial discourse analysis to examine what was absent in these brochures to do so i looked at what and who was not selected for inclusion in the brochures and what types of educations and experiences were invalidated in wkus version of an international setting i particularly focused on whether aspects related to chineselocal knowledge curriculum experiences and faculty were discussed in the promotion of wku and its graduates seeing what was absent allowed me to unpack what wku excludes from its definition of worldclass education internationalization and proud graduates as well as question the hegemonic and colonial assumptions underlying western supremacy finally i used the three pathways of whiteness as futurity as a guide to discuss how notions of colonialism and orientalism are embedded in the discourses of internationalization and worldclass education in these five documents i specifically looked at how the discourses of internationalization and worldclass education in these documents align with the tenets of whiteness as futurity and positioned western he students at ibcs and international experiences as superior to chinese he students in nonwestern universities and local experiences this analysis focused on the following three research questions how do the branding materials of wku define internationalization and worldclass education how does wkus representation of proud graduates in its branding materials implicate or not the three pathways of whiteness as futurity and colonialism to what extent is chinese education or local knowledge and experience acknowledged or ignored in wkus branding materials findings university brochure the university brochure is one of the universitys most important branding publications because it concisely represents the core values wku present to the public especially prospective students and their parents drawing on colonial discourse analysis i found wku primarily defines and advertises worldclass education and international education by western educational resources westernstyle teaching and learning english learning environments and white credentials importantly i also found the courses wku offers at their chinese curricula center such as chinese culture and history are missing from its primary branding materials as for visual representations although wku suggests 100 of the faculty are recruited globally most of the images depict white faculty teaching chinese students while representations of nonwhite faculty remained notably absent worldclass education is the main theme of the university brochure on the first page the term is used to describe wkus educational offerings the sentence a city of the world a university of the future appears on the second page representing the city of wenzhou as an international city and wku as an international university leading chinese and global he into the future the brochure suggests that the main reason wku brands itself as a provider of worldclass education is because it offers chinese students the opportunity to access us he without having to leave china wku brings advanced educational resources from the us and implements americanstyle educational methodology in an allenglish teaching environment to provide students with access to worldclass education right here in china wku additionally positions itself as a bridge for chinese students to get us credentials and study in the west for instance the brochure indicates students can obtain bachelors degrees from both wku and kean university and that they can attend exchange and graduate programs at kean university proud graduates my analysis of the proud graduates brochures centered on examining who wku defined as proud graduates and what work they had done during college that the university considered international as well as who and what types of experiences were excluded i found these brochures highlighted certain criteria of proud graduatesie graduate school application results overseas experiences internship and research experiences and english skills in the following sections i show how these criteria align with the schools definition of worldclass education in the university brochure graduate school admissions first and foremost graduates admitted to topranked universities are who wku primarily represents as proud graduates among the 43 proud graduates featured in the brochures and according to the descriptions in the brochures only eight decided not to pursue a graduate degree right after graduation but some did note they planned to apply to graduate schools in the future proud 2018proud 2019proud 2020proud 2021proud 2021 the other 35 proud graduates were admitted to topranked universities in the usa the uk australia hong kong and other ibcs in china analysis revealed an extensive use of gurs to describe the universities and programs the proud graduates were admitted to see the list below for some examples although wkus home institution kean university is not a topranked university in the usa having graduates admitted to highly ranked universities particularly in the west was an important recurring indicator wku used to evaluate the success of its curriculum as the list above demonstrates the university relies heavily on describing proud graduates in terms of university rankings such as gurs and subject rankings indeed all the universities these graduates were admitted to are top ranked but it is worth noting that the brochures did not use a consistent global university ranking rather the rankings indicating the universities performed well were selectively chosen to depict the schools graduates achievements according to western standards of education moreover given the brochures adopted gurs to evaluate the graduates accomplishments and that wku itself is a sinous cooperative university students intending to study at us institutions were predominantly featured among the universitys proud graduates overseas experiences overseas experiences including exchange semesters at kean university in the usa volunteering abroad and attending international conferences and activities were highly valued in the proud graduates brochures among the graduates from the featured classes many participated in nonacademic international conferences to broaden their horizons and gain leadership skills these activities predominantly took place in foreign countries and are feepaying programs for instance one student participated as a representative in the 6th university scholars leadership symposium in hong kong proud 2018 p 4 another student had a practice opportunity in the united nations international maritime organization in london another student had an apec experience which allow ed her not only to make many new friends but also to increase her knowledge and broaden her horizons proud 2019 p 19 and one student participated in the 24th united nations climate change conference as an ngo observer and took part in the press conference of her ngo as a chinese youth representative proud 2020 p 8 volunteer experiences outside china were also a key feature of the proud graduates some went to economically developed nations to experience cultural exchange like the student who spent two months in south korea volunteer teaching proud 2018 p 4 and another who spent 48 hours on a work exchange in australia proud 2018 p 12 others went to less economically developed countries to spread worldclass education in the form of english language and western teaching for instance one student went to thailand to support the local education and her job was to teach local children english and help these children broaden their horizons of the world proud 2019 p 8 while others went to indonesia and sri lanka to provide other types of educational aid proud 2020 pp 56 participation in an exchange semester at kean university in the usa was another major feature of wkus proud graduates wku represented these exchange experiences as highly appreciated by graduates who noted studying at kean provided them with opportunities to meet enthusiastic and friendly americans enjoyed a comfortable life and experienced the worlds top education resources proud 2018 p 5 wku also included that some students liked the experience so much that they took courses that would not satisfy wkus minor requirements proud 2018 p 7 wkus representations of their proud graduates also emphasized overseas experiences as significant assets for applying to graduate schools the university implicated these experiences would enrich students resumes and facilitate their successful admission into topranked graduate schools nevertheless the costliness of the overseas programs marginalized students without the funds to participate in these programs only those who volunteered in china and attended local activities were thus likely to be excluded from the proud graduates designation internship and research professionally wkus proud graduates actively participated in internships such that some had a variety of internship experiences and publications for instance one student started doing internships during the winter and summer holidays of her first year and her resume includes 4 separate internships proud 2018 p 9 similarly a business graduate worked as an intern in the loan departments of both icbc and bea academically many of the graduates participated in research activities with faculty members some presented their work at academic conferences and published papers in international journals for instance one student has three publications … and she is determined to be a phd in the future proud 2018 p 6 in addition some students worked with faculty on research projects and brought their research achievement to kansas city to participate in the ieee conference proud 2018 p 6 another student actively participated in scientific research and academic exchanges his research result has not only been displayed on the exhibition platform of wku student research day but also in the ibss conference held at waseda university proud 2019 p 6 one of the graduates even published four papers at international conferences and believed his research output to be the key to his final success proud 2020 p 7 like the overseas experiences in the previous section most of the graduates internship and research experiences in the brochures were selected because they are to some extent considered international one student explained engaging in research activities such as presenting at international conferences and publishing on english journals was key to his final success and a main reason why they participated in research and internship is for applying to topranked graduate schools featured experiences like these show how wku sees itself preparing students for the capacity required to attend topranked graduate schools in the west this heavy focus on graduate schools admission criteria interning at foreign companies attending academic conferences abroad and publishing in english journals is presented as a valid professional and academic experience wkus branding materials while local internships and research activities are excluded from qualifying as proud english skills english skills are especially important in ibcs where english is the medium of instruction wkus brochures presented many proud graduates experiences learning english and becoming fluent secondlanguage speakers for instance one student was described as successful in terms of the english skills he gained immersing himself in this english environment every day his english has been greatly improved to the point that he scored 75 on ielts proud 2019 p 8 similarly to improve their english another student chose one of the most tough english teachers in her freshman year to force herself to strengthen her english proud 2019 p 8 wkus representations of the importance of english in their brochures align with a larger trend in ibcs that equates speaking fluent english with more opportunities this sentiment holds that english proficiency helps students get good grades in class obtain career opportunities and facilitate graduate school applications for example a student who became an ielts teacher was chosen to speak at wkus commencement as a prime example of an outstanding graduate proud 2018 p 12 in sum although the proud graduates featured in these brochures graduated in different years and although wku states the institution is dedicated to the principle of providing students with different ways of development the graduates and wkus different ways of development are actually quite similar for instance the school presents such methods of development as admission to topranked graduate schools active participation in internships and research overseas experiences and speaking fluent english in the following section i engage in further analysis of how these merits alongside the features of wkus definition of a worldclass education adhere to the three pathways of whiteness as futurity discussions whiteness as aspiration recall that whiteness as aspiration has been defined as the manipulation of global imaginaries regarding what counts as the future of he and what others should aspire to i argue that wku exhibits this form of colonial discourse in its definition of worldclass education which primarily refers to western education models and excludes the universitys course offerings at its chinese curricula center wkus branding materials thereby elevate western knowledge as advanced in relation to other knowledges and something others should aspire to if they want to be successful by positioning western knowledge and western ibcs as worldclass and advanced these materials simultaneously suggest other universities knowledges and languages are not sources of worldclass education and are therefore inferior evaluating and equating worldclass education as equal to western education is a manifestation of whiteness as aspiration this is apparent in how ibc educations are usually dominated by western epistemologies taught by english and international faculty as well as in how the language in ibcs branding materials often describe western knowledge foreign faculty and the english language as things students in nonwhite nonwestern contexts should aspire to whiteness as aspiration is also apparent in the depictions of speaking fluent english acquiring western knowledge and holding white credentials as the universal qualifications for success in the global labor market yet this phenomenon is not only limited to ibcs to promote internationalization many nonibc chinese universities have begun offering bilingual courses in english importing western curricula and recruiting international faculty not only does whiteness as aspiration invalidate chinese knowledge it also invalidates chinese people and culture in wkus signing ceremony a leader of the zhejiang province claimed wenzhou people are wealthy in material but in need of educational opportunities especially higher education is less developed in wenzhou compared to other cities in zhejiang province but you kean university just come in time and provide the education that wenzhou people have been longing for this quote suggests that although the wenzhou people are wealthy they are undereducated by the westerndriven standards of internationalization positioning wenzhou people as such regardless of whether there is truth in it or not justifies the establishment of wku and cements its necessity in providing wenzhou people with advanced educational aid from the west this claim indicates a hierarchy of knowledge as it purports that those who seek formal colonial educations are considered educated while those who seek nonwestern educations are not as educated interestingly wenzhou is wellknown for being a regional center of global capitalism because of the rapid growth of many small and mediumsized familyowned manufacturing enterprises the regions success has been encapsulated in what is known as the wenzhou model of economic development yet by western standards wenzhous economic success is not valid because its methods are not taught at formal westernized institutions in this way western education can be seen as colonizing what counts as quality education as well as who is considered welleducated and why wku also deploys whiteness as aspiration by defining internationalization in terms of language proficiency and foregrounding students who strive to speak fluent english and enter topranked graduate schools in western nations for instance wku graduates are regularly admitted to chinese graduate schools and choose to work for local companies or government excluding them from the universitys definition of proud graduates seems to suggest they are less impressive less successful and less educated because they have not prioritized the speaking of fluent english and have not been admitted to a topranked university in the west whiteness as investment recall that whiteness as investment is a result of whiteness as aspiration in that it compels nonwhite nations to invest in whiteness to gain social and material benefits thus by virtue of the existence of whiteness as aspiration in wkus branding materials whiteness as investment is also present this is especially apparent in the cost of ibcs which are much higher than local chinese universities according to the latest wenzhoukean university undergraduate recruitment information wkus tuition fee is 65000 chinese yuan yearly which is about 10 times higher than other chinese universities however wkus tuition is lower compared to the tuitions of other ibcs for instance the university of nottingham ningbo china charges 100000 chinese yuan yearly nyu shanghai charges 200000 yuan for firstand secondyear students and duke kunshan university charges 200000 chinese yuan yearly in addition other fees at ibcs are also much higher than other chinese universities such high costs reinforce the belief that attending ibcs is an educational investment for some chinese families which in turn reinforces investment in whiteness to achieve success in the global labor market as china has the largest population in the world the massification of he in china has in turn made china the largest he system in the world however importantly this system does not serve the masses especially ibcs which are known for being exclusive the small scope of ibcs in china the requirement of english language proficiency and high tuition fees ensure these institutions can only serve students from the uppermiddle class and beyond they are extremely exclusive and thereby considered as elite education that only uppermiddleand upperclass families can afford being taught western curricula in english by foreign faculty in western ibcs can be a great investment for many chinese students through whiteness as aspiration western institutions have colonized the global market and education meaning those who possess western credentials often have an easier time entering international companies and topranked graduate schools in the west because they are likely fluent in english come with recommendations by foreign faculty have us transcripts that do not need to be translated and coursework that complies western standards these factors help them stand out among their chinese peers in chinese universities who have not made such investments in whiteness given this i contend that the proud graduates in wkus brochures also see their attendance of wku as an investment that makes whiteness and its privileges reachable many acknowledged wkus role in helping them successfully submit graduate school applications and pursue competitive careers for instance a proud graduate from the class 2019 said i benefited enormously from the americanstyle interactive environment and active classroom participation which forced me to step out of my comfort zone and enhanced my english communication skills proud 2019 p 19 another from the class 2020 mentioned faculty here at wku was international and the curriculum was international as well as the instruction at wku the smallsize classroom allenglish teaching environment group cooperation and other teaching methods are a great benefit to his study proud 2020 p 4 coupled with wkus definition of a world class education these testimonies show that although students at wku pay much higher tuition fees compared to those in local chinese universities many see this investment as worthwhile because they equate it with a greater chance of finding success in a global society colonized by whiteness as futurity whiteness as malleability finally recall that whiteness as malleability has been defined as a mode of thought that holds whiteness and its privileges are reachable it manifests in chinese students assumptions in that by attending ibcs they do not need to attend western institutions in person to obtain white credentials my analyses of wkus branding material shows the school sells students a degree they can obtain in the comfort of their home countries that they feel equates to a kean university degree in the usa in other words they feel a degree like this from a us institution of he can facilitate their graduate school applications and privilege their educational background in this way ibcs in china are seen as vehicles for people from uppermiddleto upperclass families to join the game of whiteness as futurity which further perpetuates the devaluation of chinese educations while elevating the value of western educations in chinese and global he landscapes it is important to note here that the wku branding materials portrayed its graduates as recognizing the significant role of the university in helping find successful in graduate school applications and job hunting what is absent from these accounts however is an acknowledgement of the privileged backgrounds that enable them and their families to support their investments in whiteness and its privileges the resources provided at wku that have helped them get into western nations to study are one factor but another is their families capital this capital is what allows them to pursue expensive masters degrees in the west and participate in international activities outside of china it is no mistake that these are the kinds of families and students wku values and targets for recruitment while students who do not possess such capital are relatively marginalized by the institution the lack of such capital hinders these students abilities to achieve whiteness and its attendant privileges and leaves them underrepresented in their institution and after graduation overall even though ibcs in china grant degrees that are ostensibly equivalent to those of the ibcs home institutions there is still a colonial hierarchy at work in the global education market that ranks western degrees as superior to all others even western ibcs thus without transforming the white credentials from ibcs to western institutions in western nations degrees from ibcs are not necessarily as competitive as credentials obtained directly from the west it is a combination of credentials from western ibcs and family capital that ultimately makes whiteness reachable for certain ibc graduates conclusions summary of findings in this paper i analyzed western ibcs in china via an investigation into how the wenzhoukean university international branch campus defines its provision of worldclass education and international education in terms of whiteness as futurity using an anticolonial lens i examined wkus online branding materials and found wku defines a worldclass education as the importing of educational resources from the west for teaching western curricula and knowledge in nonwestern nations such teaching employs english as the medium of instruction relies largely on foreign faculty and grants western credentials wku thus defines academic excellence in this regard by those who were admitted to topranked graduate schools those who actively participated in overseas programs and those who speak fluent english overall the present study illuminates how whiteness is reproduced by a particular ibc in china whose home institution in the west and is not top ranked by depicting western education as worldclass wku suggests western universities are by nature superior to local chinese universities regardless of gurs obtaining western credentials though ibcs can thus whiten chinese students by giving them access to more privileges in a global knowledge economy dominated by western ideals however the recent covid19 pandemic travel restrictions and mounting tensions between the usa and china have posed significant challenges to ibcs in china particularly cooperative sinous institutions nevertheless given the durability of the whiteness as futurity imaginary and the ongoing assumption that ibcs serve as agencies that make whiteness reachable for nonwhite nonwesterners it is likely ibcs will continue to be welcomed by students and parents in nonwhite nations nonwestern critiques and implications in this section i engaged critiques of internationalization global citizenship and gurs to explore implications for future practice and ways for reimagining western ibcs in china and beyond first many characteristics of worldclass education and internationalization depicted by ibcs have already been criticized knight for instance has argued internationalization should build on and respect local contexts however in many ibcs including wku local contexts are often subjugated to the dominance of western modes of thought an example of this is the exclusive use of western textbooks and the prioritization of hiring foreign faculty de wit has also pointed out that internationalisation is teaching in the english language and internationalisation is studying abroad as two of the most common misconceptions of internationalization yet as evidenced in this study these misconceptions continue to be extensively represented features of ibcs wku has further identified overseas experiences especially overseas volunteer programs through which students teach english in economically underdeveloped countries as examples of wku graduates as global citizens however these programs operate on the assumption that china and other global south nations require benevolent educational aid from the west and that economically underdeveloped countries need westerntrained global citizens to provide their benevolent educational aid to nations in the global south programs aimed for helping unfortunate others do not necessarily help the people of these regions and in many cases inflict and perpetuate harm wkus representation of ideal graduates is based on its student participation in such activities which reproduce problematic colonial imaginaries and often inflict harm on nonwhite nonwestern subjects moreover my analysis in this paper demonstrates that ibcs use gurs as measures to evaluate their graduates but gurs are not neutral and are arguably problematic stack for instance has suggested improving gurs does not improve equity and inclusion rather gurs are seen as a way of incentivizing competition among institutions via the geopolitics of knowledge that naturalize inequality as necessary for the development of society and human knowledge shahjahan and edwards have additionally argued that gurs privilege white western institutions and orient universities around the globe to conform to the norms of predominantly white institutions although ibcs do not participate in gurs themselves they compete with one another to admit the most graduates to topranked graduate schools the more graduates are admitted to topranked universities especially those in the west the more successful the ibc in this sense ibcs have become agencies and gatekeepers for reproducing topranked universities and the imaginaries that center gurs as a primary way of measuring academic excellence in nonwestern contexts based on the results of this study it is highly recommended that ibcs reconsider their role in perpetuating colonial conceptions of internationalization and move beyond mimicking and elevating the supremacy of western institutions ibcs might instead propose curricula that equitably fuse chinese and western epistemologies without elevating one over the other this study also illuminated how western educational practices can potentially harm nonwhite subjects to denaturalize the colonial assumptions embedded in global he it is therefore necessary for ibcs to value and equitably incorporate indigenous and local knowledges if they are to truly engage students to reimagining what worldclass education and global talents can look like limitations and future research this study has certain limitations in its design that should be carefully considered in future scholarship as a case study that exclusively examined webbased branding materials some findings of this study might not be generalizable to other ibcs particularly those outside of china if possible future studies exploring ibcs and internationalization should consider interviewing stakeholders at ibcs in addition to discursively analyzing university webpages social media pages and visual elements on campuses since neocolonialism is embedded in western he and the discourses of internationalization that uphold the supremacy of western he researchers studying ibcs might follow suspitsynas suggestion of applying approaches that decenter whiteness and promote more equitable inclusive futures for global he and how ibcs can contribute to this process

a case study is used to understand how western international branch campuses ibcs in china represent themselves through webbased branding materials drawing on colonial discourse analysis and the theoretical framework of whiteness as futurity this study examined the case of wenzhoukean university a sinous cooperative institution to understand how western ibcs in china interpret and promote internationalization in higher education by examining how whiteness through the discourse of worldclass education has been mobilized and reproduced this study argued that the operation of ibcs perpetuated western supremacy in the global higher education landscape at the expense of local people and knowledges

introduction extreme weather events cause damage disruption and loss of life across the world as the present climate changes extreme events like floods and heatwaves are likely to become more frequent and intense to adapt society needs to better understand how the climate might change in the future together with the associated risks by showing how the temperature may change or rainfall patterns shift over the next century climate information can help inform adaptation planning and decisionmaking national climate scenarios have taken up this challenge they paint a picture of how the future climate may change for a country on the basis of a set of greenhouse emission pathways as hulme and dessai explain scenarios have a long and varied history originating in military strategy and planning in the 1950s and expanded by the energy industry in the 1970s before becoming a common tool for decisionmaking in government 1 national climate scenarios as a result have become influential decision support tools for adaptation in the uk switzerland germany south africa ireland the netherlands the usa and australia amongst others yet climate information often remains unused because it is seen to be too complex not sufficiently relevant or unusable to narrow this usability gap scholars have focused their attention on how to bring scientists and users together to deliberately coproduce climate information if scientists understand what climate information is needed and in turn users understand what scientists can provide delivering relevant and usable science could face less barriers it is argued how this should be done is unclear however tangney and howes have shown that the credibility legitimacy and saliency of climate information are viewed differently from one country to the next different political cultures and scientific values affect how climate information is produced and the extent to which users are involved this is because in part the way science is publicly acknowledged circulated and legitimised in each country reflects its own civic epistemology that is the process by which countries assess the rationality and robustness of claims that seek to order their lives while greater scientistuser interactions should be encouraged those advocating coproduction need to be aware of the existing social and political cultures they are intervening in if not handled carefully efforts to coproduce climate knowledge may amplify the voice of some at the expense of others with different needs the relationship between the state and science differs from country to country in the uk scientific expertise and political authority are separated to deliver objective and rational knowledge to support pragmatic empiricist policymaking yet this same expertise is often funded by uk government departments with their own agendas other countries have very different setups neither switzerland nor the netherlands has a majority government decisions have to be consensual otherwise nothing proceeds inclusion of the political scientific public and private minorities is common it has been argued that compromises can be found easier through a closed nature of inclusion and a lack of transparency in how decisions are made as actors are able to negotiate without public scrutiny differences between dutch and swiss political cultures do exist though in the netherlands the policymaking process is more participatory in that it includes political elites interest groups and individual citizens in switzerland by contrast different representatives from politics public administrations and interest groups mediate policies between themselves with the swiss electorate called on to decide issues in referendums if a consensus cannot be reached in this paper we seek to understand why climate scenarios are produced differently from country to country by examining the social and scientific values that shape it to do this we focus on the experiences of suppliers of climate information namely scientists and advisors responsible for delivering climate scenarios whose voices are critical yet too often silent in coproductionist studies we performed a comparative analysis of three countriesthe netherlands switzerland and the ukwhich share a number of similarities in modelling capacities yet chose to design their climate scenarios in very different ways after explaining our methods and data we compare the modelling approaches institutional arrangements and climate information provided in each country we then investigate the different motivations for producing climate scenarios before we turn to the different scientistuser interactions to close we develop a typology to explain the differences in how and why the climate scenarios took the particular shape they did data and methods to understand how climate scenarios are produced and importantly why they differ from one country to another we adopted a case study approach to examine the recent efforts of climate scientists in the netherlands switzerland and the uk we chose these case studies because they share a number of similarities and differences each country has a history of developing climate scenarios enjoys wellfunded climate programmes and makes use of stateoftheart computing facilities and expertise yet each differs in the modelling approaches taken and the degree to which users were involved to examine these case studies in greater depth we brought together the findings from two methods first we conducted a deskbased search to identify documents relating to the release of each set of climate scenarios these documents provide a public record as to why modelling decisions were taken how users participated in the process and the reasoning behind different presentational styles in each country a total of 37 documents were imported to maxqdaa qualitative coding softwareand analysed we then manually coded the documents to identify emergent themes on a range of topics from the treatment of uncertainty involvement of users and lessons learnt second we conducted semistructured interviews with climate scientists and advisors responsible for delivering the dutch and swiss climate scenarios during 20152016 we supplemented this data with five interviews performed with actors involved in the uks climate scenarios in mid2013 whenever possible interviews were held facetoface in participants offices or via skype we adopted a conversational approach which allowed people to express their views and experiences on aspects of the production process not covered in the official documentation we analysed to that end we asked why are climate scenarios needed who was involved in the production process and what role did they play and to what extent were users involved and what did they contribute all the interviews were digitally recorded and transcribed using an intelligent verbatim transcription approachomitting filler words or hesitations once the transcripts were imported into maxqda we manually coded the responses to identify emergent themes including modelling decisions user engagement and institutional relationships to introduce greater rigour to our findings we triangulated the codes from both datasets to understand where the greatest agreement or disagreements existed context how do the british dutch and swiss climate scenarios compare despite only a few years separating the release of the british dutch and swiss climate scenarios they differ in a number of ways briefly introducing each of the climate scenarios below we highlight how these differences are not only concerned with the way climate change was assessed or the actors involved but also how each country presents climate information uks climate scenarios the ukcp09 land scenarios after 7 years of work the uk met office hadley centre released the worlds first set of probabilistic climate scenarios the ukcp09 land scenarios2 in 2009 this modelling endeavour was largely driven by the met office hadley centre whilst the uk climate impacts programme managed the user engagement funded by the uk government the climate scenarios serve as an input to the difficult choices that planners and other decisionmakers will need to make in sectors such as transport healthcare water resources and coastal defences by giving users the freedom to choose the scale time period and thresholds corresponding to their risk tolerance and appetite a major focus for ukcp09s climate scenarios was its effort to account for the inevitable uncertainty around future climate change probability distribution functions are provided to indicate the plausible range of climate change under a particular emission scenariowith an expression of how strongly different outcomes are supported by different lines of evidence for instance users can assess the likelihood that temperatures will increase by more than 3 °c in london in the 2080s relative to the 19611990 base period a large number of climate simulations were run to capture structural model uncertainties accounting for different climate models ability to replicate key aspects of current and future climate change to do this a perturbed physics ensemble with the met office hadley centres own climate model was combined with a multimodel ensemble from other modelling centres through a novel and complex bayesian approach that used a statistical climate model emulator the climate scenarios are given at a resolution of 25 km 2 over land or as averages for administrative regions and river basins confidence varies within the data however it is highest at the continental scale and lowest at the local scale which interests users most users can choose from seven time periods with overlapping 30year windows spanning 2010 to 2099 users in turn are also encouraged to work with all three emission scenarios high medium and low to learn the full extent of possible changes the climate scenarios are available free of charge via three formats key findings published materials and customisable outputs after the launch there were updates to the climate scenarios for instance spatially coherent projections were provided so that users could combine results from grid boxes to create spatial information ch2011 2011 switzerland does not have its own global climate model but eth contributed to the regional climate modelling cosmoclm community project this means ch2011s model data have been provided by several international projects instead climate simulations from the ensembles project as well as studies and assessments from the intergovernmental panel on climate change were used new but importantly peerreviewed statistical methods were used to generate multimodel ensemble estimates of changes and associated uncertainties probability statements as in the ipcc but no pdfs are assigned to temperature and precipitation only under three emission scenarios to give users an indication of the likely direction of change switzerland the climate scenarios were aggregated spatially into three broad regions with much of the alps excluded as its topographical complexity raised concerns over how to reliably interpret the model results projected changes over the twentyfirst century are broken into three time periods and are available as seasonal and daily ranges the ch2011 climate scenarios can be accessed freely for research education and commercial purposes by visiting the website and downloading the individual datasets or by requesting the published reports for the main findings following the release of ch2011 two extensions were published providing annual averages climate scenarios for the alpine region and stationscale daily data for all three emission scenarios netherlands climate scenarios knmi14 the royal netherlands meteorological institute issued the countrys most recent climate scenarios in 2014 knmi14 funded by the government the climate scenarios will be used by decision makers to map the impacts of climate change… and evaluate the importance and the urgency of climate adaptation measures for building coastal defences healthcare city planning and nature conservation a defining feature of knmi14 is the use of four scenarios to visualise how future climate may change around 2050 and 2085 each scenario differs in terms of the amount of global warming and possible changes in air circulation around 2085 under the g l scenario annual mean temperature is projected to be 13 °c warmer than the reference period whereas under the w h scenario it could be 37 °c warmer to obtain a range knmi14 provides the currently observed natural variability onto which users can superimpose the future climate change signal to derive future upper and lower bounds these scenarios show a single spatial scale the whole of the netherlands this is because any attempt to make climate predictions at a relatively small spatial scale such as the netherlands or even western europe for multiple decades ahead cannot be expected to lead to skilful results eight initialstate perturbed climate simulations with the community global climate model ecearth and their own regional climate model racmo2 were performed these were then supplemented with a multimodel ensemble from the coupled model intercomparison project phase 5 users are able to access the knmi14 climate scenarios free of charge by downloading the published reports or requesting the dataset directly from knmi after knmi14 was published an inconsistency in the w l scenario for 2085 was found which prompted knmi to issue a rectified version in late 2015 key differences between the british swiss and dutch climate scenarios we found four key differences in how the british dutch and swiss scientists approached the production and dissemination of their climate scenarios simply put these differences include modelling capacities treatment and communication of uncertainty the actors involved and access to the data first whereas the british and dutch have their own climate models the swiss rely on utilising modelling efforts of others in turn the british climate scenarios took a more computationally demanding and complex modelling approach than its counterparts second this gave rise to the british incorporating the structural model error explicitly with the help of a bayesian statistical model this inclusion of model uncertainties broadens the spread of model simulations which they communicated as pdfs for each emission scenario in theory the pdfs incorporate the expert judgment needed to interpret the information correctly the swiss and dutch followed the ipcc approach whereby interpretation and use of model results need expert judgement but they did so differently the swiss used bayesian statistics to estimate pdfs but communicated only a lower medium and upper value as representative plausible outcomes for each emission scenario because of the netherlands high vulnerability to coastal flooding and the profound implications on most national activities changes in wind direction have been judged as an additional key uncertainty coastal defences among other adaptation options need to incorporate both increased storm surges due to wind as well as sealevel rise due to emission scenarios to incorporate this the dutch assessed and communicated their uncertainties along these two dimensions providing single figures for each of the four storylines third the dutch kept the entire modelling and user engagement within a single organisation knmi whilst the british and swiss included various institutionally distinct and physically distant actors for these tasks for instance the ch2011 community comprised multiple institutions with some scientists asked to represent the views of multiple actors simultaneously lastly although the british provide users with all the output data and guidance on potential limitations the dutch and swiss restricted what information users received the swiss withheld parts of the data relating to the alps due its topographical complexity and the dutch aggregated the data into two driving variables air circulation change and temperature these different epistemological preferences affect the reasoning behind how climate scenarios are done in the first place what is the purpose of climate scenarios two main reasons were cited by all three sets of scientists as to why they felt it was important to produce and disseminate climate scenarios first in order to take wellinformed adaptation and mitigation decisions a single coherent body of locally relevant scientific information is needed second such exercises can help advance scientific understanding through the development of new methods computing power and working relationships although the three case studies share these two objectives our research suggests that they were prioritised understood and acted upon differently informing climate adaptation and mitigation decisionmaking all interviewed climate scientists agreed that their country needed its own set of climate scenarios because decisionmakers are primarily interested in their local patch and because weather patterns are different from one place to another the ipcc assessment reports and its regional climate scenario chapter are simply too coarse to inform local or sectorbased adaptation decisionmaking a growing user base with evolving requirements has also led to many requests for additional information and guidance such as the inclusion of more climate variables extreme weather events and regional details that largerscale climate scenarios cannot provide servicing the informational needs of these users is a major purpose of climate scenarios all the scientists shared this conviction and went to great lengths to stress how they wanted their work not only to be useful to decisionmakers but also importantly used by them national policies added further support for useinspired science all three countries have enacted legislation requiring climate scenarios to inform nationalscale policymaking as well as localscale decisionmaking in public and private organisations only in switzerland have climate scenarios emerged without a governmental mandate yet in each case efforts to coproduce climate scenarios have been skewed in favour of scientists who retained power over what these scenarios look like or when to provide these scenarios another key purpose of climate scenarios for knmi scientists was to initiate a paradigm shift in how users think moving away from responses based on experiences of past climatic events users should instead anticipate possible future conditions for decisions today ukcp09 scientists also felt that climate scenarios helped reaffirm the different roles and responsibilities of those involved in adaptation decisionmaking its not the climate scientists responsibility to provide a golden number for users and accept that risk for it because scientists can only provide what is the best science at the time and make all the uncertainties available before saying okay this is our best estimate so take from that what you can and then its over to users as to how they use it some users may however struggle with this epistemological position users may become frustrated or confused if they identify and manage their risks differently to how the climate scenarios have prescribed them especially if they prefer to work with single figures rather than a range as porter and dessai argue ukcp09 scientists often see users as miniature versions of themselvesminimeswho struggle to understand why anyone would not want to use probabilistic information which for them represents the best science available this can lead to tensions when users who rely on a definitive answer being provided for them fail to receive one by contrast knmi14 scientists felt one of the main purposes of climate scenarios was to engage as many people from different backgrounds with different interests as possible so as to actively avoid giving users multiple perhaps conflicting outputs for each variable users were given only a single figure for its four scenarios that is for a variable of interest users must compare four averages in order to see if there are differences or trends and their size between the four scenarios this was less likely to be misinterpreted or cause confusion it is argued advancing scientific knowledge one if not the main driver for developing each set of climate scenarios was the opportunity to advance scientific knowledge however the three groups of scientists interpreted their intellectual contribution differently for instance kmni14 and ch2011 aimed to improve and consolidate the range of scientific information used in decisionmaking for their respective countries whereas the ukcp09 climate scenarios wanted to develop a new method for quantifying uncertainty with international reach too newly developed methods improved computing power and recently released model runs alongside the availability of new observation datasets were all cited as reasons for producing climate scenarios for knmi14 scientists advances in climate modelling opened up a new dialogue with users including water managers and health specialists over what could or couldnt be done so that users helped prioritise the scientific work it also allowed knmi14 scientists to test if the predecessor knmi06 underestimated the impact of air circulation patterns on temperature rise interestingly knmi14 scientists were a little disappointed with the final result due to the similarity of the outcomes between knmi06 and knmi14 whilst knmi14 scientists reiterated their primary goal to improve the usability and use of the climate scenarios the satisfaction derived from being the first to discover some scientific novelty is still important researchers desire to advance scientific knowledge about climate and explore new ways of thinking about climate decisions it seems can conflict with the more pragmatic needs of users to enable effective adaptation planning therefore the extent to which coproduction will help to resolve these tensions or exacerbate them further as those involved in the supplying and demanding climate information became more frustrated with each other is unclear for ch2011 scientists the need to advance scientific understanding via a new set of climate scenarios was expressed differently already serving as ipcc lead authors but lacking the modelling resources enjoyed by other countries the ch2011 climate scenarios strengthened old and encouraged new collaborations between swiss research institutions it brought researchers and users to one table where everyone could discuss how the modelling should be done there wasnt always a consensus within the group because the complex topography of the swiss alps presents challenges for modelling but by bringing together the different institutions the swiss climate science community was able to speak with one voice for the first time and created the momentum to fund future climate scenarios as well as political support to establish the swiss national centre for climate services ukcp09 scientists differ from their knmi14 and ch2011 counterparts in how they understand and in turn acted upon the need to both advance scientific knowledge and inform adaptation decisionmaking for knmi14 and ch2011 scientists the two objectives can sometimes be incompatible whereas ukcp09 scientists felt that they went handinhand ukcp09 scientists assumed that if users want to make reliable robust and relevant decisions they need the best science available better science it seems equals better decisions what constitutes good science for decisionmaking for the british and dutch scientists is understood differently however in contrast to the single figures provided in knmi14 ukcp09 quantifies climate variables ranges so that users can decide about the level of risk they want to manage where multimodel ensembles have conventionally been used to assess uncertainty ukcp09 scientists felt this method failed to capture the full range of uncertainties by developing their own method not only would they make a significant intellectual contribution to quantifying model uncertainties but they could also meet the institutionalpolitical goals set by the met office the department for environment food and rural affairs and the now disbanded department of energy and climate change to produce worldleading science with the potential to influence the ipcc process different understandings different priorities all three sets of scientists were fully committed to informing adaptation decisions and advancing scientific understandings yet interpreted these commitments differently for ch2011 scientists priority was given to assembling a consistent evidence base that spoke with one voice to do this the effort was focused on improving working relationships and intellectual exchanges to advance scientific capacities for knmi14 scientists a major driver was the need to change how people think and act in relation to climate change advances in climate modelling certainly aided this process but were not the sole catalyst for ukcp09 scientists efforts to quantify uncertainty were underpinned by the assumption that users need the best science possible practical or applicationbased considerations inevitably took a backseat to intellectual contributions and the pursuit of curiositydriven science these different understandings of the purpose of climate scenarios affect the way users are involved in the process and the extent to which they are listened to how involved did scientists think users were in producing the climate scenarios our research suggests that all three sets of climate scenarios differed considerably in the extent to which they involved users what they expected them to contribute and even whom they thought the user was in the first place together these differences have had a marked effect on the particular form taken by the british dutch and swiss climate scenarios for instance how model uncertainty was quantified is based on a series of assumptions about the capacity of users to work through and make sense of complex information however narrowly defined perceptions of users and their needs have seriously diluted the stated commitment to coproduce national climate scenarios scientists perceptions of users without exception the official documents issued for all three sets of climate scenarios paint a very broad picture of potential users from actors interested in digging down and exploring the data to those interested only in the headline messages the scientists hoped that their climate scenarios will be used by the widest audience possible in other words the climate scenarios should not become the exclusive preserve of a small group of actors this manifests itself differently in each country where the knmi14 and ch2011 climate scenarios aimed to inform decisions in sectors from water healthcare agriculture and transport to infrastructure ukcp09 went even further by subdividing the users within these sectors into three categories researchers decisionmakers and communicators simply put all three climate scenarios should officially cater to different users all with different needs few of the scientists interviewed shared that view however ch2011 scientists for instance felt the end users would be either impact modellers or government officials previous experiences from the last climate scenarios ch2007 and the government agenda to develop a national adaptation strategy informed this view yet misunderstandings over what users need and what scientists think is useful soon developed ch2011 scientists realised they had produced far more information than government officials could use or make sense of lacking the time and resources to work through the probability statements provided government officials were forced to simplify the climate information they used a user bubble of likeminded individualsimpact modellersconsulted by the ch2011 scientists meant they had unintentionally overestimated the capacity of nonquantitative users upon reflection ch2011 scientists told us that while it was fairly intuitive to identify which sectors might be interested in using climate scenarios it remained a mystery how the climate scenarios would actually be used or what users needed from them ukcp09 scientists similarly were confident that they knew what users needed with over 25 years of experience developing climate scenarios scientists had formed close working relationships with several users impact modellers water managers and consultants all of these users share certain characteristics they are highly numerate motivated and knowledgeable actors these characteristics were woven into the fabric of the new climate scenarios that is ukcp09 requires users to have already assessed their vulnerability to climate change themselves to be able to use pdfs a persistent criticism though is that potential users without the time resources or capacity to make sense of their vulnerabilities can find themselves excluded indeed ukcp09 scientists were warned against defining the user too narrowly very late in the process the government funder defra pushed for the climate scenarios to be opened up to as many people as possible to avoid satisfying only a single type of user knmi14 scientists did things differently they already knew water managers were the primary user of the previous climate scenarios knmi06 unlike their ch2011 or ukcp09 counterparts the first meeting of the knmi14 project team was on user requirements put differently knmi14 scientists believe that limiting the volume of information given to users and the choices they have to make improves the accessibility and understanding of the climate scenarios asking users to focus on four storylines places less demands on their time and requires only a basic level of understanding initially at least knmi14 scientists therefore imagined different users with different needs and capacities scientists perceptions of user interactions despite initial reluctance from some scientists to involve the intended and favoured users by the end a closer working relationship between the two became highly valued scientists concerned over lack of time or the right skills to engage with favoured users soon realised that with a better understanding of how climate information is used and therein what users need they could make a few small changes with immediate impact the only way to do this was for scientists and users to meet facetoface something the uk has been doing since the early 1990s yet all three sets of climate scientists held very different views on the interaction format and the extent to which users were listened to ch2011 scientists told us that users werent involved as much as they would have liked both a lack of funding and official mandate was cited as major barriers efforts were made to ensure the voice of users was heard nonetheless although we didnt do a full user survey… canvassing only impact modellers we still had a good impression of … what users needed moreover when a coordination group was set up to oversee the production of the climate scenarios two of the six seats were filled by user representatives mirroring the political culture of swiss collegiality the coordination group required members to reach decisions collectively yet it was not always easy for user representatives to relay the heterogeneous needs of users as a consequence this institutionalised the user bubble rather than challenged it users were only introduced en masse just before the report was released where talks and events were held so that everyone who should know about the climate scenarios did know about them in advance however not only is awareness different from engagement but the introduction of users at such a late stage restricts what they can and are willing to contribute and articulate knmi14 and ukcp09 scientists both conducted surveys with users from previous versions of their climate scenarios and ran workshops to understand how user needs have changed a long shopping list of requirements was identified but was interpreted and acted upon differently for instance the explicit presentation of model uncertainties and assumptions behind them easier access to the data and higher temporal and spatial resolution data was flagged by both projects whereas this confirmed ukcp09 scientists need to advance science linearly knmi14 scientists felt a closer dialogue was needed to dispel the you ask we deliver paradigm in the hope that users reconsider their requests indeed knmi14 scientists raised concerns about the methods to elicit user needs for them surveys risk closing down fruitful conversations about user needs and therein fail to understand how or why users actually use climate information you cannot just go to users once and ask them for feedback you need to have regular contact continuous contact over a long time to get really useful feedback its not just asking what do you want and then giving it to them… many users want to do something with climate adaptation but dont know exactly what that is or how to do it… so its important to know how they use climate data to encourage as much interaction as possible many facetoface meetings between scientists and users were organised two communication experts were hired to get users more involved instead of just listening to talks light workshops with standing tables mixing scientists and users with only six people around each table… to make it easy to ask questions were used this setup helped scientists to better understand how climate information is used and in turn what users need it also opened up conversations over the advantages and disadvantages of probability distributions and the way uncertainties are presented and differences between what is doable and what is desirable by getting users to think more reflexively about th eir list of requests that discussion and dialogue between users and knmi staff really was the main contribution of the three years of work much more so than the analysis of the data and the climate scenarios ukcp09 scientists by contrast were less enthusiastic about interacting with users than their knmi14 counterparts that reluctance was due in part to different ideas about the roles and responsibilities of scientists as mahony and hulme observe ukcp09 scientists saw their job as pushing the boundaries of climate modelling and solving practical problems to inform governmental policy and decisionmaking while organisations like ukcip should engage users because they possess the right skills and time to do so part of the british political culture of evidencebased decisionmaking serves to reinforce this separation of scientists and users in order to preserve the integrity and authority of expert knowledge on the one hand and a topdown hierarchy between the two is maintained on the other that said 3 years after the modelling began the ukcp09 project was reorganised and ukcips idea of bringing users and scientists together via a user panel was achieved with the support of the funder defra practical concerns were raised such as the number of users involved how regularly to consult them and how to weigh their contributions equally for instance there is the risk that users who are able to eloquently express their needs or regularly attended meetings gain greater attention or have undue influence on the output of the user panel yet user input for the climate scenarios was highly constrained modelling decisions had gone beyond the point of being reversed users were left to comment on presentation issues over the spatial aggregation of the outputs rather than discussing how to model uncertainty differently the lecturelike setup with talk after talk focused on selling the climate scenarios to users doing things together the motivation intensity and format of the scientistuser interaction were different across the three countries the you ask we deliver paradigm was used strategically in ukcp09 to support their scientific work but dispelled by knmi as they felt that a discussion on how climate data is used was more fruitful in addition the timing was problematic for both the british and swiss climate scenarios users engaged with ukcp09 only after the major decisions have already been taken and in ch2011 the interaction was confined to awareness at best this limits what contributions users can make and at worst it can lead to frustration and disengagement this limited interaction was partly accepted because british and swiss scientists felt they knew who the user was in the swiss case this happened through official channels between federal offices or past research collaborations in the uk the met office had been working with users alongside ukcip since 1997 so ukcp09 scientists felt that they had already developed considerable knowledge of users yet the users that ukcip formally introduced to the met office often asked highly technical questions that ukcip could not answer itself that filtering process skewed how met office scientists saw users this only confirmed what ukcp09 scientists thought users wanted in both the swiss and british cases an early and broader user engagement might have flagged up some warning signs over what scientists thought users needed and what users wanted for knmi14 scientists the shift in water management practices was only the starting point it served to question preconceptions of users in other sectors too and avoid falling prey to confirmation bias discussion our comparative analysis reveals that climate scenarios are strongly influenced by the civic epistemology of each country which defines who has a say what roles scientists and users should play and how the two interact internal disagreements on methodological aspects communication and target users exist but are often masked by the prevailing sciencesociety relations as shown in table 2 what constitutes good science for decisionmaking is understood differently from one country to the next consolidator innovator and collaborator simply put the swiss are more conservative they emphasise the need for triedandtested methods that have been peerreviewed whereas the british were more adventurous they applied a new largely untested method for quantifying model uncertainties on the assumption that users need this information to adapt effectively the dutch have mixed established methods with novel ones when culturally acceptable a major concern here is when a mismatch develops between what makes science good for decisionmaking in the eyes of scientists compared to what makes science good for decisionmaking for the more pragmatic needs of users for instance ukcp09 was too complex for some users and too bold for some scientists which has impeded its uptake and use our typology of useinspired research shown in table 2 also develops other social science work on the values and assumptions that shape atmospheric science for shackley climate modelling centres judge good scientific practice differently in response to different institutionalpolitical priorities a modelling hierarchy can emerge where greater modelling complexity is assumed to provide greater realism and better decisionmaking while ukcp09 has gone down the modelling complexity route ch2011 and knmi14 question what value is added by this all three climate scenarios differ considerably in how users were engaged which speaks to different types of userscientist interaction participation elicitation and representation while the dutch knmi involved a large number of users in the production process the british and swiss limited interactions to retain power over production knowingly or not science is socially responsive different funding mechanisms institutional arrangements epistemic cultures and preferences to risk affect what knowledge is produced this develops jasanoffs civic epistemology work that climate science comes to reflect wider societal concerns expressed through national politics our two proposed typologies bring a much needed sociopolitical context into the knowledge systems framework by cash et al where the typology of scientific enterprise characterises how judgements of good science give rise to credible information the typology of user interaction explains what is involved in producing legitimate knowledge for decisionmaking through the culturally situated production of climate information the scientific output is expected to be salient for governmental decisionmakinga key argument of the civic epistemologies relevance and usability of scientific information are not synonyms however lemos et al argue that usability is high when information is tailored to needs and capacities of users a quality achieved through coproduction where scientists listen to users and respond to their needs our results support this proposition ukcp09 only included sophisticated and numerate members in their user panel while knmi14 included a broad user base the climate scenarios from both countries essentially served only the users involved in their production we conclude therefore that several future discussions are needed to better understand the different cultures for producing climate information first funders and scholars who advocate for scientists to coproduce climate information with users need to be sensitive to and reflect upon the existing social and political cultures that shape climate information generalising case studies into best practices or onesizefitsall lists disregard the cultural sensitivities which influence the successful uptake of climate information second further research is needed on the role governmentapproved climate information plays in narrowing the usability gap civic epistemologies profoundly influence how usable climate information is constructed by both scientists and users can political cultures similar to the uk produce knowledge that serves a larger user base with different capacitiesbut still be salient for government policymaking what challenges does this present and how do users with simpler needs judge the credibility and legitimacy of salient knowledge in the absence of governmental approval third the growing number of climate knowledge providers brokers and specialists has led to calls for increased harmonisation of modelling methods climate variables and climate service institutions across europe although this promises greater consistency and comparability as well as lower financial costs many national governments are keen on exercising and strengthening their own epistemic sovereignty rather than offloading power to supranational climate service institutions it is unclear how well european climate knowledge practices would travel particularly if they ignore the national civic epistemologies governing the interactions between science and society considerable institutional inertia exists to keep doing climate scenarios in the same way only the british radically changed their way it produced and communicated its climate scenarios between its last and most recent set as met office hadley centre scientists pushed for greater innovation in its climate modelling whether the europeanisation of climate knowledge is possible or even undesirable remains open to debate lastly more research is needed to reconcile the contrasting experiences of scientists and users to better understand why good science is constructed differently and the implications this has for instance after consulting seemingly the same water users why did ukcp09 and kmni14 scientists take radically different approaches to their climate scenarios different epistemic cultures alone cannot fully explain this indeed user preferences over risk politics and decisionmaking are powerful catalysts as well only by tracing the experiences of scientists and users together will we be able to fully understand what shapes climate information mediumuser has to be able to read and understand complex topics lowentry barrier for use is held as low as possible conclusion our research maps how different social and scientific values and different institutional arrangements shaped three sets of national climate scenarios what knowledge is produced how scientists and users interact and what the user expected to apply the climate scenarios are strongly influenced by the political culture of each country and the respective roles played by science government and nonstate organisations in each efforts to coproduce climate knowledge are restricted possibly even counterproductive if scientists are unwilling to listen to users in the first place and while new actors may join or user needs develop producers and brokers of climate information need to be aware of and responsive to the political culture that incentivises such changes while governmentapproved science may help improve the legitimacy and credibility of climate information the same is not necessarily true for its saliency and usability this insight has important implications for how societies will adapt to climate change and the extent to which their decisions will be effective

this paper seeks to understand why climate information is produced differently from country to country to do this we critically examined and compared the social and scientific values that shaped the production of three national climate scenarios in the netherlands switzerland and the uk a comparative analysis of documentary materials and expert interviews linked to the climate scenarios was performed our findings reveal a new typology of useinspired research in climate science for decisionmaking i innovators where the advancement of science is the main objective ii consolidators where knowledge exchanges and networks are prioritised and iii collaborators where the needs of users are put first and foremost these different values over what constitutes good science for decisionmaking are mirrored in the way users were involved in the production process i elicitation where scientists have privileged decisionmaking power ii representation where multiple organisations mediate on behalf of individual users and iii participation where a multitude of users interact with scientists in an equal partnership these differences help explain why climate knowledge gains its credibility and legitimacy differently even when the information itself might not be judged as salient and usable if the push to deliberately coproduce climate knowledge is not sensitive to the national civic epistemology at play in each country scientistuser interactions may fail to deliver more usable climate information

introduction the relationship between ecological measures of deprivation and health status measures are often used to determine the presence and scale of health inequality within national populations these findings are used to assess different health needs and inform the targeting of health resources to reduce health inequalities the decennial census of the uk population provides a robust data source with which to explore health inequalities across a number of factors including areabased deprivation however such analyses are only possible at ten year intervals reducing scope to monitor progress during the intercensal period to assess change in health inequalities at more frequent intervals alternative sources must be explored ideally a source should align closely with the census and be sufficiently large in sample terms to enable accurate estimates of populations of interest computed previously using census data this report explores the potential of the general household survey to provide an accurate intercensal measure of inequality in health expectancies across groups of small areas that experience differing levels of deprivation the department of health funded this project as part of a wider programme of work focusing on the measurement of inequalities in health background there is a clear relationship between composite measures of health status such as health expectancies and measures of socioeconomic position however the incomplete assignment of socioeconomic position at an individual level in death registrations and the absence of intercensal population estimates disaggregated by socioeconomic position restricts analyses of he by the national statistics socioeconomic classification for example mainly to longitudinal data sources to overcome this limitation measures of deprivation assigned to small areas have often been used as alternative indicators of socioeconomic position and several studies report a clear linear association between health and level of deprivation however each is defined measures of disadvantage based on area deprivation combine individual and environmental characteristics at a given point in time and provide a greater depth of analysis than measures based on occupation and employment status alone the decennial census provides a wealth of data to explore the relationship between health and area deprivation however its use to measure change over time is restricted to ten year intervals intercensal analyses provide the opportunity to monitor progress in reducing inequalities in health at more frequent intervals identifying a consistent and continual annual data source of sufficient size and complexity that is coherent with the decennial census is key to producing an intercensal measure of inequalities in health expectancy for such a measure to be worthwhile for informing policy it must be temporally distinct from the census year deliverable at least once between census years able to clearly and precisely distinguish between area deprivation clusters one likely source is the ghs which is now the general lifestyle module of the integrated household survey this survey carries a general health question consistent with the census 2001 and is currently in use to inform national estimates of healthy life expectancy with an annual sample of approximately 20000 people in england this survey is small compared to the census but the data collected over several years can be combined to produce a larger aggregated dataset in national estimates of he for example current practice is to combine three years of ghsglf survey data a further concern surrounds the measure of deprivation used in assessing health inequality previous studies have used the carstairs index to define distinct geographical areas of deprivation both at census and intercensally using the health survey for england however it is not possible to update the carstairs index after 2001 an integral component namely the registrar generals social class has ceased collection in national surveys moreover there is a lack of comparability between the census 2001 and hse due to differences in the question used to capture general health prevalence in the population the index of multiple deprivation first introduced in 1999 for electoral wards is a viable alternative to the carstairs index providing a numeric indicator of ecological deprivation based on relative scores across a number of distinct domains such as income employment and health in 2004 the imd was updated to allow for analysis at lower super output area geographies see box 1 ghs data can be readily assigned to lsoa level deprivation groupings according to imd 2004 through postcode matching restricting the analysis to quintiles of deprivation and combining five years of ghs data provides a sample of approximately 20000 people for each quintile which is sufficient for calculating an intercensal estimate of health expectancy moreover after the initial five year aggregated period it is feasible to update the measure prior to the census 2011 using subsequent years of ghsglf data to track change in the gap in health expectancies this study assesses the potential of using the ghs as a data source for the intercensal measurement of inequalities in he across quintiles of ecological deprivation as defined by imd 2004 the initial focus compares health status prevalence and hle by age and gender for each quintile of deprivation calculated from census 2001data and ghs 200105 data the similarity of quintile specific estimates and therefore the inequality using each data source will indicate the usefulness of the ghs to provide an intercensal measure of the inequality in he by area deprivation methods the analyses in this report contain the prevalence of selfreported health status among the private household population of england residents of communal establishments are excluded because the ghs does not survey the institutional population the suitability of the five year aggregated ghs data to provide an intercensal measure of he between areas experiencing different degrees of deprivation is assessed by comparing the conformity of its estimates of health status prevalence and health expectancy with those based on the census 2001 data boxes 2 3 and 4 provide brief descriptions of the survey data and methods used during this study box 1 area deprivation imd 2004 combines seven distinct domains of data to produce a single measure of relative deprivation for each lsoa in england similar measures have also been constructed for wales northern ireland and scotland lsoas are relatively homogenous in terms of population size and structure each has approximately 1500 residents in this study the 32482 lsoas in england are ranked into quintiles in order to achieve a sufficiently large sample size for subsequent analyses of survey data although these quintiles represent a continuum of relative deprivation there is likely to be a significant degree of heterogeneity within each such that those at the bottom of quintile 1 are more closely related to those at the top of quintile 2 than those at the top of quintile 1 the imd has been criticised as conceptually difficult when used in health related studies since it includes a health domain to calculate relative levels of area deprivation therefore measurements of health using the imd as a geographical anchor may potentially suffer from mathematicalcoupling where the integral health domain of the imd influences the relationship with the health outcome under investigation recent studies however have found little evidence to support this effect concluding that the presence or absence of the health domain in the imd 2004 has little or no effect on observed health inequalities particularly when using general health limiting chronic illness andor mortality as outcome measures box 2 survey data data relating to residents of private households in england were collected from census 2001 and the ghs 200105 an aggregation of five years of ghs data achieves a sufficiently large sample for meaningful analysis across quintiles of deprivation a similar approach is used in the annual ons estimates of health expectancies for england census and ghs records were mapped to lsoa geographical boundaries using a postcode identifier and assigned to the relevant quintile of the imd 2004 for that area census and ghs populations were evenly distributed across deprivation quintiles each quintile contributing around onefifth of the populationsurvey sample residents of communal establishments were excluded from the census data to allow better comparison with the ghs which does not collect this data it should be noted however that mortality data used to calculate he includes deaths in both private household and communal establishment populations box 3 health status prevalence the prevalence of health status by sex and five year ageband was derived from responses to the following general health question asked in both census 2001 and ghs 200105 over the last 12 months would you say your health has on the whole been… good fairly good not good in this analysis a binary measure of general health is used to distinguish states of good and poor health specifically responses to the general health question were dichotomised by collapsing those reporting good or fairly good health into a single state of good health the remainder were classified as being in poor health in comparisons of health status prevalence between census and ghs data were age standardised to the european standard population to control for the possibility of differences in the age structure between the 2001 census and the ghs samples used box 4 health expectancies healthy life expectancy and disability free life expectancy hle is partly derived from health status prevalence and partitions life expectancy into periods of good and not good health dfle is partly derived from reports of limiting longstandingterm illness he were calculated using the sullivan method combining prevalence and mortality data and midyear population estimates lsoa level mype and mortality data are not available prior to 2001 therefore estimates of hle derived from census 2001 data use mortality data only from 2001 and the census population was used as a proxy measure of the mype for estimates of hle and dfle based on the ghs all data were aggregated over the period 200105 comparisons were made between census and ghs based estimates of hle for males and females at birth and at age 65 across deprivation quintiles results comparison of health status prevalence and hle by area deprivation quintile according to census 2001 and ghs 200105 health status prevalence both census and ghs data showed a similar consistent pattern of increasing prevalence of poor health with rising levels of deprivation and a greater degree of inequality between extremes of deprivation for males compared to females at national level the prevalence of poor health was somewhat higher according to the ghs compared to the census and the gender gap was also more pronounced approximately 8 per cent of males and females were in poor health according to census and around 10 and 11 per cent of males and females respectively were in poor health according to the ghs compared to the census the prevalence of poor health was higher for both males and females in the ghs in each quintile of deprivation and this difference was greatest in those living in the most deprived areas as with national figures the gender gap was also more pronounced in the ghs compared to the census at each quintile of deprivation in the 2001 census the prevalence of poor health for males living in the most deprived fifth of lsoas was three times higher than for males living in the least deprived areas for females the equivalent inequality was narrower the prevalence of poor health in the most deprived areas being 27 times higher than in the least deprived areas similarly in the ghs the prevalence of poor health for males in the most deprived areas was 28 times higher than in the least deprived areas the equivalent inequality was again less pronounced for females the prevalence of poor health being just 23 times higher in the most compared to the least deprived areas healthy life expectancy as with health prevalence census and ghs estimates of hle showed similar and consistent patterns across the deprivation quintiles and between the sexes for both sources each quintile of deprivation in the cohorts of males or females at birth or at age 65 was significantly different estimates of hle got significantly worse with increasing levels of deprivation and were lower at birth and at age 65 for males compared to females in addition the difference between the extremes of deprivation was greater for males than for females significant difference in hle between census and ghs hle was lower for males and females at birth in the ghs compared to census but estimates at age 65 were similar in both data sources at national level hle for males at birth according to census was around 69 years significantly higher than in the ghs where hle was approximately 68 years similarly hle was significantly higher at census for females at birth 728 years compared to the ghs at 707 years by deprivation quintile estimates of hle at birth for males and females were also significantly greater in the census compared to the ghs additionally the inequality of hle between the least and most deprived quintiles was greater in the ghs than in the census 143 vs 132 years for males and 122 and 112 years for females in the ghs and census respectively the difference in the scale of inequality between genders however was similar at around 2 years in each data source at age 65 estimates of hle for males and females according to census and ghs data were largely equivalent nationally at this age hle was 128 and 127 years for males and 150 and 149 years for females according to census and ghs based data respectively for each quintile at age 65 estimates of hle for males and females were comparable across sources with one exception among females in quintile 2 hle was significantly higher at 162 years according to census compared to only 157 years according to the ghs confidence intervals signifying the precision of estimates of hle were substantially narrower for census based estimates compared to those derived from the ghs as with hle le declined with increasing levels of deprivation however the difference between the least and most deprived quintiles was much narrower the range in le at birth between the least and most deprived areas was around half that of hle at birth and twothirds that of hle at age 65 for both sexes the proportion of life spent in good or fairly good health that is hle divided by le was broadly similar for males and females in each quintile of deprivation but between quintiles this proportion varied notably at birth males and females in the least deprived quintiles could expect to spend approximately 91 to 92 per cent of their lives in good or fairly good health but for the most deprived quintiles this fell to just 81 to 82 per cent a difference of around 10 per cent between the extremes of deprivation for males in particular the greatest difference exists between the most and next most deprived areas where the proportional difference was almost as great as that between quintiles 1 to 4 combined at age 65 differences in the estimated proportion of remaining life spent in good or fairly good health between quintiles was more extreme than at birth at this age the gap between the least and most deprived areas was around 17 per cent for males and 13 per cent for females however the incremental change between quintiles was on the whole smoother than at birth disability free life expectancy as with hle there were clear and significant differences between estimates of dfle in each quintile of deprivation within the cohorts of males and females at birth and at age 65 dfle was observed to decrease with increasing level of deprivation males at birth and at age 65 had significantly lower estimates than females in each quintile and the inequality in estimated dfle between the least and most deprived quintile was narrower for females than for males at birth males and females living in the least deprived areas could expect some 135 or 114 more years of life free from a limiting longstanding illness or disability than their counterparts in the most deprived areas at age 65 the inequality in dfle between the least and most deprived quintiles was approximately 45 years for males and 40 years for females this difference was of a similar magnitude to the inequality between quintiles seen with hle although the 95 per cent cis were a little wider at around 1112 years at birth and 0809 years at age 65 at birth males and females in the least deprived areas could expect to spend around 910 per cent more of their lives without a disability than those in the most deprived areas at age 65 these differences are larger 14 per cent for males and 12 per cent for females discussion this report explores the potential of the ghs to provide an adequate intercensal measure of health inequality between advantaged and disadvantaged populations defined using the imd 2004 measure of deprivation at small area level initially comparisons of health status prevalence and hle for areabased deprivation quintiles in each data source were undertaken to assess level of conformity these represent the first use of lsoa level geographical groupings in health expectancy reporting by ons and provide further supporting evidence of the relationship between deprivation and health found in previous investigations the strong association of deprivation and health status and health expectancies are consistent with previous research increasing levels of deprivation equate to shorter lives and longer periods of life in states of poor health and disability in both absolute and relative terms census 2001 data clearly distinguishes between level of health status and health expectancy by quintile of deprivation significantly fewer people residing in the least deprived areas reported poor health than their counterparts experiencing greater deprivation the reporting of poor health increased in a predominantly linear pattern with increasing deprivation which produces a substantial gap between the least and most deprived quintiles in fact these data show that in 2001 there were three times as many people reporting poor health in the most compared to the least deprived areas similar and consistent differentials were found using the ghs in 200105 although the prevalence of poor health was greater in each quintile and the inequality between the least and most deprived areas was slightly narrower significantly so for females survey data were agestandardised and so differences in the ages of respondents between the ghs and census would not account for the differences observed differences in the design of the census and ghs however in addition to the wider time period applying to ghs data may contribute to the observed differences in the prevalence of poor health between sources there is evidence to suggest that respondents completing selfadministered questionnaires are subject to primacy effects whereby the uppermost choices in a list are more likely to be selected in contrast respondents in facetoface interviews are more likely to be influenced by recency effects where the answers at the bottom of a list are more likely to be selected such effects could go some way to explain the differences between the census and ghs in this study other likely contributors to the observed differences include interviewer prompting in the ghs and proxy effects in the census data whereby forms may be completed by one household member on behalf of another it is also noteworthy that studies have shown that facetoface interviews result in more positive and socially desirable responses particularly for health status and behaviour compared with selfadministered questionnaires in the ghs responses to the general health question may vary with other forms of bias such as interviewer characteristics and the social setting in which questions are asked in contrast the selfcompletion nature of the census may present a cognitive burden on respondents as it assumes a certain level of literacy understanding of the question and ability to recall events without probing given the complex interaction of mode effects and responses to the general health question it is difficult to disentangle their impact on the reported prevalence of poor health in this study the patterns in health status prevalence rates were also observed in estimates of hle for the census there was again a clear linear relationship between deprivation and estimates of life spent in good or fairly good health hle decreased significantly with each declining quintile leading to a substantial gap in hle between those in the least compared to the most deprived areas female hle was significantly higher than for males at birth and at age 65 in each deprivation quintile although the inequality in estimates between the least and most deprived areas was narrower for the reasons noted above and because of differences in mortality and midyear population estimate data used in their construction estimates of hle derived from ghs 200105 and census 2001 cannot be directly compared however the relationships between hle and deprivation between males and females and between areas of deprivation within each cohort at birth and at age 65 are consistent between the ghs and census in the ghs 200105 the scale of inequality in he between the least and most deprived quintiles was substantial some 11 to 14 years of hle separated people residing in the least and most deprived quintiles males and females at birth living in the least deprived areas between 2001 and 2005 could expect to spend approximately 91 to 94 per cent of their lives in good or fairly good health compared with only 82 to 86 per cent in the most deprived areas at age 65 these differences were more pronounced those in the least deprived areas can expect to spend 82 to 84 per cent of their remaining lives in good or fairly good health states compared with just 65 to 70 per cent for those in the most deprived areas similar patterns were observed for dfle the scale of inequality was greater for men than for women at each point in life examined this concurs with previous evidence on inequalities in le and he by socioeconomic position however the pattern of inequality across social classes or nssec classes in women is more irregular than the predominantly linear pattern in men however by area deprivation the pattern is predominantly linear for both sexes and therefore provides a better indication of graduated need the estimates reported here are broadly consistent with those found in a study using carstairs deprivation twentieths to identify health inequalities between electoral ward groupings in this study differences in hle at birth between the least and most deprived twentieth of wards for males and females respectively were 134 and 118 years at birth and 52 and 47 years at age 65 the finer gradation used in that study did not lead to an undue difference in the scale of inequality suggesting breakdowns of areas into fifths on the basis of level of deprivation are adequate for determining the presence of inequality and its scale the similar findings serve to verify the approach taken here as with other studies results here also show that measures of longevity alone underestimate the magnitude of inequality between areas or extremes of deprivation when compared with measures which combine mortality and morbidity data into a summary index of quality and quantity of life the gaps in inequality found in hle and dfle were much wider than those found in le the gaps in hle and dfle at birth between the least and the most deprived areas were approximately twice as great as those observed for le we now intend to extend this analysis to cover more recent years of the ghsglf in an attempt to monitor changes in health inequalities over time this planned work will focus on dfle as the measure of inequality as the general health question used to inform estimates of hle in this study was discontinued in the ghs in 2007 replaced by a euharmonised question limitations of ghs data of primary concern is the precision of estimates of hle computed by pooling five years of survey data to form quintiles of deprivation populations this precision is determined by the width of the per cent cis surrounding estimates of hle ideally the 95 per cent ci should be less than 1 year at birth and less than 05 years at age 65 in order to detect real changes over time the estimates surrounding ghs based estimates of hle presented here are a little wider than this target but broadly equivalent to national estimates of hle for england and considerably narrower than national estimates for wales and scotland the cis would become narrower with each additional year of survey data but this would make the time period of the estimate much less desirable as an intercensal measure despite the fact that the cis are a little larger than desired the similarities in the differentials and relationships by deprivation quintile gender and age between the data sources used in this study indicates that the ghs is a suitable source for an intercensal measure health expectancy by quintile of area deprivation the precision of intercensal estimates in the near future will improve as data from the integrated household survey core module becomes available for use this source has a considerably larger sample compared with the ghsglf used in this analysis conclusions the ghs is a useful data source to inform intercensal estimates of hle across quintiles of ecological deprivation as defined by imd 2004 as the pattern observed by level of deprivation concurs with that reported using the census 2001 this report provides estimates of le hle and dfle at birth and age 65 by quintile of deprivation across england for the period 200105 as such it provides further evidence of the importance of material deprivation for health outcomes the clustering of deprivation found in very small population units such as lsoas serves to guide the targeting of interventions to mitigate differences and set benchmarks to monitor change list of tables

deprivation and ill health are intimately linked monitoring this relationship in detail and with sufficient frequency is key in attempts to reduce health inequalities through more efficient targeting of healthcare resources this study explores the potential of the general household survey ghs to provide an intercensal measure of health expectancies in small areas experiencing differing degrees of deprivationthe prevalence of health status and the health expectancy of males and females at birth and at age 65 by quintiles of small area deprivation are estimated comparisons are made between census 2001 and ghs 200105 to inform the suitability of the latter as an intercensal measure of health expectancy across small areas comparisons are also made between the health expectancies of people living in more and less deprived areasreports of good and fairly good health fell and health expectancies declined as deprivation increased consistency between census and ghs data indicates that the latter is a suitable source for the intercensal measurement of health expectancies across quintiles of deprivation at birth people living in the least deprived areas can expect more than 12 additional years of life in good or fairly good health than those in the most deprived areas at age 65 the difference was more than four years in terms of the proportion of life spent in favourable health states at birth those living in the least deprived areas could expect to spend around 91 per cent or more of their lives in good or fairly good health compared to 82 per cent for those in the most deprived areas at age 65 people in the least deprived areas could expect to spend around 82 per cent of their remaining life in good or fairly good health compared to 69 per cent or less for those in the most deprived areasthis study represents the first use of the index of multiple deprivation imd 2004 in the measurement of health expectancy across small areas both the census and ghs highlighted substantial differences in the health status and health expectancies of people experiencing differing degrees of ecological deprivation these findings serve as a useful measure and benchmark in the targeting and assessment of interventions designed to ameliorate health inequalities

introduction children below the age of 18 years who are made to work is considered child labour according to the international labour organization they work in various industries and households for meagre wages which is prevalent all over the world many studies explore that poverty illiteracy and lack of education are the major issues for increasing child labour in the society which is a significant problem in many developing countries including india the study made by the international labour organization reveals that there are more than 152 million children who are involving in child labour worldwide at present in india 39 child labour cases are found who are aged in between 5 to 14 years they violate the constitutional provisions like fundamental rights of children and also harm to themselves physically mentally and emotionally for the sake of unwanted burden imposed upon them 1 the child labour prohibition and regulation act 1986 this act prohibits the labour of children below 14 years of age in hazardous activities like mining explosives brickkilns etc however the act regulates the working condition of children in nonhazardous occupations like agriculture manufacturing services etc however there are some limitations in it ie not more than six hours a day it has a provision of imposing penalty whoever breaks the rule with a fine of rs 50000 and imprisonment of two years 2 the juvenile justice act 2015 the provisions of this act shall be applied to all matters concerning children in need of care and protection and children in conflict with law such as apprehension detention prosecution penalty or imprisonment rehabilitation and social reintegration of children in conflict with law along with procedures and decisions or orders 3 adoption regulation 2017 it has come into force on 16 th january 2017 as per this law any orphan or abandoned or surrendered child who are declared legally free for adoption by the child welfare committee is eligible to be adopted by parents irrespective of heshe is married or unmarried and shall have physically mentally and emotionally stable and financially capable 4 the juvenile justice act 2021 this act mandates equal rights for children and protection of children it also fulfils the indias commitment as a signatory to united nations convention on the rights of the child in this act the district magistrate is empowered to deal with child protection and adoption process an outlook onchild labour and covid19 in india child labour most probably is a frequently used term around the world soon after the covid19 epidemic slows down its devastating appearance with crores of death and unexpected cases people become jobless and homeless due to continuous lockdown and no means of living arrangement is set up for many on 24 th of march 2020 the prime minister of india mr narendra modi announced lock down for 21 days which was followed by 14 hours curfew two days backand again the lock down was extended until the virus spread minimizes the societal change is noticed due to this sole reason in degrading the status of living by not only the poor people but also the people from higher classes educated classes middle class or any other class without justification of who they are many people have lost their job and migrated from working place to native place during that period the mass movement of people at that time was described as the largest movement after the partition of india in 1947 many children lost their parents duringtravelling due to mass rush at the station or somewhere in the road and that later on bound the children to do work in a low wage to keep themselves alive many children who become orphan have to be selfsufficient to earn money and to keep living the parents allow their children to work and support the family due the socioeconomic condition and poverty they face a study made by reddy reveals that the children of daily wage earners are worst affected by covid19 they have very little earnings and their children have to remain hungry for another meal the unicef of the united nations have warned the world being child right crisis for covid19 which have also threated india having 472 million children the largest child population in the world the press has repeatedly reported that despite having many existing child labour act in india the children work tirelessly in the agriculture sector like paddy vegetables and other farms to continue their livelihood in assam the press has reported that a large number of children have left their school education and joined tea garden brick yard masonry paddy field fishing and so on for earning to continue their living in morigaon district of assam population plays an important role in the entire process of socioeconomic scenario it had 776256 population in 2001 which is increased to 957423 in 2011 in the total area of 1551 sq kmit is a matter of fact that growth of human population occurs due to the lack of education the literacy rate of morigaon district is found 6803 percent in 2011 census which demarcate it as under developed in the matter of business trade industry culture education and so on in comparison to many other districts of assam the children of illiterate people are unsafe become child labourer child abuse victim and they may alsodevelop the habit of bad practice in the society like stealing smuggling like drugs narcotics women trafficking spread hiv infected diseases and so on the relevance of covid19 in child labour in india the pandemic has caused a massive increase of child labour in the world as well as in the countries like india it has pushed many children to work in worst form that has threatened the child right organizations like educo and the stakeholders in india the country director of educo mr guruprasadsaya among the various groups affected by the global pandemic children remain one of the worsthit across the globe the pandemic has triggered a massive increase in the cases of abuse and violation faced by children in india as well the condition of working children and children in forced or bonded labour in the country has only worsened in the light of covid19 pandemic the main cause of child labour in india due to covid19 was recognised as economic crisis followed by lock downs jobless unsafe migration closure of schools and cut down from various existing facilities the country director of educo also added that the child labour problem was not a new thing in india but after the crisis of pandemic it becomes prominent so we need to understand that unless the opportunities created for marginalised children to engage in meaningful developmental activities the problem cannot be reduced significantly objectives of the study the objectives of the paper are  to analyse the causes and consequences ofchild labour in postcovid19 situation  to identify the elements that contribute to child labour in morigaon town  to find out recovery measures taken by the stakeholders to restore the child labour cases  to forward some suggestions to develop present status of child labour if needed research design for the proposed study as this work is in the nature of an analytical study the researcher has adopted the following methodology for choosing the sample and collecting and analysing the relevant data a sample the sample were collected from four sources  the district child protection unitmorigaon assam  the sarva shiksha abhiyan morigaon assam  the secondary schools and  the advocate dealing with child labour case of morigaon district from the district child protection unit morigaon assam the data were collected from the incharge of this officewith the help of a questionnaire containing 15 openended questions from the sarva shiksha abhiyan morigaon assam the data were collected from the incharge of this office with the help of interaction method from thesecondary schools of morigaon town the data were collected from the restored children who were learning there with the help of interaction and observation method again some interactions were made with their parents for thisprefixed proforma was used from the morigaon court the data were collected from the advocates dealing with child labour cases of morigaon district in nagaon district court in morigaon no child labour court is available at present for this a questionnaire is used b tools used for conducting the field study and collecting relevant data following tools and techniques are used questionnaire observation and interaction delimitation of the study the child labour is a worldwide problem every society has greater responsibility to eradicate this problem as the children are the future of the society a country will develop when the children are properly taken care of and nurtured properly this type of study can help a society stakeholders govt and nongovt organizations and research scholars however due to time and cost constraints the current study delimits to morigaon town only but the study can be extended to wide range such as morigaon district assam north east india or the world the above table shows that in the year 2022 with the help of district child protection unit total 38 child labourers were apprehended of which 35 were male child and 3 were female they were registered under the child protection act 2021 and restored with the permission of district magistrate after proper counselling by them as declared by the unit data interpretation and analysis the analysis of data shows that in the year 2022 when covid19 pandemic was almost relaxed and people started their regular life again the child labour cases came into notice among them male child cases were higher than the females ie 9211 of total population from the analysis of data it can be assumed that they are from the lower socioeconomic group and engaging themselves in lowpaid work and may not properly support the family they belong to as a result no satisfaction is pursued from the work they do rigorously from the table 3 it is known that during 202223 total 3092 students from the age group of 614 years have left the school of them 2122 were male child and 970 were female the study finds out that in morigaon district the male drops out case is greater than the females ie 6863 of total population the table 1 also proofs this fact where among the apprehended children female case is lesser than the males ie 789 of total population from the analysis of data we can assume that male child is taking more family responsibility than the females and they suspended themselves from the educational rights as well as child rights facilitated by the govt or constitution of india the data can be analysed that among the dropout teenage studentsmales are more prone to continue work than back to education again some of the registered cases of these age group are also found involved in antisocial activities like drugs sex abuse etc some of the female students are victim of child marriage also the above table shows that in the year 2018 the child labour case was found only one on the other hand in 2022 the case has increased to 38 numbers which is very significant from the analysis of data it is clear that covid19 has affected the people living in this place and it has directly impacted many children who are bound to do work for their living though the child labour case was existed before the pandemic spread that was very minimum in 2018 only one such case was found which was however in 2022 just after the covid19 was calm down found significantly high so it is a matter to be discussed and find out the solution to eradicate the problem data regarding remedialsinitiatives taken by the dcpu a a leaflet is published yearly containing information regarding child labour b arrange meetings between headmaster of school and dropout students c awareness programme is arranged d the girl child labourers who are drop out for 2 years or more than that are given admission in kasturba gandhi school in morigaon district assam from the study it is found that covid19 affects the socioeconomic condition of the people of morigaon district assam due to lock downmany people lost their source of income most of the cattle farm and poultry farm were being closed due to the unavailability of foods and decreasing of sell again other natural calamities like heavy rainfall flood erosion destruction of crops and paddy fields jute fields and vegetable fields etc also affect people of morigaon in the year 2020 within next one year ie in 202223 3552 students are found out of schooland engage themselves in various activities so that they could earn money and support their family data regarding remedialsinitiatives taken by the sarva shiksha abhiyan 2 it is significant that in comparison to total drop out cases in morigaon district only 38 child labours are apprehended or recovered by the district child protection unit in the year 2022 that is only 001 of the total population the remaining 9999 is untraced 3 though the govt of assam in collaboration with sarva shiksha abhiyan flags a mission to trace the drop out children but that is not satisfactory till now 4 the study finds out that the number of boys drop out are larger than the girls in the year 2022 in the age group of 614 years the percentage of boys drop out is 6863 and in the age group of 1517 years the percentage of boys drop out is 5956 from the interaction it is found that boys have to take more responsibility of their family for the reasons like family population poverty poor livelihood prolonged health issues of the elder family members death of parents in covid19 hike of essential commodity prices and so onagain it is also significant that some of the drug cases and child marriage cases are from these teenage drop out groups 5 the study also finds out that many students left their school during covid19 due to the online education method many poor students were unable to buy the android mobile phone to continue their study besides this many students found it difficult to operate due to expertise in the technical issues of it therefore they left the school and did not come back to school due to fear shame anxiety and yearloss 6 the study finds out that some initiatives are taken by the district child protection unit and sarva shiksha abhiyan to restore the child labour as  publish leaflet  arrange meeting with head masters  conduct awareness programme occasionally  arrange special training etc but in the real picture these are useless for many 7 the consequences of child labour are also found significant i 4736 of the child labourer who worked in factories or garage were injured some of them became cripple lost eye cut hand or finger duringmachinery or hazardous work ii cent percent of the child labourer wanted to live a free life without any responsibility they are suffering from mental illness like fear anxiety depression etc and live an unsatisfactory life iii 50 of the child labourer have suffered from the serious health issues like respiratory diseases ear problem eye problem stomach problem fever and etc iv cent percent of the child labourer are deprived from child rights like labour free life free and compulsory education midday meal and other facilities provided by the govt of india some suggestions and recommendations 1 strict law should be enforced against child labour 2 access to education should be made easy for the sufferervictim without considering their age and year loss 3 more awareness camp should be organised in the society to aware the impact of child labour 4 create easy income opportunities for elderly persons weak persons child bearing mothers and so on 5 utilization of free time in vocational or skillbased work like soft toys making craft work tailoring weaving and so on 6 provide financial assistance to the needy person to overcome from the situation 7 improve social protection such as health care nutrition sanitation and so on 8 emotional attachment and societal support for the weaker section of the society should be given conclusion child labour in india is a significant problem it requires a comprehensive approach to eradicate from the society it needs involvement of stakeholders including the govt ngos communities civil society and other sectors by working together it can be possible to reduce prevalent child labour only then future of the child will be saved and secured data analysis from the interaction and observation during data collection the researchers have interacted with the stakeholders the victim children and with their parents and found different causes and consequences of child labour relating to the covid19 they are discussed below main causes found a despite covid19 other natural calamities like rain hail storm flood erosion destruction of crops and etc during 202122 b parental death disability and ailment c poverty insufficient resources for living d poor income low wages after day long service e big family uncontrolled population many members live together in a single roof suffocated f lack of education no understanding about quality life no proper family planning no proper investment no literacy little numerical ability g online education uncapable of purchasing android mobile lack of technical skills network issues and so on h hike of essential commodity price unbearable rate of daily using things i jobless common thing during covid19 due to lock down and safety purpose j unemployment after investing in education no job guarantee no proper job available in the society struggle etc main consequences found a physical injured or suffered quite often while working b emotional lack of love and care from the family members working place and from the society

child labour being a risk factor all over the worldnow a day is considered an urgent matter of discussion it needs to sort out various causes and consequencesof child exploitation in any form and find immediate solutions to conduce a serene environment so that budding children can move freely enjoy their childhood in fearless environment and grow mentally strong to become good human beings of the society it is seen that child labour is increasing day by day at present due to the post effect of covid19 and other causes like poverty lack of education societal negligence addiction illness and so on thus this paper aimsto find out various causes and factors responsible for child labour in morigaon town assam at present for this the data will be collected with the help of questionnaire from theincharge ofdistrict child protection unit dcpu morigaon assam the sarva shiksha abhiyan morigaon assam the secondary schools of morigaon town assamand by using observation and interaction method with the childlabourers and their parents belong to thiscentral areaconnected from different villages and mini towns moreover many case reports of childlabour after covid19 will be collected from the advocates of morigaon courtwill be analysed

introduction breast cancer is the leading cancer diagnosed in african american women and is the second leading cause of cancer death 1 furthermore african american women have the highest ageadjusted rates of breast cancer mortality 12 a diagnosis of breast cancer can cause varying degrees of psychological distress among women and oftentimes there is the potential for future mental health issues and reduced quality of life if it is unresolved 34 furthermore depression in breast cancer patients has been related to lower medication treatment adherence and higher mortality rates 5 6 7 despite depressions detrimental impact in breast cancer prognosis this condition is rarely recognized and treated 7 thus identification of factors that are related to depression among women with breast cancer is important to help clinicians address and integrate psychosocial needs into routine cancer care as recommended by the new quality standard 8 this endeavor is especially important for african american breast cancer patients who face a worse prognosis after diagnosis than other racial and ethnic groups and who are understudied compared to their white counterparts 9 there is some evidence to suggest that depression prevalence may vary by race and ethnicity though data are equivocal and research in this area has been scarce 10 11 12 a womans response to her diagnosis is complex and may be the result of interaction of several factors including her internal capacities as well as her interactions with others therefore consequences of negative life events such as breast cancer may differ between african american and white women a womans psychosocial response to breast cancer diagnosis has been examined for the most part through administration of personality inventories and structured clinical interviews however limited empirical data exist that assess the level of depression symptoms in african american women with breast cancer or whether these rates are similar to african american women in the general community without breast cancer the need for attention to mental health concerns of african american women has been noted in qualitative studies 13 but specific aspects are lacking such as examination of ego strength and the role of social support in mediating depression therefore it is important to investigate african american womens psychological response to breast cancer status this will provide a better understanding of the correlates of depressive symptoms in this group which may help to reduce disparities in cancer outcomes existing studies have not examined the role that specific personality traits such as ego strength play in the manifestation of depressive symptomatology in response to breast cancer diagnosis in african american women ego strength a concept widely examined in the field of psychology has been defined as a measure of the internal psychological equipment or capacities that an individual brings to his or her interactions with others and with the social environment 14 because therapists and researchers have utilized ego strength to predict psychological adjustment and the success of patients in psychotherapy 15 16 17 it seems prudent to examine whether different levels of ego strength can assist in predicting the development of depressive symptoms in african american breast cancer patients another important element related to the psychological response to breast cancer diagnosis is social support social support often functions as a buffer from negative psychological reactions to both mental and physical illness 18 several investigators have examined the valuable role that social support plays in assisting breast cancer patients adjustment to diagnosis 19 20 21 22 23 24 25 26 27 28 29 and have demonstrated an association between social support and depression among patients with the disease researchers have also found that perceived adequacy of support is a positive predictor of psychological outcome and response to breast cancer diagnosis 21 30 31 32 some studies suggest that the dynamics of social support may vary by race one study 21 found a racerelationship between perceived social support and adjustment and another study 33 showed that african americans and white breast cancer patients tended to seek different sources of support the national comprehensive cancer network 34 recommends that oncologists routinely assess distress in cancer patients yet there are scientific gaps in knowledge about the level of depressive symptomology in african american women with breast cancerparticularly in comparison to women without breast cancer although black women tend have an earlier age of onset of breast cancer compared to white women 35 there is paucity of research with younger women the current study begins to address some of these gaps by addressing the following what are the levels of depressive symptomatology in young african american women with breast cancer does the level of depressive symptoms vary according to selected demographic factors and how much variance in depressive symptomatology is explained by ego strength stage of breast cancer and social support methods design and study participants approval for this study was obtained from the institutional review board of the nih georgetown university medical center and howard university this study compared depression in women diagnosed with breast cancer to those in the general community the study focused on women between the age of 40 and 50 to capture women that were old enough to have mammography recommended and also to account for the fact that african american women tend to have an earlier onset of breast cancer yet younger breast cancer patients are underrepresented in the literature breast cancer cases were eligible if they were african american between 4050 years old diagnosed with breast cancer within 12 months of data collection not currently being treated for depression and not currently engaged in abuse of illicit drugs breast cancer cases were identified from pathology reports in a location hospital registry 100 patients were mailed invitation letters from their physician and contacted for participation from which 76 agreed to join the study a comparison group of women were recruited from health fairs which were geared to provide cancer screening services to residents in the washington dc metropolitan area women were eligible for the comparison group if they were african american between 4050 years old reported having had a mammogram within the last year with benign results and not being treated for depression or a mental illness women recruited from health fairs scheduled an inperson interview with the research assistant all recruited participants were consented by a trained research assistant at university study offices where participants completed a selfadministered survey which took approximately 90 minutes to complete 36 no monetary incentives were provided instruments the outcome variable was depressive symptomatology and major predictor variables were ego strength social support stage of breast cancer and demographic factors outcome measurethe beck depression inventoryshort form was used to assess depression symptomatology this tool is widely used and includes 13 items that assess the severity of current affective motivational and behavioral symptoms of depression in psychiatrically diagnosed patients and in normal populations 3738 in the current study alpha089 each item consists of a list of four statements organized in increasing severity about a particular symptom of depression and a 910 cutoff point is suggested for medical patients 39 predictorsthe barrons ego strength scale includes 52 items that measure aspects of effective functioning adaptability and personal resourcefulness the scale has demonstrated good reliability 40 also in this study emotional and tangible support from networks was measured using the norbeck social support questionnaire nssq assesses structural properties and functional properties respondents answer questions regarding a list of significant people in ones life length of association and frequency of contact with these individuals the degree to which each person provides emotional and tangible support and recent losses of supportive relationships at least three scores are yielded from the nssq a total functional score a total network score and a total loss score reported internal consistency cronbach alpha coefficients for the norbeck social questionnaire range from 089 to 098 4142 in this study cronbach alpha coefficient was 093 other variables included on the survey were age marital status income level occupation education family history of breast cancer breast cancer was captured for breast cancer patients statistical analysis descriptive statistics were used to describe sample characteristics of the study participants independent sample ttest chi square test and analyses of variance were used to examine whether depression symptoms varied by the various groups posthoc procedures were performed for pairwise comparisons two multiple regression models were fit to the data to identify correlates of depression symptoms among women with breast cancer and among disease free women coefficient of determination was reported to estimate the amount of variation in depression symptoms scale explained by the explanatory variables in the model all data analysis was conducted using sas results sample characteristics the sample consisted of 152 african american women between the ages of 40 and 50 years with a mean age of 440 both women with breast cancer and those in the comparison group had a fairly high level of education with 553 and 726 respectively having some college education or higher similarity 487 and 539 respectively were employed in professional positions table 1 provides additional demographic information no significant differences between cases and comparison groups were found in demographic variables as expected depression was statistically higher in cases than in the comparison group additionally total functioning was significantly lower among cases compared to the comparison group depressive symptoms varied according to the womans stage of breast cancer which emerged as the only significant main effect f 665 p 00001 mean levels of depression increased significantly as stage of breast cancer advanced stage i mean5 53 tables 3 and4 display results from the stepwise multiple regression analyses among breast cancer cases stage of disease and age were positively related to depression both factors were the only independent predictors of depression and explained 84 of the variance among women in the comparison group ego strength and tangible support were independent negative predictors of depressive symptoms explaining 32 of the variance discussion to our knowledge this is among the first studies to compare levels of depressive symptomatology in african american women with and without breast cancer while examining the impact of internal characteristics and social support we found that african american women with breast cancer reported greater levels of depression than women without cancer from community settings and rates in this group were higher than found in a recent study of mostly white breast cancer patients using the same screening tool 43 we also found that women with breast cancer reported lower levels of functioning compared to women without cancer these findings underscore the importance of recent guidelines to screen routinely for psychological morbidity in breast cancer patients compared to their white counterparts relatively little is known about adaptation in african american survivors while previous research demonstrated that individuals with cancer have greater levels of psychiatric illness especially depression when compared to the general population 44 45 46 47 48 49 we have now expanded this knowledge to african american breast cancer survivors we found that breast cancer stage and age were independently associated with depressive symptoms in african american woman with breast cancer accounting for a significant amount of the explained variance our finding that older age was associated with higher levels of depression is contrary to some reports that examined anxiety and depression and found that depression and anxiety were higher in younger african american women 50 one explanation for this difference may be that the current study had a more narrow age range and thus did not allow for comparisons between very young or very old african american women 5152 overall the sample could be regarded as younger in general since participants were ≤50 years of age and data suggests that compared to older breast cancer survivors younger survivors report more psychological problems and adjustment difficulties 53 our findings point to important implications for longterm wellbeing in african american survivors because they are more likely to have an earlier age of onset of breast cancer compared to white women 35 while there is limited empirical data regarding reasons for the depressive symptoms in african american women younger women may have more concerns about taking care of their children future childbearing and sexuality than their older counterparts 53 54 55 in addition to age certain contextual factors may exacerbate these issues and increase vulnerability to depressive symptomatology in african american women compared to their white counterparts such as financial barriers lower socioeconomic status and access to mental health services 56 more information is needed about the particular problems andor concerns of younger african american breast cancer patients as well as interventions to address these issues a higher stage of breast cancer was associated with higher levels of depressive symptoms which have been reported in other populations 5758 these findings are consistent with previous research demonstrating relatively high levels of psychiatric distress in patients with advanced stages of breast cancer 5960 fultons study 59 examined 80 women diagnosed with advance stage breast cancer from initial diagnosis through a 16month period in an effort to monitor levels of depression and anxiety along with identifying mood disturbance when using cut off scores on the hospital anxiety and depression scale fulton found that a relatively large proportion of the sample fell into the borderline and cases ranged for both depression and anxiety in contrast a crosssectional study conducted by kissane and colleagues 60 found high rates of psychiatric distress and disturbances in a sample of 303 women with earlystage breast cancer these studies however did not compare depressive symptoms across breast cancer stage a plausible explanation for the relationship between clinical stage and depression is that the clinical aspects of the disease may be more robust predictors of depression than psychosocial variables included in this study thus not accounting for significant amounts of the explained variance although previous research has not specifically examined predictors of depression in african american women with breast cancer ego strength and multidimensions of social support have been related to psychological adjustment to breast cancer 1516196162 the consistency of these findings across research designs and with different samples gives strength to the conclusion that associations exist between ego strength social support and depression however the fact that stage of breast cancer did emerge as the best predictor of depression in the present study underscores the important role that stage of disease plays in the psychological functioning of women within the sample while ego strength and the various social support variables seem to be nonsignificant predictors of depressive symptoms for women with breast cancer ego strength and tangible support accounted for 32 of the total explained variance in depressive symptoms in the comparison group one possible explanation for the difference between the two groups is that simply the clinical condition for breast cancer is more stable and robust predictor of depressive symptoms than intrapsychic characteristics of the individual and sociocultural factors however an alternative explanation may be that other personality factors that were not explored in this investigation could possibly predict depression for example research has shown that type d personality also called distressed personality has been linked with depression in other clinical populations 63 future studies in african american patients that include measures of personality traits such as type d may be useful another explanation of the lack of association between social support and depression in the breast cancer group may rely in the inadequacy of the instrument to capture all the relevant types of social support for this group current measures of social support have often been developed and validated in white middle class populations and might not include some types of social support deemed to be important for ethnic minorities or specific subpopulations such as breast cancer patients 64 for instance in a qualitative study that explored perceptions and experiences of social support in african american women with breast cancer hamilton and colleagues 64 found various types of emotional support and tangible support not included in norbecks emotional and tangible support subscales furthermore informational support was found to be very relevant among african american breast cancer women but it was a dimension of support not covered by norbecks social support questionnaire 4142 additionally structural properties of the network included in the survey such as the size of the network might have a different impact on mental health than expected in breast cancer patients compared to the comparison group for instance ashida and colleagues 20 found that for younger breast cancer women a reduction of network size was associated with better psychological adjustment thus further research to understand the impact of various types of social support in mental health for specific subpopulations is warranted therefore it is important to emphasize that one should not discount the valuable role that personality characteristics of the individuals and the social support available to these individuals can play in the psychological functioning of women with breast cancer given the findings regarding the benefits social support and support groups in addition to support groups cancer providers have and important role of providing emotional and social support to women diagnosed with breast cancer 13 thus future studies should examine healthcare interactions and access barriers as other potential predictors of psychological morbidity in recently diagnosed patients 6566 while it is well noted that many african american women have strong spiritual coping 1067 this does not preclude the need for psychosocial support during cancer treatment the stress and fear associated with the diagnosis of breast cancer may indeed trigger a depressive response or reaction additionally it is likely that african american breast cancer patients especially those of lower socioeconomic status encounter economic as well as other barriers to cancer care 68 which has been shown to be associated with depressive symptomatology in other minority groups 5869 currently little is known about the mental health referral process for african american women with breast cancer however limited data suggest that african american women are less likely to seek andor receive necessary mental health services than their white counterparts 65667071 thus receipt of appropriate psychosocial assessments and mental health referral warrants attention for this group based on our data greater efforts should be implemented to offer psychosocial support services especially to younger african american women with breast cancer because comprehensive supportive care may not be readily available to all women with breast cancer ensuring interdisciplinary collaborations between oncologists and mental health professionals is one practical step in this direction the study had certain limitations due to the crosssectional nature of the study we cannot determine the causal direction of the association between depression symptoms and the predictors women were recruited in urban areas and eligible participants were between 4050 years old thus results may not generalize to younger or older populations or to women that live in rural areas we did not capture information about stage of treatment which prevented us from analyzing the impact that stage of treatment may have had on depression levels nevertheless this study is among the first to compare cases and controls in african american breast cancer patients adding to the paucity of empirical data about correlates of depression and on the internal consistency and reliability of the selected measures for the african american female population as such this research begins to close the gaps in knowledge about the general psychological presentation of african american women with breast cancer note the scores on the ego strength range from 052 the depression scale range from 039 the range of scores on the other variables vary since they were able to cite as many individuals as they wanted in their list of networks

purposethis study assessed the levels of depressive symptomatology in african americans women with breast cancer compared to those of women without breast cancer and examined demographic psychosocial and clinical factors were correlated with depression methodsa total of 152 african american women were recruited from washington dc and surrounding suburbs breast cancer patients n76 cases were recruited from a healthcare center and women without cancer were recruited from health fairs n76 comparison we assessed depression psychosocial variables ego strength and social support and sociodemographic factors from inperson interviews stage and clinical factors were abstracted from medical records independent sample ttest chi square test anova and multiple regression models were used to identify differences in depression and correlates of depression among the cases and comparison groups resultswomen with breast cancer reported significantly greater levels of depression m115 sd50 than women without breast cancer m39 sd38 p 001 higher cancer stage beta91 and higher age beta 11 were associated with depression in the breast patients explaining 84 of the variance in the comparison group ego strength and tangible support were inversely associated with depressive symptoms accounting for 32 of the variance conclusionswomen with more advanced disease may require interdisciplinary approaches to cancer care ie caring for the whole person implications for cancer survivorsdepression is often underrecognized and undertreated in african american breast cancer patients understanding the factors related to depression is necessary to integrate psychosocial needs to routine cancer care to improve survivors quality of life

introduction disentangling the relationship between social protection and social cohesion introduction to the special issue résumé il existe dimportantes données probantes concernant leffet de la protection sociale sur la pauvreté et la vulnérabilité cependant les études qui se penchent sur les effets au niveau de la société sont peu nombreuses cet article fait office dintroduction à un numéro spécial qui étudie la relation entre la protection sociale et la cohésion sociale dans les pays à revenu faible et intermédiaire au cours des dernières années la cohésion sociale est devenue un objectif central de la politique de développement lintroduction et les articles de ce numéro spécial utilisent une définition commune de la cohésion sociale en tant que phénomène à multiples facettes comprenant trois attributs la coopération la confiance et lidentité inclusive cet article introductif fournit un cadre conceptuel reliant la protection sociale à la cohésion sociale montre les preuves empiriques actuelles des liens bidirectionnels et met en lumière la façon dont les articles de ce numéro spécial contribuent à combler les lacunes de la recherche existante en plus de cette introduction le numéro spécial comprend sept articles qui couvrent différentes régions du monde et divers régimes de protection sociale et font usage de différentes méthodes quantitatives et qualitatives jel classification d63 • h41 • h53 • h55 • i38 setting the scene the development community has shown an increasing interest in social protection since the start of the new millennium this trend is due to the increasing evidence that sustainable poverty reduction is difficult to achieve without investment in social protection because economic growth does not usually trickle down to reach an entire population moreover social protection is increasingly recognised as a key driver of economic growth especially if it incentivises productive investments by lowincome households and finally an increasing number of publications show that social protection can also contribute to political and broader societal developments even if such effects are often not its primary intended goals this special issue contributes to this wideranging and multifaceted debate focusing specifically on social cohesion over recent years social cohesion has emerged as a central goal of development policy as demonstrated by numerous publications by international organisations and bilateral donors such as undp the world bank and the oecd the reasons for this are threefold first societies that are more cohesive are believed to be more resilient in particular with respect to natural disasters and public health crises such as the ongoing global covid19 pandemic second social cohesion fosters societal peace third social cohesion contributes to local community development which often depends on a communitys ability to agree on common goods to be created for the benefit of all community members identifying policies that foster social cohesion is therefore crucial not least because political and social polarisation is currently rising in many countries worldwide social protection is potentially one of these policies examining its effects on social cohesion is particularly important in the context of the covid19 pandemics impact on health societies and economic development globally people around the world feel more vulnerable which can undermine resilience and thereby bring about societal and political instability however the relationship between social protection and social cohesion is unlikely to be a oneway street socially cohesive societies are deemed in their turn to provide better and more allencompassing and acceptable social protection systems because their members share similar values a shared understanding of the common good helps to identify generally acceptable compromises for the design of social protection systems this bidirectional relationship even though it is quite intuitive has received only limited attention so far one major reason is that there is no universally agreed concept of social cohesion and no established set of indicators to measure it in this special issue we address the problem by relying on a clear definition of social cohesion which is quite similar to many definitions already suggested by the existing literature but is sufficiently narrow for straightforward operationalisation according to this definition social cohesion is composed of three main attributes cooperation for the common good trust and inclusive identity the si examines the possible effects of social protection on social cohesion andthough less sothose of social cohesion on social protection it aims to address three sets of interrelated guiding research questions the first set is whether different social protection schemes generate effects on social cohesion and which ones have the strongest effects and on whom only the direct beneficiaries or the entire population mainly people in poverty mainly people working in the formal sector mainly women or men the second set concerns the conditions under which these effects materialise when exactly do they arise in which contexts does it matter if a social protection scheme has been set up by the state or by other actors does the quality of targeting or quality of benefit delivery play a role how important is the reliability and institutional durability of the schemes and the third set of questions is whether social protection influences all aspects of social cohesion in the same way or does it perhaps affect mostly inclusive identity because beneficiaries all feel better integrated into societyor horizontal trust because social benefits can bridge gaps and overcome hostility between different socioeconomic classes likewise we have to ask if all of these components are equally important for the existence and functionality of social protection schemes and at the same time we ask what role social cohesion plays for the planning design setup and operation of social protection programmes the remainder of this introductory article is structured as follows the next two sections present the concepts of social protection and social cohesion endorsed in this si the fourth section introduces the conceptual framework linking social protection to social cohesion while the fifth reviews the existing empirical literature on the causal effects going either way the last section presents the key findings of the papers in this si as well as the gaps remaining in research so far social protection the notion of social protection in international development is still quite ambiguous most people would probably agree with the definition of social protection as … the entirety of policies and programmes that protect people against poverty and risks to their livelihoods and wellbeing this means that social protection includes all measures that help people in their efforts to prevent risks mitigate risks and cope with the effects of risks at the same time there is still disagreement on some feature of social protection such as the following who can provide social protection and which risks should be covered at the very minimum though social protection includes noncontributory transfers social insurance microinsurance labour market policies and social services the core purpose of social protection is to reduce vulnerability and poverty in a country by preventing people from falling into poverty providing support to those who are living in poverty and enabling lowincome earners escape from poverty thereby it contributes to nutrition education and health because it allows even lowincome people to buy food consult a physician when they are sick and send their children to school rather than work and social protection is also one of the most powerful tools to reduce income inequality between social classes and genders however social protection can also have a transformational function by addressing the root causes of poverty and vulnerabilities such as unequal power relations or unjust distribution of public resources this function has been less explored so far given the indirect link between many social protection programmes and transformational outcomes of interest such as social equity and inclusion empowerment and rights at the same time social protection matters also for economic development on the one hand it enables even lowincome households to address risks smooth income volatility and improve intertemporal allocation of income thereby it improves the lifetime utility of households and reduces pressure put on networks and society as a whole to provide support for people in need who have failed or omitted to make provision for themselves on the other hand social protection encourages lowincome earners to make investments and thereby improve their future income expectations this effect is due to the fact people with lowincome and insufficient social protection tend to deposit any possible small savings in a safe place from which they can easily withdraw the savings without penalty whenever they suffer a loss caused by bad harvest illness unemployment or any other risk this preference changes only once people enjoy reliable and sufficient social protection against at least their most fundamental risks some empirical evidence shows that from then on people start investing at least some of their savings in machines new modes of production training or better education for their kids investments like these bring about new risks but they raise future income expectancy likewise borga and dambrosio find that beneficiaries and nonbeneficiaries alike increased their investment in asset formation and livestock holding in response to the launch of cashforwork programmes in india and ethiopia and bastagli et al confirm a clear relationship between cash transfer receipt and increased school attendance the use of health services and investment in livestock and agricultural assets if well designed social protection can thus be a key driver of propoor growth growth that benefits predominantly lowincome people social cohesion social cohesion refers to the ties or the glue that hold societies together overall there is a broad agreement that social cohesion is a complex multifaceted phenomenon encompassing a horizontal and a vertical dimension while early studies only equated social cohesion with the relationship among individuals and groups in a society over the last years equal emphasis has been placed on the relationship between individuals and state institutions in the search for an operational definition of social cohesion we adapt the minimalist approach suggested by chan et al according to whom the concept should be thin including only the core attributes and excluding the determinants and the outcomes of social cohesion as often generally stated in academic and policy debates inequality is likely to play a key role in determining social cohesion in a society however verifying the relationship between social cohesion and inequality analytically is not possible if they are part of the same concept against this background in this si we endorse the definition provided by leininger et al social cohesion refers to both the vertical and the horizontal relations among members of society and the state as characterised by a set of attitudes and norms that includes trust an inclusive identity and cooperation for the common good based on this definition social cohesion has three attributes cooperation for the common good trust and inclusive identity all three attributes have a horizontal and a vertical dimension the first attribute is cooperation for the common good when many people groups cooperate for interests that go beyondand sometimes even conflict withthose of the individuals involved it is a clear sign of high social cohesion because people who cooperate for the common good do care about society cooperation among individuals and groups represents that horizontal dimension while cooperation between individualsgroups and state institutions represents the vertical dimension for instance the maed magarat in ethiopiaa foodsharing initiative between neighbours to counter the effects of the first wave of the covid19 pandemic is a form of horizontal cooperation in turn investing time to take part in participatory budget processes to define the purposes of public spending is an example of vertical cooperation for the common good the second attribute is trust social cohesion includes two types of trust generalised trust and institutional trust generalised trust is the ability to trust people outside ones familiar or kinship circles and it captures the horizontal dimension of social cohesion institutional trust instead refers to the trust towards the core structural public institutions of a country and thus covers the vertical dimension the third attribute of social cohesion is inclusive identity most people feel they belong to different groups and thus have several identities a socially cohesive society is one in which individuals can have different identities and yet live together in a peaceful way and where a minority with a shared identity does not dominate the majority with a collective identity in other words different group identities tolerate recognise and protect each other while state institutions support such tolerance for different identities in cohesive societies individuals can still have different group identities but they should also have a feeling of mutual belonging to a broader unity that is more than the sum of its members and can bridge identities there are still diverging views in the literature especially regarding some potential ingredients of social cohesion as stressed in a comprehensive review article by schiefer and van der noll these ingredients would be quality of life wellbeing and inequality we do not integrate wellbeing and inequality into our concept of social cohesion for three reasons first in line with other scholars we argue that social cohesion is a macrolevel or mesolevel phenomenon it is thus a specific trait of a community a country a region or the world as a whole the literature on wellbeing instead focuses on individuals or households as units of analysis and refers to their living conditions in different life domains second it is problematic to include inequality as one of the constitutive elements of social cohesion as a notable number of studies do it would imply that by construction societies that are more unequal are less socially cohesive while it is plausible to expect a relationship between inequality and social cohesion incorporating the former in the definition of the latter does not allow for testing it empirically third in view of the objectives of this si having wellbeing or inequality as integral parts of the concept of social cohesion would generate particular problems the expansion of wellbeing and the reduction of inequality are often considered two direct objectives of social protection if included in the concept of social cohesion social cohesion would be identified as a primary goal of social protection as well in other words any policy that enlarges wellbeing or reduces disparities would automatically increase social cohesion it is instead important to verify whether it contributes also to social cohesion through either of these two channels conceptual framework relationship between social protection and social cohesion there are good conceptual arguments for the assumption that social protection and social cohesion affect each other as highlighted in the second section of this article the goal of social protection is to reduce poverty and vulnerability and to contribute to propoor growth in this si we argue that social protection can contribute to societal and political development as well more concretely we state that social protection can have positive effects on all elements of social cohesion inclusive identity trust and cooperation for the common good households that are well protected against the most serious of their individual risks can be assumed to have more confidence in themselves feel better included in society because they have more opportunities than other households do and hence feel less alienated from other groups of society this includes the positive impact of effective measures to mitigate climate change in addition social protection is an important tool to reduce inequality ie disparities between different parts of the population it would thus contribute not only to the inclusive identity of beneficiaries but also to their trust in other members of society even if these belong to other segments groups of society these effects can be particularly strong if social protection schemes incentivize interactions between members of different societal groups their cooperation in the creation of a common good can foster the acceptance into a group of individuals from outside that group and the acceptance and legitimacy of social protection schemes in a society in addition we assume social protection schemes strengthen vertical trustat least if they are implemented or financed by the state their beneficiaries are likely to be grateful to the actors that support them financially or by providing efficient instruments to deal with risk and poverty1 consequently the overall trust of beneficiary countries with high sc supposedly face less resistance against the implementaɵon of sp schemes where sc is strong government officials are more likely to engage in sp where verɵcal trust is strong people rely on the conɵnuity of sp and hence are more likely to change their behaviour moderaɵng non mediaɵng fig 1 main mechanisms between social protection and social cohesion source authors households in public institutions is likely to increaseat least if social protection schemes are universal or well targeted at those in need social protection thereby establishes a stronger relation between citizens and the government as a result citizens tend to be more willing to accept their current government and the given political order and to invest in public goods such as public order the tidiness of streets or communal action this effect on vertical trust is found to be especially relevant in climate change mitigation policies where both cash transfers and trust in government play a key role the intensity of all these effects depends on the design and implementation of social protection schemes for example trust in the government is likely to increase mainly if the social protection schemes are set up or are effectively financed by the government and if the population is aware of this fact if however social protection schemes are run and financed by nongovernmental organisations or foreign donors they might even have negative effects on citizens trust in their state good communication can also be helpful vertical trust and cooperation is likely to increase more if the government gives a clear explanation of the rationale for the existence and design of a social protection scheme and that it is financed by scarce public resources the most effective strategy to foster trust in the government is to establish social protection as a citizens right rather than as poverty relief in addition social protections effect on vertical trust is likely to be stronger if membership and targeting criteria are reasonable and transparent and if citizens have reason to believe that the targeting is rulebased and fair in practice in contrast we can assume that high errors of inclusion and exclusion have negative effects on citizens trust in the government lack of transparency can create feelings of unfairness and resentment as well thereby worsening horizontal trust in particular it can create conflicts between direct programme beneficiaries and those excluded but perceived to be in similar conditions even worse could be a situation whereby these programmes are targeted based on political considerations or are at least perceived as such by the population for example social protection programmes often benefit mainly the middle class rather than the poor which can be intentional or not but in any case intensifies existing inequalities and hence weakens both horizontal and vertical trust moreover some schemes such as cash transfers targeted at the poor can increase stigma and thus reduce social inclusion and social cohesion when not adequately designed finally if these programmes are not endorsed by the sections of society not directly addressed by these interventions the net effect may be negative in the best case the target population itself participates in the design and implementation of social protection programmes which adds to the positive effects on horizontal and vertical trust likewise the effect of social protection on peoples inclusive identity rises with the level and reliability of benefits and the way beneficiaries are treated by government officials certainly plays a role as well also social protection supposedly improves the vertical dimension of all attributes assuming they are universal rather than differentiated according to social groups povertytargeted programmes may also be acceptable to large parts of the population if their targeting criteria are just transparent and easy to understand in any case social transfer schemes are likely to generate stronger effects on social cohesion than social insurance schemes whereby members finance their own benefits though this si mostly focuses on the effect of social protection on social cohesion it also touches on the reverse relationship in addition to being a goal in itself social cohesion is also crucial for the implementation design and effectiveness of social protection schemes first policymaking depends highly on the readiness of policymakers to set up social protection schemes benefitting not just their clientele or peer group but the entire population or poor and other vulnerable groups in particular supposedly this readiness is higher in countries with strong horizontal and vertical trust and cooperation for the common good in addition governments of countries with high social cohesion are less likely to face resistance against the implementation of social protection schemes for the poor and vulnerable recent studies in the context of covid19 have highlighted that trust in government is crucial for the selection of and compliance with containment policies this shows that high social cohesion enhances governments with public confidence when social cohesion is weak however it may be much more difficult for governments to set up social protection schemes successfully as citizens may feel resentful about social protection programmes they do not like which may ultimately foster grievances in society second policy implementation benefits from social cohesion too where social cohesion is strong government officials are more likely to take actions that enhance the welfare of the population as a whole and less likely to neglect their duties misappropriate public funds and give preferential treatment to their peer group as a result social protection schemes are more efficient and functional third policy reception is possibly even more important where vertical trust in the government is strong people rely on the continuity of social protection policies and schemes and hence are more likely to change their behaviour where sense of belonging and horizontal trust are strong beneficiaries are more likely to share their benefits with other households and invest in social capital as a result the effectiveness of social protection schemes increases including their multiplier effects for traditional social protection schemes based on societal structures social cohesion is even more important they cannot work without horizontal trust and if horizontal trust and sense of belonging are particularly strong traditional social protection schemes are even based on generalised rather than balanced reciprocity ie they function like an insurance rather than a mutual credit club where people have lived together for most of their lives and hence can trust each other they are ready to help relatives neighbours and friends in need without an expectation that their support will ever be paid back everybody receives support from those who are able to provide it and gives support whenever they can to whatever person is in needbut this other person is not necessarily the same person that has provided help before the reciprocity is thus between individuals and the community rather than between individuals such as in the case of balanced reciprocity in this si we would have liked to discuss equally both directions of the relationship between social protection and social cohesion much of the discussion in subsequent sections focuses however on the effects of social protection on social cohesion the reasons are twofold the increasing importance of social cohesion as a policy outcome and goal which also feeds into empirical research agendas and the fact that there is even less empirical literature on the effects of social cohesion on social protection than on the effects of social protection on social cohesion this is possibly for two reasons first testing the effects of social cohesion on social protection requires variance in social cohesion which exists mainly in crosscountry comparisons which are often impossible because of the lack of comparable data on social protection systems second given the presence of several confounding factors it is difficult to attribute differences in social protection programmes clearly to differences in the level of social cohesion empirical evidence unfortunately empirical evidence for the assumed bidirectional relationship between social protection and social cohesion is limited and scattered because social cohesion is hardly ever an explicit goal of social protection programmes and hence rarely considered in monitoring and evaluation reports the few existing empirical studies define social cohesion in quite different ways but most of them operate with attributes that are no different from or very similar to the ones we use cooperation for the common good trust and inclusive identity unfortunately the bulk of the studies focus on the horizontal dimension of these three attributes in addition studies in this si applied different research methods which do justice to their specific research subjects and questions a number of studies are providing empirical evidence of the positive effects on the horizontal dimension of social cohesion most of them look at cash transfer schemes in subsaharan africa or latin america adato for example conducted focus group discussions with different actors in 70 communities across six states of mexico and finds that cash transfers have positive effects on horizontal trust two studies using both survey and experimental data document that a conditional cash transfer in colombia has increased beneficiaries willingness to cooperate with each other relying on existing secondary data primary data and the implementation of different qualitative and participatory methods in yemen west bank and gaza kenya uganda and mozambique pavanello et al confirm that both social insurance and assistance schemes can contribute to horizontal trust and inclusive identity by promoting local economic development fao provides evidence from several cash transfer schemes in subsaharan africa indicating their positive impacts on social relations and participation in community events orima and the asia foundation argue that timorlestes covid19 cash transfer programme has a positive effect on horizontal trust 82 of the population stated that covid19 had brought their community together in contrast to 70 immediately before the pandemic also in this si beierl and dodlova find that cfw activities in malawi increase the readiness of people to invest in public goods as well as to interact with others from the same or a different societal group andrews and kryeziu provide evidence that cfw programmes in ethiopia and yemen have improved social cohesion by citizen participation in programme design roxin et al find that cfw schemes in turkey and jordan have contributed to horizontal trust and the sense of belonging of participants and nonparticipants zintl and loewe confirm the finding for jordan unhcr also finds that the kalobeyei integrated social and economic development programme in kenya which enables refugees to purchase supplies from local shops and thereby promote interactions has positive effects on horizontal trust between refugees and locals in turkana likewise köhler presents some case studies to show that social protection programmes reduce poverty and thereby contribute to social inclusion the overall satisfaction of people and ultimately social cohesion reeg suggests that the existence of social protection programmes raises the opportunity costs of being part of an armed group and two studies have assessed quantitatively the impacts of specific social protection programmes in refugee settings providing initial evidence of positive effects on social relations among refugees and between refugees and in one case also between refuges and local communities however few studies suggest negative effects of social protection programmes on social relations in the majority of cases the authors find that the lack of transparency andor clarity in the targeting of beneficiaries generated feelings of jealousy among households that did not benefit from the programmes thus increasing tensions with beneficiaries in addition benefitting from social protection can also bring stigma and lower social cohesion in a study based on individual interviews with different actors in sri lanka godamunne shows that disrespectful treatment by government officials and delays in the transfer of benefits weaken the vertical trust of beneficiaries of a social transfer programme roelen et al provide insights into different graduation programmes in burundi and haiti showing that social protection can have positive and negative effects at the same time while it can contribute to dignity participation in social activities and sense of belonging stringent targeting and discretionary provision of benefits can in time undermine trust among nonparticipants the evidence concerning the relationship between social protection and the vertical dimension of social cohesion is even scarcer and hence even less conclusive building on experimental data evans et al find that a conditional cash transfer in tanzania significantly increased vertical trust in local leaders and a selfreported willingness to participate in local projects and this effect seems to be higher when beneficiaries are better informed about the central role played by the local government in brazil however bolsa familia did not reach the same positive results because beneficiaries did not believe that the designed institutional space to ensure their representationthe municipallevel councilswere truly available to them for participation monitoring and accountability other studies find negative effects of social protection schemes on societal perceptions of government likewise zepeda and alarcón show that social protection programmes foster vertical trust only if they are institutionally sustainable gehrke and hartwig conduct an extensive literature review on public work programmes and finally suggest that the involvement of foreign donors in social protection policies can harm vertical trust zintl and loewe provide evidence in support of this assumption they find cfw programmes to have positive effects on horizontal trust in jordan however they report also that these same effects are much weaker where participants are aware of the fact that foreign donors rather than the national government have set up the respective cfw schemes in addition the effect is also much weaker if the targeting of transfers is perceived as unfair or nontransparent similarly camacho finds that the conditional cash transfer in peru increases vertical trust only among the beneficiaries and decreases it among nonbeneficiaries köhler presents anecdotal evidence that the introduction of a social pension and a child benefit scheme in nepal has been a major factor in the increase in vertical trust in nepal after 2009 while the dismantling of pension schemes in chile led to a decrease in vertical trust looking at the reverse side of the relationship we find even less empirical evidence based on qualitative analysis hossain et al find that the indonesian unconditional cash transfer programme bantuan langsung tunai had positive effects on different outcomes only in high social cohesion communities in a study covering four asian countries babajanian et al find that the impacts of social protection schemes depend substantially on the local institutional setting and above all on the nature of the relationship among social groups indeed where gender and ethnic disparities were high especially due to existence of discriminatory rules against women and specific groups programme performance was lower roelen et al shows that the quality of horizontal relationships at the community level plays an important role in the success of two different graduation programmes in haiti and burundi findings of this si and their implications for future research the remainder of the articles in this si contribute to filling some of the gaps outlined in this introduction in two ways the first is by using a common understanding and definition of social cohesion some papers focus on just some components of the definition but they all share a common understanding this facilitates a comparison of the findings across papers second the articles look at several mechanisms linking social protection and social cohesion and also represent a good balance between qualitative and quantitative methods in addition the aforementioned comparability advantage of the si is strengthened by the different contexts and countries considered as well as the different social protection programmes analysed ranging from longterm to shortterm ones from conditional and unconditional cash transfers and public works schemes to graduation programmes2 and contributory social insurance schemes table 1 provides a brief overview of the main features of the different articles of the si the majority of the articles advance our understanding of the effects of social protection on social cohesion burchi and roscioli for example look at the effects of an integrated social protection programme on social cohesion in malawi using a mixedmethods approach specifically they exploit an experimental design and primary household data for about 800 households in total to investigate the impact of three different components of the programme on a set of indicators for the trust and cooperation attributes informed by the results of the econometric analysis they then examine the contribution of one specific componentparticipation in the saving groupsthrough focus group discussions and individual interviews the study shows no concrete effect of a lumpsum payment on social cohesion but a positive effect of both the training and participation in savings groups on withingroup trust and cooperation conversely vertical trust towards local institutions and horizontal trust towards other village members declined in particular due to jealousy and tensions arising from the targeting of social protection the authors thus underline the possible limitations of just giving cash as well as the potential of savings groups still in malawi beierl and dodlova investigate whether a public works programme effects cooperation for the common good the authors address this research question through quantitative analysis applied to primary and secondary data the primary data collected in two waves cover 500 randomly selected households secondary data are from the nationally representative integrated household survey conducted by the world bank in three waves the paper finds that the scheme improves cooperation among community members and speculates that this may in turn improve trust among community members and the perception of state institutions strupat examines the effects of social protection on social cohesion during a large covariate shock such as the covid19 pandemic in kenya he does so econometrically by using a differenceindifference model and household data collected before and after the covid19 pandemic his analysis suggests that social assistance has no statistically significant preserving effect on social cohesion overall ongowo presents the results of qualitative research on the effects of social protection on social cohesion focusing on street children in kenya the author conducted comprehensive qualitative content analysis of key informant interviews with twelve government officials and indepth qualitative interviews with twelve randomly selected former street children who previously benefited from social protection programmes he finds that social protection can be an important tool to build social capital and solidarity in particular he concludes that social protection programmes improve the chances of street children developing a career reduce public resentment towards street children and thus enhance various aspects of social cohesion zintl and loewe in turn look at social cohesion in the context of state fragility and migration with a focus on donorfunded programmes they analyse the effects of public workscfw programmes in jordan on participants and nonparticipants in both cases syrian refugees and jordanian locals females and males their results are based on qualitative analysis of key informant interviews four group discussions and quantitative analysis of a census among all participants of one specific cfw programme the results confirm effects on the sense of belonging and horizontal trust of participants and nonparticipants refugees and locals they provide evidence in particular for a positive effect on women being more active in the economy and the society the results for vertical trust however are more ambiguous because many syrians and jordanians attribute positive effects to donor support rather than to jordanian authorities other papers in the si look at the broader picture by also including the effects running from social cohesion to social protection roelen et al conduct extensive qualitative analysis to investigate the bidirectional relationship between social protection and social cohesion in burundi and haiti in particular key informant interviews and focus group discussions were performed with programme participants and programme staff data collection was based on semistructured discussions as well as interactive activities such as ranking exercises they find that the existing programmes have strengthened some aspects of social cohesion such as dignity and positive identity whilst also having negative effects on others such as sense of belonging and togetherness however they also find that social cohesion enhanced the positive effects of social protection programmes malerba looks at social protection and social cohesion in the context of climate change mitigation this is important as climate mitigation policies are strictly related to socioeconomic development in lowand middleincome countries while some of the issues have been investigated in separate literatures there was a lack of unifying framework or empirical analysis when considering the combined effects of social protection and social cohesion on the implementation of climate mitigation in more detail the econometric analysis employs data collected in 34 countries in a multilevel model framework the data used collected preferences for environmental policies as well as other relevant information the results show that social cohesion in the form of trust is positively correlated with support for climate mitigation conversely social protection has positive effects only in highincome countries but not in middleincome countries this suggests low complementarity between climate and social policies and higher prioritisation of social goals in lowerincome contexts in sum the papers in this volume provide support and empirical evidence to different aspects of the relationship between social protection and social cohesion as outlined in the conceptual framework however despite the important contribution that the si makes to the topic further research needs to be done on the remaining critical gaps one of these is the impact of social cohesion on the effectiveness of social protection as this si focuses more on the inverse relationship such research can definitely benefit from applying the definitions of social protection and social cohesion used by all authors of the articles in this si future research should also address the other gaps outlined in the first section social cohesion has become prominent only in recent years and the relationship between social protection and social cohesion is not direct and straightforward these facts make the empirical analysis challenging from a methodological point of view therefore better data which will hopefully become increasingly available can improve the empirical evidence and the knowledge of these issues and as a third research gap it remains to be seen how the ongoing expansion of social protection programmes in the aftermath of the covid19 pandemic can be better linked with the goal of improving social cohesion

while there is substantial evidence of the effect of social protection on poverty and vulnerability limited research has focused on societal outcomes this paper serves as introduction to a special issue si examining the relationship between social protection and social cohesion in lowand middleincome countries over the last years social cohesion has emerged as a central goal of development policy the introduction and the papers in the si use a common definition of social cohesion as a multifaceted phenomenon comprising three attributes cooperation trust and inclusive identity this introductory article provides a conceptual framework linking social protection to social cohesion shows the current empirical evidence for the bidirectional linkages and highlights how the papers in the si contribute to filling existing research gaps in addition to this introduction the si encompasses seven papers covering different world regions and social protection schemes and using different quantitative and qualitative methods

introduction s ociological general theories have been criticized for being too abstract to be of much practical use for empirical sociological work such a criticism was made by robert merton of talcott parsons theoretical system but similar criticisms have been levelled at many other wellknown general theories the claim has been especially often made that general theories cannot explain phenomena and are therefore irrelevant to empirical research this article advances the idea that a sociological general theory may be written around the concept of a social game and that this general theory may have an edge over competing general theories when it comes to giving guidance on interpretation explanation and translation into middlerange theories the concept of game is used here not as a metaphor but as a heuristic startingpoint and center for the general theory 1 a general theory is what merton calls general sociological orientations a series of interlinked concepts that may guide the researchers thinking and be translated if made more specific into substantive middlerange theory this means that general theory cannot be immediately tested empirically however neither should it be selfcontained or immunized from empirical falsification there are scholars who would a priori question the utility of such general theory on the other hand general theorizing if successful may have important functions it allows us to summarize sociological knowledge makes findings from different substantive fields comparative and most importantly may provide ideas and guidance for substantive theorizing and empirical work the goal of this article is to show that the theory of social games is as general as other competing grand theories but that it offers a more straightforward way of being translated into middlerange theorizing and empirical work 2 the link to middlerange theory and empirical work is created with a descriptive heuristic an explanatory heuristic and formal and agentbased modeling the contribution of the article is thus to offer a highly abstract unifying scheme both for qualitative quantitative and formal and agent modeling in sociology i will construct the theory by starting with very simple gamesforfun such as noughts and crosses and chess abstracting their basic properties and showing how such a model can be applied to social games in general in doing so i draw freely on and integrate the insights of wellknown theorists from different disciplines my main inspirations come from sociology i draw in particular on the work of goffman garfinkel elias and coleman goffman analyzed social life in respect to the ways that individualsinroles playeither for other individuals as in a theater performance or with other individuals as in a game garfinkel showed that social games use various layers of both discursive and tacit rules and that the reproduction of these games rests on a level of general trust that these rules will prevail elias argued that using game models of varying levels of abstraction to analyze the social can help overcome the individualsociety dichotomy coleman realized that the playing of social games leads to emergent outcomes that can be explained by independent game elements and the process of the game however important insights regarding games as models can also be taken from the writings of boudon bourdieu fligsteinadams merton and weber more recently diciccobloomgibson and stachura have argued that real games such as chess go poker and cycling competitions could help us devise sociological theory but the theory of social games also draws on the insights from disciplines other than sociology a whole research tradition in economics and mathematics launched by neumann and morgenstern has shown that gamesforfun can be the startingpoint for a mathematical modeling of strategic situations thus leading us to formal models of idealized games probability theory was invented by huygens in the 17th century by analyzing dice games in philosophy searle used gamesforfun to demonstrate how social reality is both real and constructed and winch following wittgenstein showed that the understanding of social phenomena resembles the understanding of gamesforfun biology and evolutionary social science argues that play is used both in animals and humans to learn behavior useful in later adult life humans extend the period of immaturity and let their children play and engage in gamesforfun for an increasingly long time here children also learn complex interactions and role identities through playing 3 this point of view is grosso modo corroborated by anthropologists who study early huntergatherer pastoral and horticultural societies finally in cultural and game studies huizinga argued that human culture is in essence gamelike caillois proposed important ways of classifying games and scholars such as klabbers have shown how computer games can create whole new worlds creating a general social theory with gamesforfun as a startingpoint has been criticized however with scholars arguing that unlike a game the rules of social life are often complex ambivalent and open to different interpretations by different actors that the actors may not consciously know these rules and sometimes only discover them while playing the game and that there may be substantial disagreement on the rules which may be contested and changed by powerful players furthermore critics have argued that unlike gamesforfun situations in social life are extremely complex actors have to react to cues that belong to various and sometimes conflicting frames and contexts and that a game does not have this complexity finally it has been argued that unlike in gamesforfun actors in social life are not in a makebelieve world of a game but in the real world thus they cannot just stop the game take time out or ignore the consequences of their actions i do not find these criticisms convincing contrary to what these critics think many gamesforfun are in fact complex ambivalent and open to different interpretations rules can be complex and contradictory in improvisational games the application of rules is routinely challenged in football when children play games they constantly discuss the existence and form of rules and in russian roulette and runningforthebride the game may have serious consequences the problem is that the definition of game that these critics use is very narrow and automatically excludes many phenomena of interest a broader definition of social game would provide us with a powerful tool to understand and explain precisely the phenomena mentioned in the criticisms above this outline article can only show the central elements of the general theory since every part could be treated in much greater detail many possible questions must remain unanswered but there is a rationale for presenting a first overview to see if further work on such a project is warranted social games defining social games a social game is a form of ordering the social sphere in which players with resources use objects to engage in actions which are shaped by goals rules and representations the social game creates game time game space and leads to game outcomes the game takes place in and is influenced by a context figure 1 shows the main idea the arrow loop points to the recursive nature of social games game interactions lead to new game interactions until the game is finished social games operate in a societal context they use actors and their behavior as well as physical objects and transform them into players game actions and game objects with a symbolic reality that would not exist without the game thus when i play rockpaperscissors i become a player and my fist becomes a rock in football a round leather object becomes a football and a person in black becomes the referee the ontological status of social games a note is in order here on the ontological status of social games social games exist in the realworld and are at the same time socially constructed this problem has long bedevilled social theorists and much energy has been expended on discussing whether social reality is real or constructed in the current discussion the constructionist view is often merged with postcolonial critical and discourse theories while the realist view is often confounded with analytical sociology the theory of social games easily shows that social games are both real and socially constructed they exist independently of how social scientists represent or are aware of them and are thus part of the realworld out there nevertheless social games exist only insofar as the players themselves believe that they exist and actually play these games this can be easily demonstrated with a gameforfun when i play rockpaperscissors my fist is not a real rock it is socially constructed in the sense that it only represents a rock as long as i and the other players treat it as a rock in the framework of the game nevertheless in that framework it has its undeniable reality with the real consequence that i can really win or lose the game but the same point can be made for all social games a 100 bill is socially constructed in that it is worth 100 only insofar as i and many others believe in its worthif those beliefs crumbled i would be left with a worthless piece of paper nevertheless and insofar as these beliefs pertain i can go to a shop and buy real objects for my 100 bill forms of social games social games come in a staggering variety of forms and many different classifications have been proposed social games may or may not have spectators exhibit external effects have a function for yet other games have the same or different goal for the different players may involve only two or hundreds and thousands of players their rules and representations may be consensual or contested may or may not be known to all the players etc for this outline i focus on two classifications the distinction of gamesforfun and social games and the distinction between levels of social games gamesforfun and serious games a first distinction is between gamesforfun and serious games or games that are not played for fun the main distinction between the two types is the fact that gamesforfun are abstracted from manifest interests and functions in the social world this is why gamesforfun exhibit a sense of freedom absence of necessity and enjoyment huizinga 1963huizinga serious games on the other hand are seen as belonging to the real worl where serious work and necessity reign apart from this point however gamesforfun and serious games exhibit exactly the same properties the basic assumption made in the theory of social games is that there exists one overall gamelike structure of social organization gamesforfun are just the emergence of exactly this same form in a miniformat and for enjoyment this is why they lend themselves particularly well as models for theorizing i have found that some people have difficulty in extending the game definition to serious matters such as presidential elections police raids or faculty meetings they may object that calling a faculty meeting which is arguably often devoid of fun a game is only true metaphorically but fun is not part of our definition of a social game and a faculty meeting falls very nicely under the definition of social game that we have given above levels of social games a second classification concerns different levels of social games these different levels being distinguishable according to how players are accepted as players for example interactions are formed by players who see each other as present in a concrete situation and as currently playing a game groups are formed by players who accept each other as members based on certain criteria and markets are formed by players who buy and sell goods and services from and to each other in this way we can distinguish between very different types of social games that are wellknown in the social sciences such as interactions groups organizations networks movements milieus markets and societal subsystems which are all analyzed as social games thus a conversation between neighbors is just as much a social game as a book club or a fridayforfuture meeting note that this is quite similar to how luhmannian systems theory sees different levels of social systems i allow more types of games than luhmann however and my criterion to distinguish the types is different to his an indepth treatment of these different types of social games would require another article it is only important at this point that the theory of social games aims to be very general and that its fundamental concepts are applicable to phenomena of very different extension like competing grand theories the theory of social games claims to be applicable to the social world in general social games are thought to exist in all domains and at all levels of the social however i do not claim to offer a theory of the social as suchwhich would require deep treatments of language communication social evolution etc but rather a theory of the social whenever it takes the form of social games in fact not everything belonging to the social world is a game most notably most game elements thus the rules of a game are not themselves a game and nor are the players the goals the objects or the representations individuals may also take individual actions that are not part of an obvious social game furthermore the socalled lifeworld is not itself a game but consist of the complicated coupling and nesting of several games when i go to a manchester united match with my friends we form an interaction game that also belongs to a group game to enter the stadium we have to go through security an interaction game that is part of a larger organization game when inside we buy hotdogs and beer when we watch the match the teams are each a group game there is a further interaction game between the public and the teams every one of these games could be subject to an indepth analysis regarding its players rules representations objects etc assumptions about individuals a theory of social games must necessarily make at least six assumptions about the individuals who play such games i call this actor model homo ludens first homo ludens speaks and understands a language games are languagebased and without language the actor could not play a social game second homo ludens has basic human needs such as the need for food water clothing sleep shelter security the sense of belonging and social worth third homo ludens recognizes social games in her surroundings and can adopt and internalize their goals understand their representations and follow their rules as well as also being able to a certain extent to explain them causally and to predict their outcomes much of the waking time of a homo ludens consists in scanning the world for clues of various games fourth homo ludens makes different games and their goals the center of her action and uses them to fulfill her basic needs and motives she does so by identifying her personal goals with the game goals thus homo ludens seeks to gain social worth through being in a group of friends to earn money through being employed in an organization and to reach her place of work through driving through traffic fifth homo ludens creates a sense of who she is of her own identity by monitoring and judging her relative performance in the game and by identifying with a game that she or others are playing she may also create identity by identifying with the leaders of some of the games that she plays finally homo ludens will try to satisfy her needs as much as possible by expending as little energyinput on a game as possible she will try to balance her engagement in different games to maximize the satisfaction of her overall needs this is not to say that homo ludens always calculates in a perfectly rational way rather it is assumed that homo ludens tries overall to play the games well these assumptions seem quite uncontroversial but should they require justification then we can turn to literature in sociobiology humans have at a certain point in time acquired language and goalrelated ruleguided symbolic cooperative action and we take it that this is now human nature as readers will notice homo ludens combines the two elements of normfollowing and rationality this is obvious we could not play a game of chess without at the same time wanting to follow the rules and seeking to choose winning strategies also note that while homo ludens is rational her preferences are not fixed but rather are transformed by the game that she is playing for example she may be engaged in a game where the goal is to be altruistic or heroic and where social worth is created by looking out for others more than for herself and while she will normally try to strike a balance regarding her involvement in different games she might become so caught up in a certain game that she no longer satisfies some of her basic needs it is also worth emphasizing that this model of the individual has at its center the symbolic nature of the human being social reality which is made up of social games is symbolic and we could not understand even the simplest human game actions without understanding the game representations in which this action is immersed the elements of social games players games are played by actors in their capacity of players actors are individual human beings a player can be defined as an actor who is accepted by other players as such and who actually plays the game players have gamerelevant attributes and roles player attributes are the traits of players that are relevant for the game these include the amount of game resources and the amount or type of social physical psychological corporal resources or attributes for example in monopoly it is only important how much game money a person has at a certain point in the game but it is not important whether a person is male or female on the titanic on the other hand both money and gender were important factors in survival player attributes can also be negative ie rules may specify what attributes certain players are not allowed to have a player role is a bundle of rights and obligations concerning the actions and behavior of the respective player thus in copsandrobbers some players are cops and others are robbers in football one player per team is the goalkeeper while all the others are field players resources the term resources is used to capture all the means that players may use to achieve the goals of the game resources are also sometimes called different forms of capital resources do not denote a separate area of the game but encompass all the game elements described in this article insofar as they help players achieve the goal of the game thus player attributes rules representations context and even other game goals themselves may all become in one situation or another a resource in a given game a good tactic that can help a person find resources in a game is when she asks herself what she needs to be successful as a playera list of resources will then come to mind resources come in a large variety of forms and different typologies have been proposed from a socialgame perspective resources comprise objects cultural knowledge social capital mental and physical attributes positional attributes but also game and context attributes that a player may use to achieve the goal of the game in general forms of resources or capital differ strongly according to the game in question being tall helps with basketball but not with chess a profound knowledge of einsteins field equations may be an important resource when doing a physics exam but will not help much when chatting someone up in a bar actions an action may be defined as a socially constructed model of a short duration of behavior that is distinguished from other behavior on the part of one or several actors the distinguishing or counting as may happen before during or after the strip of behavior examples of actions would be score a goal give a statement in a presidential debate ignore somebody and chop wood these models of behavior can be used by actors to plan conduct and monitor their own behavior as well as to interpret the behavior of other actors we would be unable to conduct our lives if we could not interpret plan conduct and monitor our stream of behavior in terms of these socially constructed models of action a game action is a model of a strip of behavior by a player that is accepted by other players as being part of a social game in game actions players orient their behavior towards the other game elements ie they try to achieve the game goals with game resources and objects thereby keeping in mind the rules and representations of the game game actions are often called moves if i score a goal in football or give a statement in a presidential debate then this is counted as a game action if i voluntarily ignore somebody acting as if that person were not present and if others perceive this behavior as such then this action becomes a game action goals games have at least one but often several goal the goals of a game can be defined as the typical states events or things that players aim for which is the reason that they enter a playing relationship with other players the goal is what the game is about what is at stake in tennis for example the game is about winning the match in a us presidential race it is about becoming president in science it is about discovering new knowledge in a chat with a neighbor it is about having a short and friendly exchange that is not too profound there is a large array of types of goals and i can only mention some of the most important distinctions goals can be final or intermediate in tennis a player has to win sets to win the match in a us presidential race a candidate has to win the primaries to win the presidency goals can be competitive noncompetitive or a mixture of the two competitive goals demand that players try to be superior to the other players in achieving the goals noncompetitive goals can and should be achieved without its being intended or even possible to compare the players goals in games may apply to individuals or groups in some games all the players have the same goals while in other games different types of players have different goals as can be seen clearly in presidential races even people or groups that detest each other may share the same game goal goals should be distinguished from players motives to play the game social games have the power of channeling players goalseeking behavior into a similar direction but motives to play the game may vary widely on a first level there is variation in whether the primary player motivation is to reach the game goal most players will play the game to reach the game goal but sometimes players may have other motives to play the game on a second level even when players are motivated primarily by the game goal their motive as to why they want to win may vary widely the playing of a social game very often involves a mix of motives as has often been noted players may also internalize the gamegoals and fuse them with their innermost motives scientists may believe that finding something new is the most important thing in their life musicians may think that they could not live without music rules social games have rules these can be defined as instructions that are applied intersubjectively and under certain circumstances to perceivecount a certain phenomenon in certain ways or act in certain ways thus a rule may stipulate that the person who was fastest be seen as the winner or it may tell us that once one player begins counting to 40 the others have to run away and hide the rules in a game derive their existence and validity from being shared a rule is valid if players share the belief that it is valid in turn this belief is created by the observation that most of the other players in their actions obey the rules and that transgressions are either sanctioned or otherwise repaired as garfinkel has shown social games use various layers of both discursive and tacit rules if there are written rules we often find that there are other rules of how to apply the firstorder rules yet there are even other often unwritten rules of how everybody knows that these rules and their application really have to be applied under different circumstances this phenomenon can be found both in gamesforfun and in social games in general rules may be more or less legitimate legitimacy may be defined as the correctness of rules in both a cognitive and a normative sense rules are legitimate for players if the latter think that they are actually the rules and that there are convincing values that show these rules to be good rules may also be typologized according to their form following merton we can distinguish prescriptions preferences permissions and proscriptions as such rules may regulate every aspect of the game such as the nature of the goal of the game the kinds of actors that are allowed to be players and what attributes of actors are gamerelevant many social games have known ways of breaking the rules ways of acting that the players of the game find particularly iniquitous in sports doping in science plagiarizing and fabricating results in standup comedy stealing material from other comedians in criminal gangs snitching the breaking of rules can lead to different reactions and effects the rule can be upheld by negative sanctions which are actions or events that punish the rulebreaker more minor infringements will normally be dealt with first within the framework of the game itself thus in football the referee may punish the guilty player by awarding the other team a free kick likewise cheating in an exam at school may lead to the mark 0 more major infringements may also have effects outside the game as when cheating in a casino is dealt with by the police negative sanctions may be applied by other players by leaders of the group or by individuals or groups with game roles that involve policingjudging however there are other ways of reacting to transgression and maintaining the rule the rulebreaker may try to repair the situation by apologizing or by explaining her action through shifting the responsibility elsewhere if rules are broken and the normbreakers are not sanctioned or the normbreaking is not repaired in some other form by apology or explanation then the rules might simply disappear such as when littering in public spaces becomes acceptable or a teacher loses all authority in her classroom representations games are based not only on rules but also on representations which can be defined as signs that signify something else according to convention and in a public way representations are symbols or associations of symbols the representations of a game are what we could also call its culture and this is how cultural sociology is incorporated into social game theory we can distinguish three types of representation in a game the first concerns signs for different game elements objects and events have names rules come in the form of language the second concerns representations that are attached to game elements so that the players can communicate reflexively about the game such representations can legitimize mythologize systematize comment on or critique the game in chess there is a large literature on chess tactics the ritual of christian communion is linked to various biblical stories and concepts the third type concerns the language used when playing the game in most games players have to use language to communicate before during and after the game to pull the game off players must greet each other determine when and where to begin decide on whose turn is it next etc games are made out of representations but they are also immersed in the wider context of language as well as of other social games and their representations it is important here to understand that social games are by nature representational or symbolic what all the different strands of interpretive sociology have said about interaction is true also of social games to take away the meaning of the different game elements is to take away the game economists versed in economic game theory have sometimes objected that representations are not important once the structure of the game is fixed it does not matter what the different options are called this may be true in certain cases for example it is possible to play a game of chess with a board depicting a court with a king and queen or with figures from star wars or harry potter or in the form of birds or made out of cookies or corks if the figures retain their function then the form and imagery and culture that are present make little difference nevertheless in most social games representations are of the utmost importance since these are what give the social game its true meaning it is their imagery that makes us feel that the game is worth it if that were not the case then marketing branding and spinning political messages would make no sense as weber wrote not ideas but material and ideal interests directly govern mens conduct yet very frequently the world images that have been created by ideas have like switchmen determined the tracks along which action has been pushed by the dynamic of interest objects an object can be defined as a nonhuman material entity people do not count as objects 4 and nor do ideas or ideational phenomena games do not always need objects for example the material basis of paperscissorsrock or a spontaneous rap battle is provided by the bodies of the players and the sounds that they make and the game objects in digital gaming are not material entities but digital representations that are encountered in the digital world nevertheless all game elements can be linked to or represented by objects the goals can be represented as objects in some games the goal of the game is to obtain an object as in a raffle or lottery in other games special objects symbolize the win medals trophies and pedestals rules and representations are immaterial by nature but they are often symbolized by objects written down in books or engraved in stones or the objects may themselves be the signs representing the rules and representations such as in traffic signs statues of gods or crowns resources very often come in the form of objects in gamesforfun we find gaming pieces cards balls sticks sportswear etc in social games everything that marx called the means of production qualifies factory halls technical equipment machines tools but also all kinds of objects that represent symbolic power such as clothing means of transportation luxury items etc game space is often symbolized by objects such as game boards fields buildings fences border stones and curtains finally objects can also characterize actors who may wear uniforms robes rings crowns colored belts or have slit ears interestingly objects may also stand for players as avatars for example every player in monopoly is represented by a small figure while a person in black magic may use a doll to represent her enemy space and time concrete games are always situated in time space and a societal context interestingly though they also create their specific game time game space and game context game time is the time during which the game is played the beginning internal temporal structure and end of a game are often marked by specific actions for example by uttering words or making sounds they may be regulated by fixed rules as when a seminar at university takes place from 9 oclock until 1030 games very often have an internal temporal structure such as tennis where a number of games make up a set and a number of sets make up a match or a ba degree where weeks are nested in semesters semesters nested in years and years nested in the overall curriculum another example is the liturgy of a catholic mass which gives the different elements of the ritual a sequence that can be repeated game space is the space where the game is played and is often marked by objects the game space is sometimes inside a special building or room and is very often spatially differentiated internally as when a football pitch is divided into two halves with each goal having a sixyard box and a penalty area outcomes games have outcomes which are the states events or dynamics of a game or its context that result from game interaction they can coincide with the game goals or not be intended or not and be measured by the game or not other metatheories call outcomes explananda or effects outcomes can take different forms one type of outcome is the creation or change of a game element examples are the occurrence of checkmate in chess or hitlers decision to invade poland on 1 september 1939 a second type comes in the form of a statistic of a game or context variable often a point measurement sum mean or variance for example the number of goals scored by each team in a football match or the percentage of overall wealth owned by a societys wealthiest 2 third outcomes may also present themselves as the covariance of two game or context variables often a crosstabulation correlation coefficient regression coefficient or odds ratio for example the mean difference in the number of goals scored by manchester united and manchester city or the difference in mean income earned by men and women finally outcomes may present themselves as a statistic of the form the game process over time for example the way that property and money become concentrated in a game of monopoly or the way that a medical innovation is disseminated over time game outcomes that are created for a higherlevel game or the players are called game functions thus a commission may be set up with the function of finding a new president for an organization a university has the function of educating the elites for the wider society and a football match may be played for the enjoyment of the public some of these functions may be latent and not consciously known by the players as when christmas traditions have the latent function of maintaining the social bonds of families or when the kula game helps strengthen social control in trobriand societies of course the existence of games should not be explained by their function or the needs of the players as classical functionalism thought possible parsons 1977 current effects are not the same as historical causes nonetheless some games are consciously set up to fulfill a certain function the planned function then being one of the causes behind the settingup of the game furthermore some games are very stable because their function creates an interest among powerful players or stakeholders who will counter any attempts to stop the game or change its game elements context game context consists of all the phenomena outside the gameto the extent that these phenomena were are or might in the future be important for the playing of the game game context is not everything that exists outside the game and clearly defining its limits is difficult thus the invention of the spiked leather running shoe in the 1890s certainly belongs to the context of football whereas the invention of the flexible vaulting pole in the 1950s does not social games and empirical research the theory of social games is a general theory and cannot as such be tested directly to render the theory empirically testable we would have to transform it into a middlerange substantive theory it is here that the theory has in my view an advantage over alternative theories since it uses a descriptiveinterpretive heuristic an explanatory heuristic and formal and agentbased modeling descriptiveinterpretive heuristic social games can be reconstructed with a descriptiveinterpretive heuristic this consists of several questions that can be asked to create a model of the game the questions are simply constructed by going through the list of necessary elements of a game we would thus ask what kind of game is played here where can we place this game in the different game typologies what are the relevant players resources actions goals rules representations objects game space game time game context and outcomes is this game coupled with other games does it encompass other games or is it nested within other games and if so how in practice this means that depending on their initial knowledge researchers will often begin with a rather crude model and tentative game elements that they will then specify during the analysis the descriptiveinterpretive heuristic has to be used in a qualitative manner to yield ever more valid answers to their questions of what the goals rules representations etc of this social game are researchers have to spend time with the social game use participant observation conduct interviews read documents thus researchers do in a more systematic way what individuals in the everyday world do when they try to learn a new game an additional heuristic trick that proves extremely useful when reconstructing a social game is to ask what elements would i minimally have to use to create a board or computer game that would create the dynamics and the outcome of interest this question forces researchers to specify the necessary elements of the game and often makes them notice previously unobserved assumptions and mechanisms readers acquainted with qualitative research will have noticed that the proposed heuristic resembles the coding paradigm in grounded theory strauss andcorbin 2014 this paradigm distinguishes conditions interactions strategies and effects and i will replace it here with our game model as a heuristic startingpoint we call this heuristic descriptiveinterpretive because at the same time it leads researchers to a description and an interpretive understanding of the central game elements understanding an element of a social game means capturing its possible meanings within the framework of the entire social game for example i understand the chess rule castling if i know under what conditions with what reasons and with what resourcesobjects a player may typically apply it thus understanding a social game means understanding the game language and being able at least in principle to play the game this is similar to what the later wittgenstein and winch proposed explanatory heuristic the game mechanisms of social games can be tested with what i call an explanatory heuristic which consists of several general hypotheses that steer researchers to useful and more substantive hypotheses and mechanisms that can be directly tested the hypotheses are created by distilling central sociological insights from the literature and expressing them as game mechanisms we do not have space to give all the explanatory hypotheses here and point the reader to a companion paper the goal at this point is just to show how the heuristic functions we will therefore stick to three examples of hypotheses involving rulesbut analogous hypotheses exist for all other game elements rule change if a new rule is created in a game and if it is enforced then it will change the behavior of the players in accordance with the rule since rules restrict the chance that actors have of achieving some of their goals some of these actors may try to find ways around the rule leading to nonintended effects the rulechange hypothesis seems to be obvious but rule change is the most important way that interventions are effectuated in social games which we can see very well in gamesforfun in 1925 football officials changed the offside law reducing from three to two the number of players needed to make an attacker offside this was done because the old rules had favored the defending team who could plan very efficient offside traps thus increasing the number of stoppages and decreasing the number of goals the rule change did in fact have the intended effect with the number of goals scored in the football league increasing from 4700 in 192425 to 6373 in 192526 5 but it also had several unintended effects for example the defending team played much closer to their goal and the attacking team made more use of their wingers as for nonfun games rule changes are one of the main types of intervention used in both democratic and authoritarian states a prominent example being the use of lockdown rules and cards to prove vaccination status during pandemics the unintended effects of this are of course financial problems for cafés and shops and the fact that people might begin forging their vaccination cards absence or overuse of sanctioninganomie if transgressions of the rules are not sanctioned in a game then the rules tend to disappear and a state of anomie ensues esser 2000a conversely overuse of sanctioning may have the same effect overuse of sanctioning signals that rules are in effect not obeyed by other players and that further disobedience may be expected in such a situation players may be encouraged to join in the contestation of authority both absence or overuse of sanctioning may lead to the collapse of the game and there are many examples of this hypothesis in one infamous chilean football game the referee showed a red card to a player and then slapped the player across the face when the player confronted him this led to his losing all authority with many other players then confronting him and finally chasing him around the pitch in a scene resembling a benny hill sketch 6 other good examples of everyday anomie are unruly classrooms with teachers who lack authority or a state of lawlessness in failed states rule advantagesocial closure if a game offers important benefits to players then people from the outside will try to join the game and share in the benefits the games current players will then try to set up entry barriers to keep the benefits to themselves social closure exists with regard to players who try to enter a game from the outside or to players who try to enter higherranked subgames from below there are numerous examples that illustrate this hypothesis pastors try to prevent deacons from preaching the gospel psychiatrists try to prevent psychologists from prescribing medication western countries try to stop immigrants from entering their territory the aristocracy tries to stop the bourgeoisie from entering its circle using this type of mechanism heuristic brings us close to the tradition of analytical sociology analytical sociology is very strong in explanation and methods but has had difficulty in reaching consensus about its central theoretical concepts especially the definition of social mechanisms against this backdrop the socialgame perspective proposes to define social mechanisms as typical causal relationships in one or several social games explaining an outcome of a social game then means showing how a change in a game parameter has led causally via a game mechanism to a change in the game output two types of explanations may be distinguished a reconstructive explanation accounts for a specific game move or a game process by showing that precisely this game move or game process could have been predicted in a specific historical instance if we combine different specific explanations in a historical chain then this may result in a historicalgenetic explanation of a specific game we try to reconstruct the game situation at different points in time look at the options open to different players and try to understandexplain all moves made by the players in this way we could for example explain the outbreak of the french revolution historically genetically a statistical explanation occurs when we explain variance in game outcomes here we account for the typical statistical effect of a change of a game element on a game outcome in this case we normally assume a game mechanism to be at work ie a typical way in which a combination of game elements creates a specific game outcome through game interaction 7 for example we find that when a larger ball was introduced in table tennis in 2000 the average number of exchanges in a rally increased the mechanism lies in the fact that the larger ball is slower due to more air resistance which decreases the importance of the difficult serve increases the chances of players receiving the serve and allows for more attacking play overall both reconstructive and statistical explanations are causal explanations that assume counterfactual causality such explanations make statements such as the changing of rule r1 has caused outcome o in such and such a way and had we not changed rule r1 outcome o would not have changed in this way formal modeling social games can be formally studied in the style of economic game theory game theory can be defined as a branch of applied mathematics that provides tools for analyzing situations in which parties called players make decisions that are interdependent this interdependence causes each player to consider the other players possible decisions or strategies in formulating strategy the main types of game theory are classical game theory evolutionary game theory and behavioral game theory and a further distinction is the gametheoretical analysis of cooperative and noncooperative games just like the theory of social games economic game theory starts with the analysis of gamesforfun and is then extended to a mathematical and economic theory that claims to be applicable to a wide range of social phenomena the initial idea is that multiperson strategic situations are different from rational action facing nature they are like a game in which player a faces a player b who also wants to win the game both players know this about each other the situation is one of circularity neumann asks what rational action player a should perform in such a situation and what the outcome of such a game will be if all the players are rational neumann and later neumann and morgenstern show that a certain number of very simple games have clear solutions are called equilibria ie endpoints that necessarily result if all players play rationally interestingly they may also create suboptimal social effects even though all individuals play rationally to be able to calculate the solution of such a game neumann and morgenstern need to make very strong assumptions players must be perfectly rational and perfectly informed the types of moves must be welldefined and the payoffs for each outcome must be fixed game theory has had important successes in disciplines such as economics political science international relations and biology but has been used less often in sociology with many scholars in the social sciences criticizing the theory just as they criticize the rationalchoice approach for being unrealistic and irrelevant it is probably fair to say that the games constructed by game theory are strongly simplified and idealized they often assume that information is perfect that players are perfectly rational that payoffs are welldefined and that no other variables influence the game most realworld games are more complex however rules have many layers and different players interpret them differently games are routinely played even though the players only have a very unclear knowledge of a very restricted part of the game and even if they do not yet understand the main payoffs it is for this reason that we need the descriptive and explanatory heuristics described abovenamely in order to gain information about complex and constantly changing social games when it comes to complex reallife games formal game theory often has only limited applicability from the point of view of the theory of social games however formal modeling and agentbased modeling do have an important function first formal modeling may help clarify the deep structure of a certain type of game understanding that a certain reallife game has the deep structure of a prisoners dilemma can be very illuminating second the models created by formal modeling may function as ideal types that can be used to measure real cases by measuring the difference to ideal situations they tell us what the pure form of the game looks like and how perfectly rational players would play it in this sense they are normative third formal and agentbased modeling may help us uncover hidden assumptions and simulate how different parameters may lead to different game outcomes an illustration blaus dynamics of bureaucracy to illustrate the three heuristics consider the following example in his fascinating book the dynamics of bureaucracy peter m blau describes the very different effects of a new monitoring systemproductivity statisticson two sections of a jobreferral agency of a large state bureaucracy with a technique close to what i have described as a descriptiveinterpretive heuristic blau reconstructs the structures and processes of the agency with its two sections in terms of social game theory he shows us the goals rules representations and outcomes of the social game that is played here agents receive jobseeking individuals with the goal of matching them with job offerings the outcome being a certain number of job placements per day in an exploratory manner blau shows us the great complexity of the social game being playeda complexity that could only be unearthed with qualitative methods for example blau demonstrates that the official rules and goals set down in official regulations are adjusted for the specific needs and contexts at hand to give one illustration among many agents should officially choose the best applicant for a job opening in practice however and since jobs have to be filled quickly and agents are evaluated on the number of placements such maximizing behavior is never observable rather agents choose the first possible applicant for a job opening or to give another illustration receptionists receiving jobseekers for jobs that have no opening should tell these jobseekers to come back two months later to minimize tension receptionists frequently give earlier due dates at their own discretion with an explanatory technique close to what i have described as explanatory heuristic blau gives several reconstructive and statistical explanations of bureaucratic practices for example he routinely uses the heuristic device to check how rule changes lead to changed intended and nonintended behavior in one especially interesting case he shows how the introduction of a new monitoring system leads to nonintended consequences in section a of the agency the new monitoring system consists in counting the number of placements per agent per day and thus showing every agents productivity the nonintended effect consists in the fact that agents are afraid of being judged negatively if their individual scores are suboptimal therefore they try to increase their placement score by using dirty tricks conversely agents in section b react differently the new monitoring system leads to norms forbidding fast and competitive work and everybody continues to work with everybody else blau explains the difference in reaction by three combined factors the supervisor in section b puts less emphasis on statistics as a measure of individual productivity than the supervisor in section a the agents in section b have previously developed a professional code of employment interviewing the agents in section b have more job security than the agents in section a interestingly the cooperative section b provesas a sectionto be more productive than the competitive section a while blau does not use formal modeling his analysis makes it very clear that formal modeling could nicely be used to elucidate the deep structure of what is going on in the two sections the overall situation is one of a prisoners dilemma where agents have an incentive to defect if everybody uses dirty tricks the overall outcome is suboptimal additional factors may lead to the creation of norms that impede defecting thus leading to a better outcome my point is neither that blau uses social game theory nor am i suggesting that his study would have become better had he consciously used the theory of social gamesas it is it is a remarkably good piece of social research rather my claim is that this seminal piece of empirical work can be very well reconstructed with the grand theory of social games the three heuristics are very close to what blau actually does the theory of social games thus brings the heuristics implicitly used by blau into a coherent and explicit whole but why should one reconstruct the case with a grand theory in the first place as i have argued above grand theories have two important functions and they can be seen in this case first the grand theory may provide new ideas and guidance to study a specific case in our example the theory of social games could not strongly improve the blau study in descriptiveinterpretive and explanatory terms since the study is already so expertly conducted still we might get the idea to formally model the deep structure in the two sections second grand theory summarizes sociological knowledge and makes findings from different substantive fields comparative applying the social game perspective to this case we see the agency as a social game of the organizational type where a rule change leads to nonintended consequences of a prisoners dilemma type in a next step we might for example use the case in a more general account about nonintended consequences in organizations alternatively we might engage in comparative case studies about how rules in different social settings are adjusted to specific contexts both in organizations and other social games to give just one example the filling of lifeboats on the titanic as analyzed by stolz et al is an extremely different phenomenon than blaus job agency however here too we find the phenomenon that official rules are adapted to specific circumstances on starboard since not enough women were present lifeboats were filled up with men the fact that very different phenomena may be summarized in an overall theoretical framework is a progress in sociological theorizing to reiterate the functions of grand theory lie not so much in explaining specific facts better than competing theories but in providing a helpful conceptual and heuristic environment for middlerange empirical research in all stages of the research process the blau study is an illustration of how the theory of social games may do this conclusion the main contribution of this paper is to propose an outline of a new grand theory which has a similar level of abstractness as its competitors but a clearer link to empirical qualitative quantitative formal and agentbased modeling research i have outlined a metatheory for the social sciences called theory of social games readers acquainted with sociological theory will have noticed that much of what this theory says is based on its integration of ideas from various strands of existing sociological traditions while simply including some previous insights the new general theory often also adds a new twist thus the idea of causal game mechanisms is very close to the mechanisms described in the tradition of analytical sociology what is added is that game mechanisms are assumed to consist of interlinked game elements and are therefore never only causal but also symbolic likewise the idea that social games are both real and socially constructed owes much to the writings of searle what is added is that such a games perspective can be put to explanatory use because games have outputs that are the causal effects of playing the game the idea that there are different levels of social games is taken from luhmann who speaks of systems rather than games unlike luhmann though we allow many more forms of social games and distinguish them according to how individuals become players to give a final example we can see that the idea that those players who are consistently disadvantaged by playing the game will try to change the rules while those advantaged by the game will try to preserve and legitimize the rules is of course inspired by weber and different field theories what is added is that this element of contesting the rules of the game as well as other game parameters can be generalized from strategic action fields to games in general and can be found in childrens games in everyday interactions and in societal fields like art and science the generality of the theory can be seen in the fact that it starts from a very abstract model of social games that is nevertheless able to capture phenomena at very different social levels interactions groups milieus movements networks organizations are all cast as social games phenomena of extreme complexity are seen and analyzed as combinations of nested and coupled social games the theory can show that social reality is both real and constructed that social action incorporates both rulefollowing and instrumental aspects and that it is both causal and meaningful but this generality and these insights are not yet what sets the theory apart since systems theory practice theory discourse theory and structuration theory all have such a high level of generality and make some or all of these points the main advantage of the proposed grand theory of social games though is that it is better able than its competitors to bridge the theoreticalempirical research divide by using a descriptive heuristic an explanatory heuristic and formal and agentbased modeling the descriptiveinterpretive heuristic consists in several questions directly linked to the game elements this heuristic works much like the coding paradigm in grounded theory and lends itself very well to explorative qualitative work it allows researchers to reconstruct a game model one that is as simple as possible yet as complex as necessary and one that the players may not know consciously this heuristic is strong because it is a systematization of how real people learn real games in the social world the explanatory heuristic consists of several hypotheses which are again linked directly to the central game elements this heuristic allows researchers to focus on typical game mechanisms that crop up time and time again in social games they function like a toolbox of possible nuts and bolts that may or may not be applicable in an empirical social game explaining an outcome of a social game means showing how a change in a game parameter has led causally to a change in the game output again this heuristic is strong because its central elements are straightforward and easily observable and because this is how players try to have a causal influence on games in social reality in other words our explanatory heuristic is a systematization of how real people try to have a causal influence on real games in the social world finally social games can also be analyzed with formal game theory which can be very useful when it comes to understanding whether such games have solutions that would be chosen by rational players such formal analysis may help clarify the deep structure of a certain type of game create ideal types from which to measure real cases by measuring the difference to ideal situations and reveal other possibilities not observed empirically agentbased modeling may also help towards a better understanding of emergent game behavior given various types of initial parameters some critics might say we already have economic game theory so why do we need the theory of social games my answer is that economic game theory does not exhaust the possibilities of the game model for the social sciences economic game theory is extremely strong in its domain ie when it comes to formal analysis experimental research and simulation but my point is that games as starting points are also very useful in additional fields such as when we think about how individuals learn and understand games how they create their identities and how they create the symbolic worlds in which we live thus for a vast number of research questions in the social sciences economic game theory must be supplemented with a sociological take on games these questions must be addressed with qualitative or quantitative empirical methods and they may or may not lead to an additional formalization à la game theory to give just one example if you want to know about football reading only gametheoretical accounts of the sport will not be of much use other critics might say this is all very well so we can see social reality as a number of interlinked social games but we could just as well see it as several fields social systems configurations or structures what is the advantage of starting from scratch with the game concept i have argued that the major advantage that the theory of social games has over its theoretical competitors is that it is just as general as its competitors while having a more straightforward link to middlerange theory and empirical research this article of course has limits it is only an outline that sets out the major ideas in a very general way and it has had to skip many deeper issuessomething that is difficult to avoid in an initial sketch of a new theory thus i have only alluded to the different types of games and to how games may be interlinked i have not been able to present the descriptive and explanatory heuristic in full and nor have i been able to go into questions of trust and power it is also evident that while formal game theory and agentbased modeling are already wellestablished scientific fields using descriptive and explanatory game heuristics must still prove its usefulness in the future these limits notwithstanding i am convinced that there is some promise in developing a general theory of social games and i welcome both theoretical and empirical studies that develop this new research path further data sharing data sharing is not applicable to this research as no data were generated or analyzed received 3 september 2022 accepted 19 june 2023 notes 1 my use of the concept social game is not metaphorical since i define the concept of game identify its elements and show how the concept can be operationalized and put to practical use in the proposed heuristics 2 some readers may expect a theory to single out a specific area of social life in which it describes and explains phenomena in a novel way but that is not the goal and function of grand theory 3 among the sociological and philosophical classics on games and their link to social evolution and socialization mead takes a special place mead gh january 2022 7 the terms game mechanism and game have to be distinguished as can be seen by the definitions given one game may therefore include a variety of game mechanisms motivating mechanism playerrecruitment mechanism etc competing interests the author declares no competing interests ethical approval this article does not contain any studies with human participants performed by any of the authors

sociological general theories or grand theories have been criticized for being too abstract to be of any practical use for empirical sociological work this paper presents the outline of a general theory that claims to be better linked to empirical social research than previous theoretical attempts the theory analyzes social life as a multitude of interacting social games a social game is an entity created by players with resources who engage in action that is shaped by goals rules and representations that involves objects and that leads to game outcomes the general theory is as encompassing as previous theoretical attempts while allowing us to integrate both instrumental and normative action at different levels of the social its main advantage is that it is linked to middlerange theory and empirical research by a descriptiveinterpretive heuristic an explanatory heuristic and formal and agentbased modeling the article provides many examples to illustrate the claims

introduction despite efforts to improve access to basic resources 768 million people rely on unimproved drinkingwater for daily consumption and an estimated 25 billion people lack access to improved sanitation facilities 1 the link between access to these basic resources and psychosocial outcomes is an emerging area of importance in global health research a study in ethiopia found that water insecurity was significantly associated with psychosocial distress 2 in bolivia wutich and ragsdale found that gender and the process of accessing water resources were significantly associated with emotional distress citing fear worry anger and bother 3 though the literature focuses on water insecurity sanitation access presents similar psychosocial risks particularly for women and girls in kenya henley and colleagues studied hair cortisol concentrations as a biomarker for chronic stress finding that concentrations were significantly higher in women who reported feeling unsafe while collecting water or accessing sanitation 4 in a study of mental health in urban slums in bangladesh gruebner et al found that elements of the built environment including access to a better toilet facility were significantly associated with high quality of life scores 5 in addition to navigating the built and physical environment for sanitation activities women face daily struggles with social status access to resources and social conflicts 6 7 8 time of day and privacy contribute to sanitationrelated stress 9 moreover women may have to cope with violence 1011 or sexual assault and rape 12 13 14 while completing sanitationrelated behaviors the present study seeks to add to the emerging body of research on the impact and determinants of sanitationrelated psychosocial stress data for this study are part of a larger mixedmethods study exploring womens relationship with sanitation in lowincome infrastructurerestricted settings in odisha india we build upon an initial grounded theory study that provided an empirically based conceptual understanding for srps among women of reproductive age in odisha 15 findings from this study suggest that sanitation encompasses a range of behaviors specific to the local cultural context including ritual anal cleansing menstrual management practices bathing and changing clothes prior to reentering the house after defecation sanitationrelated psychosocial stressors arise when women are unable to perform these behaviors free from worry fear or anxiety according to the conceptual model proposed in the study there are three categories of stressors environmental social and sexual genderbased violence stressors whose intensity is modified by a womans life stage living environment or access to sanitation facilities the current study aims to examine and compare stress as it relates to the specific sanitationrelated behaviors as well as explore the relative frequency and severity of individual stressors that contribute to srps among a sample of women in odisha recognizing that these sanitationrelated behaviors and stressors are contextually bound and dynamic in nature this analysis explores the differential impact of common psychosocial stressors on women living in different geographic settings and occupying differing social roles within the household and community we selected systematic data collection methodsa broad family of interviewing techniques originally intended to examine tacit knowledge in ethnography and cognitive anthropologyfor use in this study 16 these methods have been used to explore the boundaries and dimensions of specific cognitive domains that may be culturally defined or difficult to articulate such as kinship terms 17 or medicinal classifications 1819 and the internal systems of classification that individuals employ unlike openended interviewing or participant observations systematic methods entail asking all respondents the same questions and analyzing responses according to emic categorization rather than those imposed by the researcher for the purposes of this study the successive application of multiple systematic data collection methods allowed us to simultaneously examine the dynamic nature of sanitationrelated behaviors the relative degree to which these behaviors have contributed to psychosocial stress and the frequency and severity with which women in the sample and women like them in the broader population have dealt with psychosocial stressors methods study sites access to sanitation in much of india remains scarce and an estimated 44 of the population practices open defecation 1 however access to water and sanitation facilities may vary considerably by geographic context therefore we chose three resourcepoor geographic locations in odisha to reflect differing access to sanitation infrastructure as well as differing social and cultural practices urban slums rural villages and rural tribal villages with a large proportion of ethnically distinct residents in the urban site we interviewed women in two slums in bhubaneswar the capital of odisha some slum residents had access to either privately owned or public latrines but several participants still reported practicing open defecation rural women were selected from khurda district an agricultural region outside of bhubaneswar lowdensity rural tribal villages were selected from sundargarh district where about half of the population belongs to scheduled tribes recognized by the indian government 20 including oraron munda and kisan tribes in local terms tribal is used to describe both the geographically isolated regions and ethnic minority populations and we use the term tribal when referring to women from this site both sanitation practices and access to infrastructure vary here compared to rural areas in odisha and tribal women were therefore expected to face unique sanitation challenges sample and selection of participants we purposively sampled women from four life stages that are reflective of social and biological characteristics that influence a womans place in her household and community 1 adolescents unmarried women aged 1424 who had reached menarche and who lived with their parents and extended families 2 newly married women married two years or less the majority of whom had moved to a new social and physical geography to join the husbands family household 3 pregnant women women who identified as pregnant during data collection for whom pregnancy changed their household roles and created distinct physical needs for sanitation and 4 established adult women women between the ages of 25 and 45 who had been married more than two years and were not currently pregnant this sampling technique while not providing a proportionally representative sample of the population of women in odisha offered us an opportunity to assess life stagebased variance in srps in a small sample data collection volunteer community health workers affiliated with the asian institute for public health identified 20 women at each study site for participation in the study for a total of 60 participants our stratified purposive sampling strategy ensured equal representation from each of the four life stage groups of interest and a sample of latrine users and nonusers similar to the general population a team of four female interviewers trained in systematic data collection methods completed recruitment and data collection data were collected from april to may of 2014 we carried out structured interviews that employed two systematic methods pile sorting and ranking pile sorting methods have traditionally been used to understand the internal organization of domains through the generation of graphical multidimensional scaling plots 21 or hierarchical clusters 19 however the flexibility of these methods to examine the categorization and organization of a range of topics has resulted in innovative adaptations to for example explore abstract concepts such as stress in children 22 perceptions of posttraumatic mental health 23 and gender roles 24 ranking and rating techniques have been used to develop measurement tools for wealth and wellbeing reflective of local understandings of economic security 2526 and as participatory tools to engage residents in identifying and prioritizing needs in their communities 27 structured interviews began with basic demographic questions about the womans household followed by a data collection module on sanitation behaviors and one on stressors for behaviors we identified a local taxonomy 28 of sanitationrelated behaviors from our initial qualitative study 15 that included defecation urination menstruation postdefecation cleaning postdefecation bathing changing clothes and carrying water for use in sanitation field staff verbally presented participants with seven index cards each labeled with one of these specificsanitation related behaviors and explained each card to the respondent as interviewers introduced each card women indicated if the behaviors were part of their typical routines if not applicable the card associated with a behavior was set aside and excluded from further data collection in the interview next interviewers asked women to rank stress associated with each behavior most stressful to least stressful using a quicksort ranking method 16 in which respondents organize items along a specific continuum the rank order of cards was read back to the participant and recorded by the interviewer next the interviewer shuffled the cards and asked respondents to rank behaviors by freedomfrom the behavior they had the most freedom to choose when and how to practice to the least freedom rank order was again recorded for stressors we presented women with index cards labeled with specific sanitationrelated stressors and challenges identified in previously conducted indepth interviews 15 interviewers again verbally presented each card and women identified cards with stressors that they considered applicable to their typical routines excluding those that were not applicable from the remaining questions next interviewers asked women to sort the cards into three piles based on how frequently they encountered the problem always sometimes or rarely the groupings were recorded and the interviewer shuffled the cards for the next question finally participants were asked to sort cards based on perceived severity high medium or low after each exercise interviewers reviewed the rankings or piles and asked participants to describe their reasoning with openended questions interviewers took detailed notes of both the ranking and sorting outcomes as well as participant responses ranking and sorting results were entered into a database and openended questions were digitally recorded transcribed translated and deidentified data analysis for sanitation behaviors ranking data on stress and freedom were modeled using rankordered logistic regression by maximum likelihood specifically with the rologit command in stata 131 29 rankordered logistic regression is used to estimate the probability that an itemin our case a sanitation behaviorwould be ranked by a respondent as first along the characteristic of interest rankordered logistic regression accepts incomplete rankings making it amenable to data where participants can discard some items or as in our case exclude inapplicable items as long as we assume that omitted items are ranked lower along the trait of interest than all items that were retained unlike conditional logit models that only account for how often an item was ranked first among a set rankordered logistic regression takes into account all ranks assigned to an item therefore two items with equal numbers of first place rankings can be differentiated in the rankordered model based on how many second third etc rankings they received frequency and severity data regarding stressors arising during sanitation practice were interpreted as likerttype scale ratings we found that reporting and comparing percentages of high severity and always responses was sufficient to illustrate variations of concerns across groups ethical approval prior to the interviews all participants provided written consent for girls under 18 interviewers collected written assent from the participant and written consent from her parent participants were informed of their rights to terminate the interview at any time and to skip any questions or topics that they did not wish to discuss names and other identifiers collected during the interview were redacted during the transcription process and the original audio files destroyed ethical approval for this study was provided by the ethical review committee at aiph and the institutional review board at emory university results participant characteristics table 1 presents characteristics of the 60 study participants by geographic site women ranged in age from 14 to 45 years old the majority of the participants and all women in rural areas identified as hindu access to a private or public latrine was limited the majority of our participants did not have access to latrine facilities and were forced to practice open defecation latrine access was highest among participants in the urban population sanitation behaviors table 2 presents the percentage of women in each geographic region who selfreported engaging in each of the seven sanitationrelated behaviors of interest we assessed whether or not women engaged in these activities to ensure that women only responded to issues that were pertinent to them in the subsequent exercises these questions were not asked to compare habits of women in urban versus rural versus tribal areas women everywhere report defecation urination postdefecation cleaning and bathing as part of normal sanitation practice women in rural areas reported less carrying water for sanitation purposes since many use sites at or near open water sources or were more likely to walk to a pond or a river to complete their washing only 25 of women in the tribal site reported changing clothes after defecation a practice that women reported in previous qualitative interviews to be strongly linked to hindu beliefs about ritual cleanliness 15 stress table 3 shows results of the rankordered logistic regression analysis for stress and freedom indicating the probability of a specific behavior being ranked first we present the data in as raw a format as possible to encourage a more nuanced understanding of the responses than statistics such as modes and or measures of dispersion would supply menstruation was most likely to be ranked as the most stressful behavior in our total population followed by defecation and urination however the ranking of stress associated with these behaviors varied considerably according to geographic site for example menstruation was highly likely to be ranked as most stressful among rural and tribal women but carrying water was the most stressful aspect of sanitation practice in urban areas tribal women were about twice as likely to rank defecation as most stressful compared to urban and rural respondents stress rankings also varied by life stage for adolescents defecation was ranked as the highest stress followed by menstruation bathing and post defecation cleaning menstruation was most likely to be ranked as high stress among newly married and pregnant women carrying water was also among the most stressful activities among newly married women pregnant women and established adults freedom daily sanitation activities take women out of the domestic environment in order to access latrines fields for open defecation or communal water sources women face restrictions dictating when and how they may practice these activities such as when they leave the household where they go and whom they are allowed to go with table 3 presents the probability that a woman ranks a sanitationrelated activity as the one she can practice with the most freedom overall women had a high probability of ranking urination as the behavior with the most freedom a pattern consistent among all of our geographic and life course groups the two activities least likely to be ranked as having a high degree of freedom were changing clothes and menstruation we note some variation in freedom by geographic site and life stage group among rural women the activity most likely to be ranked as having the highest degree of freedom was changing clothes followed by urination postdefecation cleaning and bathing when comparing across life stages though urination is most likely to be ranked as most free by adolescents newly married and pregnant women established adults had a higher probability of ranking bathing as most free defecation was ranked with a relatively high degree of freedom for adolescents newly married and established adult women however this is the least likely to be ranked as most free among pregnant women indicating that pregnant women may face greater restrictions associated with this practice based on their physical needs and the social and cultural restrictions accompanying pregnancy fig 1 provides a visual representation of results combining data on the percentage of women who reported completing specific behaviors probability of a behavior being ranked as most stressful and the probability of a behavior being ranked as having the most freedom fig 2 depicts this same visualization by life stage and geographic region among the total population we note a clear and expected negative correlation between the probability that a behavior would be ranked as most stressful and as having the most freedom only changing clothes is an outlier from this general trend this trend is less pronounced when visualizations are developed for each geographic area and for each life stage group in particular the graph of rural responses shows a steep association linking high freedom activities with lower stress compared to more restricted activities like menstruation with a high degree of stress in the tribal site the relationship between stress and freedom was less clear however the relative association between activities does follow the general trend conversely among adult women the relationship applicability stress and freedom associated with sanitation activities the diameter of each circle is proportional to the percentage of women who indicated the activity was applicable to them the location of the center of the circle relative to the horizontal and vertical axes indicates the probability that the activity was rated most stressful and most free respectively doi101371journalpone0141883g002 between stress and freedom is slightly positive and activities less likely to be associated with freedom are more likely to be associated with greater stress sanitation stressors we asked women to indicate what stressors they faced during sanitation based on twenty previously identified problems that were highly salient to women in odisha 15 overall women most commonly indicated rain nightdarkness animals and health during illness as sanitation stressors with 87 or more of women indicating these were problems they faced in all sites women identified an average of 13 out of the 20 potential stressors as applicable to their sanitation practice table 4 summarizes the results of constrained pile sorting of stressors by frequency with which it is encountered and severity of the stressor frequency and severity overall the issues more likely than not to be considered applicable as always a concern and as stressors of high severity were rapeassault distance reputation and ghosts for the minority who considered it applicable lack of space was also predominantly considered a persistent and severe concern these stressors span multiple domains related to sanitationrelated psychosocial stress 15 including the built and social environments lack of space and distance stand out as especially prominent sanitation infrastructurerelated concerns compared to physical barriers rapesexual assault and reputation are distinguished from for example being scolded as particularly poignant constructs of the social environment that induce srps among the most concerning of stressors we also find an example from the domain of cultural beliefs namely encountering ghosts the types of stressors and the frequency and severity with which they were encountered ranged by geographic site and life stage group while the majority of women in all sites and life stage groups reported the majority of the 20 stressors as applicable the variation in describing those stressors as frequent or severe manifests the importance of understanding the context in which women encounter srps for example urban women identified physical barriers as more applicable to their sanitation behaviors than rural or tribal women and half of urban women rated physical barriers as a high severity concern rape and sexual assault was particularly salient in the urban group where 70 of women said it was a stressor among these urban women 86 were always concerned about it and 100 described it as a highly severe issue in comparison only 55 of rural and tribal women identified rapesexual assault as applicable and among these women it was not categorized as always a concern and 64 of women in both groups said it was highly severe being seen a construct of the social environment had roughly equal applicability across groups but happened infrequently among women in the tribal site and seldom considered severe males teasing or throwing stones was also similarly applicable across geographic sites but varied greatly from rural women indicating that even when applicable it was never a high severity stressor nor one that was always a problem tribal women agreed that males teasing or throwing stones was not always a problem but when it was it was severe the salience of specific stressors also changed by life stage rape was salient to a majority of women in all groups but in no group was it as often considered salient frequent and severe as it was among adolescents reputation was a concern shared almost equally by adolescents and newly married women with 80 in both groups considering it salient and 83 in both groups considering it high severity half of newly married women and 67 of adolescents viewed it as always a concern pregnant women were especially concerned with issues that they perceived to be detrimental to their pregnancies such as encountering ghostsa concern that was not as often salient frequent or high severity in other life course groups we note a general positive trend between the perceived severity and perceived frequencies of stressor issues that were commonly ranked as highly severe were also commonly ranked as issues they always encounter lack of space sexual assault and distance were likely to be ranked as both high frequency and high severity issues visualizing results also shows us exceptions to this relationship for example when applicable adolescents encountering physical barriers ranked them as something they always encounter however this was not likely to be ranked as a severe stressor likewise adult women who ranked ghosts as a stressor were not likely to rank them as a frequent stressor but they were often ranked as a high severity issue discussion using structured data collection methods for this research allowed us to explore the scope and dimensions of key sanitationrelated stressors in a more nuanced manner than a survey would afford and more systematic than exploratory qualitative research ranking sanitationrelated behaviors from most stressful to least stressful helped us to explore how stress manifests across sanitation activities women consistently ranked menstruation and carrying water as highly stressful activities contributing to srps water is an essential component of sanitation related behaviors in this setting and was used in postdefecation cleaning bathing and for menstrual hygiene management 15 in urban areas women usually rely on shared public water sources that may be intermittently available and the burden of collecting and carrying water to a site for defecation or urination was highly problematic despite the links between carrying water and other sanitation behaviors water and sanitation provision in india are often operationalized independently the delivery and provisioning of water may be coordinated by a states department of public health and engineering or by the state water board however different statelevel departments may implement sanitation programs in theory indias total sanitation campaign aimed to incentivize userand communitydriven demand for sanitation but the focus on infrastructure development has been criticized as a topdown governmentled approach 30 the swachh bharat mission the recently launched governmentled sanitation campaign in india has committed billions of dollars to improve sanitation coverage through infrastructure development user incentives and communitymobilization however efforts remain targeted on sanitation infrastructure at the householdlevel though the nonprofit and private sectors play a role in increasing water sanitation and hygiene services throughout the country our data show that sanitation behaviors rely heavily on water access suggesting the need for coordinated interventions among different levels of government and the public and private sector that respond to the social and physical needs of the users furthermore the majority of sanitation interventions focus on defecation and fecal management and often ignore other sanitation related behaviors like washing and menstrual hygiene in addition though the psychosocial implications of menstruation and menstrual management have been documented among adolescent girls 31 32 33 34 few studies have critically examined the psychological interpersonal and social repercussions among older populations our data highlight that stress related to menstrual management is particularly salient among newly married and pregnant women newly married women described that menstruation is highly stressful because they are new in their households and have to curtail their regular activities based on cultural traditions restricting sanitation behaviors they feel uncomfortable talking about menstruation with their husbands and inlaws and the physical symptoms associated with the diameter of the circle is proportional to the percentage of women who reported that the stressor was applicable to them the location of the midpoint of the circle on the horizontal and vertical axes reflects the proportion of those women who indicated that the item was a high severity stressor and high frequency stressor respectively only stressors that were highly applicable severe or frequent are included in each graph doi101371journalpone0141883g003 menstruation inhibit their normal activities similarly pregnant women described menstruation as highly stressful even though they were not currently experiencing monthly periods newly married and pregnant women living in their inlaws households face social restrictions surrounding menstruation and all sanitationrelated behaviors such as restricted water access and taboos related to sexual intercourse cooking or religious practices during their periods 3536 correspondingly menstruation was also the least likely to be associated with a high degree of freedom among these women strategies that women may have had as adolescents may need to be renewed upon marriage and relocation into a new household our results highlight the dimensionality of sanitationrelated of stressors we found that even stressors that occur less frequently may still be high severity issues and that the intensity of stressors vary by life stage and geographic location examining stress and food security a recent food and agriculture organization study found a relationship between severity and frequency discussing how more severe indicators of food security are less frequently noted than less severe items 37 in our study we similarly found that fewer women encountered some of the stressors that were most severe for example sexual assault was not commonly included as applicable but when included it was likely to be ranked as a high severity high frequency issue especially for adolescents and in urban areas violence that occurs due to inadequate access to water sanitation and hygiene facilities is of increasing concern in the water sanitation and hygiene community recently rape and sexual assault associated with sanitation have received more attention in indian media explicitly linking lack of sanitation facilities with violence rape and lack of safety for women 38 39 40 a review of literature examining genderbased violence and wash shows how sensitivity secrecy and the complexity of violence inhibits the collection of reliable data and the authors advocate for building an evidence base grounded in systematic ethical evaluation of wash related violence 41 our research identified violence and sexual assault as high severity stressors but further research is needed to quantify the scope of the problem and suggest interventions beyond the physical and social stressors associated with sanitation this study illustrated how fear of ghosts was also perceived to be highly severe especially among rural pregnant and adult women the high severity of this issue may be due local traditional beliefs linking miscarriage to encounters with ghosts though we were unable to find studies specific to odisha an ethnographic study by pauline mahar kolenda of sweepers in north india discusses a range of anxieties related to ghost and supernatural encounters including the attribution of miscarriages to malevolent female ghosts 42 this example highlights the usefulness of examining the stratification of stressors especially when culturally significant proscriptions impact sanitation behaviors understanding the dynamic sanitation behaviors stressors and the attributed level of severity is essential for informing practitioners about the context and implications of intervention identifying how stressors are related to location and life stage may help assign priorities in creating safe sanitation spaces for example for newly married women physical barriers were less likely to be ranked as highly severe than for women in other life stage groups women in our study occasionally mentioned special places near the home where newly married women could defecate and in some cases improvements to the home are used in negotiating a marriage in rural haryana india access to sanitation was used as bargaining power in a campaign called no toilet no bride minimizing social restrictions for newly married women during sanitation and improving standards for sanitation access 43 this example suggests that interventions focused on physical barriers are more greatly needed for adolescent pregnant and established women than for newly married women in advocating for a contextualized gender sensitive approach to sanitation our research findings inform future study of srps illustrating key differences across life stages and social settings additionally given the numerous ways women experience stress related to sanitation further study may illuminate factors that ameliorate stress using systematic data collection techniques helps to populate a range of factors and then explore them to identify relevance key priorities and more nuanced dimensions like stress severity and frequency women in different parts of india face a distinct constellation of stressors and their severity depending on physical surroundings life stage and access to sanitation facilities understanding the dynamics of how social geographies and life course stages shape womens sanitation experience may help to tailor sanitation needs given cultural and geographic diversity strengths and limitations the systematic data collection methods employed in this study helped us to explore sanitation related psychosocial stress using an interactive format and generating comparisons between women of different ages living in different geographic locations the results highlight some key areas that can help to inform future research on sanitation related to mental health however more research is needed to develop locally relevant psychometric scales we recruited five women per life stage group per site for 60 total participants allowing us to examine results in both social and geographic groupings however a larger sample size may afford more granularity in examining trends by life stage group and geographic site simultaneously it would also be valuable to explore the relationship between freedom and stress using a larger sample size additionally some of the sanitation behaviors and stressors are shaped by cultural practices and socially defined roles so the generalizability of some of our findings may be limited to lowresource settings of india conclusions factors contributing to srps differ by life stage and geographic site and the context of sanitation must be understood to inform successful sanitation interventions understanding the network of factors relationships and activities influencing mental health and feelings of distress gives us a more nuanced understanding of the ways women negotiate their sanitation environments further research measuring srps may help to significantly inform sanitation interventions signposting key areas for infrastructural development and behavior change messaging all relevant data are within the paper and its supporting information files

emerging evidence demonstrates how inadequate access to water and sanitation is linked to psychosocial stress especially among women forcing them to navigate social and physical barriers during their daily sanitation routines we examine sanitationrelated psychosocial stress srps across womens reproductive lives in three distinct geographic sites urban slums rural villages and rural tribal villages in odisha india we explored daily sanitation practices of adolescent newly married pregnant and established adult women n 60 and identified stressors encountered during sanitation responding to structured data collection methods women ranked seven sanitation activities defecation urination menstruation bathing postdefecation cleaning carrying water and changing clothes based on stress high to low and level of freedom associated with greatest freedom to having the most restrictions women then identified common stressors they encountered when practicing sanitation and sorted stressors in constrained piles based on frequency and severity of each issue the constellation of factors influencing srps varies by life stage and location overall sanitation behaviors that were most restricted ie menstruation were the most stressful women in different sites encountered different stressors and the level of perceived severity varied based on site and life stage understanding the influence of place and life stage on srps provides a nuanced understanding of sanitation and may help identify areas for intervention

background alcohol is a psychoactive substance that can produce addiction and dependence 1 chronic alcohol use is associated with a myriad of negative health outcomes including damage to the central nervous system 1 alcohol use is causally associated with more than 200 diseases and injuries and is a major contributor to mortality globally 1 the who global status report on alcohol and health reported that 3 million deaths and millions of disabilities are caused by alcohol consumption each year which constitutes over 53 of deaths worldwide 2 however drinking behavior remains very common especially in china in 20152016 the prevalence of alcohol use in china defined as the percentage of people who have drunk alcohol in the past 12 months was 437 among adults 18 years of age and older prevalence is higher among adult men than adult women 3 multiple factors are associated with alcohol consumption including biological 4 sociocultural 5 and psychological factors 67 for example genetics appears to play a critical role in alcohol dependence and consumption polymorphisms in alcohol dehydrogenase genes specifically can lead to an increased risk of alcohol dependence 8 9 10 ecological systems theory posits that people s behavior is influenced by nested ecological systems including microsystem mesosystem exosystem and macrosystem macrosystems which refer to as the culture subculture and social environment are of particular interest 11 the macrosystem in china where there is a strong historical influence of confucian culture may figure prominently in chinese alcohol use particularly among men the confucian culture emphasizes developing and maintaining social bonds via gift exchange which is seen as a social norm 51213 chinese consumers spend more money on alcohol when purchasing alcohol as a gift compared to when it is purchased for their own use this may reflect a desire for people to be perceived favorably among their peers 14 this idea is further supported by findings that gifting alcohol serves as a mechanism to maintain good relationships with elders and promote camaraderie among peers 15 especially in higher social classes 16 gender ideals are also associated with alcohol use where men who consumed alcohol are seen as full of masculine charm and loyalty 1517 while global per capita alcohol consumption rose from 55 l in 2005 to 64 l in 2016 per capita alcohol consumption in china rose to an even greater extent from 41 l in 2005 to 72 l in 2016 this increasing rate of per capita alcohol consumption may indicate a great challenge for alcohol control in china 1 identifying factors associated with alcohol gifting behavior in china may inform future interventions however there is little published literature on this topic one of the few existing studies showed that spending more money on wine gifting in china is associated with younger age and higher education 18 top reasons for consuming wine included business while a top reason for purchasing wine was gifting it should be noted however that these relationships often vary by region 18 although this study offers some insight into correlates with demographic factors the influence of the social environment should also be considered social capital theory predicts that individuals with strong social capital inherently have access to more supportive resources and have a higher capacity to utilize them 1920 higher social capital can result in the spread of health information such as information about the harms of drinking via social networks which can influence healthrelated behaviors 21 according to social capital theory and behavioral accessibility theory alcohol gifting as a norm may further increase contact with and consumption of alcohol for both nondrinkers and drinkers attempting to quit it is also important to consider the potential adverse consequences of alcohol exchange in addition to factors and characteristics associated with alcohol gifting given the hypothesis proposed by previous empirical research 22 gifting alcohol may be associated with alcohol use however there is a lack of evidencebased studies that quantitatively identify the relationship between alcohol gifting behavior and potential hazardous behavioral outcomes such as alcohol drinking and tobacco smoking in china although there is no research on this relationship in china there have been studies assessing this relationship in other countries reviews from the us identified a significantly higher risk for alcohol misuse among those who use tobacco 23 nationally representative data from the usbased add health survey also found a high prevalence of polysubstance use behavior including the use of alcohol marijuana and cigarettes among adolescents in 2008 24 polysubstance use of alcohol and tobacco is particularly concerning because they enhance the effects of each other a reaction that tobacco and alcohol companies have exploited to promote sales 23 the purpose of this study is to investigate the prevalence and correlates of alcohol gifting including associations with social capital we additionally aim to explore whether alcohol gifting is associated with alcohol or tobacco consumption in china we employ quantitative analysis on a large sample at the regionalprovincial level to inform evidencebased alcohol control practices relevant to chinas alcohol gifting culture methods study design and participants a multistage sampling design was utilized in this study and the sample consisted of the heads of households from two provinces in china guangdong and shaanxi province were selected based on their regional diversity and existing research collaboration guangdong is a southeastern coastal province with a population of 12684 million and 14546 per capita gdp whereas shaanxi is a northwestern inland province with 3954 million people and 11153 per capita gdp in 2021 25 hh refers to the head of the family on the household register in china the head of the household is the person in charge of the current household 26 one university each from guangdong and shaanxi province was selected based on their regional diversity and existing research collaboration with the primary investigators within the two universities all students that had health professional courses were invited to collect data as investigators a survey link was given to all eligible students which they were encouraged to distribute to their parents in total 982 hhs from guangdong province and 530 hhs from shaanxi province consented to participate in the study more detailed information on the sampling and recruitment process can be found in wu et al 22 the online survey was developed on the wenjuanxing platform and conducted from april 30 to july 30 2020 the study protocol was approved by the ethics committee of guangdong medical university and all participants provided written informed consent before they began the survey measures sociodemographic characteristics sociodemographic information was collected including age gender place of residence ethnicity marital status educational attainment and per capita annual family income given the participants in this survey were parents of college students which are probably between 4550 years old in general 27 the age category was divided into 45 4549 and 49 social capital participants social capital was assessed using the 12item social capital questionnaire 28 which has acceptable internal reliability the higher this score on this scale the greater the social capital the social capital questionnaire assesses the three factors of social capital cognitive social capital social participation and social network we analyze the subscales separately the subscale for cognitive social capital contained four questions and the cronbachs alpha coefficient was 0786 the subscale for social participation contained four questions and the cronbachs alpha coefficient was 0805 suggesting good reliability social network was assessed by ascertaining the number of good friends trustable classmates helpful neighbors close relatives and cooperative partners cronbachs alpha coefficient for social network was 0827 which suggests good reliability of this subscale drinking status drinking status was ascertained by asking respondents on how many days they drank during the past month using the following response options yes drank every day yes drank on one or more days but not every day no days 29 daily drinkers were defined as drinking every day occasional drinkers were defined as drinking on one or more days but not every day and current nondrinkers were defined as those who did not drink in the past month including neverdrinker and former drinker 3031 categories for occasional drinkers and daily drinkers were combined and compared to nondrinkers to form a dichotomous indicator for drinking status smoking status smoking status was ascertained by asking respondents on how many days they smoked during the past month using the following response options yes smoked every day yes smoked on one or more days but not every day no days participants who smoked every day were classified as daily smokers while those who smoked on one or more days but not every day were classified as occasional smokers current nonsmokers were defined as those who did not smoke in the past month including neversmoker and former smoker 32 33 34 categories for occasional smokers and daily smokers were combined and compared to nonsmokers to form a dichotomous indicator for smoking status 22 gifting alcohol behavior gifting alcohol included two types of behaviors offering and receiving alcohol offering alcohol was defined as offering at least one unopened bottle of alcohol as a gift to others in the past year receiving alcohol was defined as receiving at least one unopened bottle of alcohol as a gift from others in the past year data analysis the data was exported from the survey platform to microsoft excel and then uploaded to spss for statistical analysis descriptive statistics for sociodemographic characteristics social capital and alcohol gifting behaviors are reported the significance of differences between offering and receiving alcohol gifts across sociodemographic characteristics was determined using chisquare analyses differences that reached statistically significance were included in a multiple logistic regression the significance of each coefficient in the model was determined using the wald test adjusted odds ratios were used to express the odds of offering receiving alcohol compared to the odds of not offering receiving alcohol for each covariate controlling for other covariates in the model to determine the association between gifting alcohol and alcohol use and cigarette use six logistic regression models were constructed where substance use was included as the outcome the demographic characteristics which were significantly associated with smoking and drinking in the univariate analysis were included as covariates in the six multiple logistic regression models model 1 assessed the relationship between offering gifted alcohol and alcohol use model 2 assessed the relationship between receiving gifted alcohol and alcohol use models 3 included both offering and receiving gifted alcohol as covariates with alcohol use as the outcome model 4 assessed the relationship between offering gifted alcohol and tobacco use model 5 evaluated the relationship between receiving gifted alcohol and tobacco use model 6 included both offering and receiving gifted alcohol with tobacco use as the outcome results individual sociodemographic characteristics and drinking behavior the average age of the participants was 478 years old with 392 of the participants aged 4549 years participants were majority male and married more sociodemographic characteristics were shown in table 1 almost half of the participants reported being current drinkers of which 62 were daily drinkers and 384 were occasional drinkers the correlates of alcohol gifting the study showed that 435 of participants had received alcohol and 299 had offered alcohol the results from the chisquare tests in table 1 demonstrated that age gender marital status education region social network and social participation were all significantly associated with both offering and receiving alcohol place of residence and household annual income were only associated with offering alcohol while smoking status and cognitive social capital were only associated with receiving alcohol ethnicity was unrelated to either offering or receiving alcohol the results from the multiple logistic regression analysis in table 2 further showed that participants aged 45 to 49 years old were more likely to offer alcohol than the people aged more than 50 years old meanwhile those younger than 45 years were less likely to receive alcohol than those older than 50 years the male household heads were 234 times more likely to offer alcohol and 140 times more likely to receive alcohol than the female household heads participants from shaanxi province had higher odds of offering alcohol and receiving alcohol than participants from guangdong province drinking status and social participation were also significantly associated with offering and receiving alcohol participants who were daily drinkers and occasional drinkers or had a higher frequency of social participation were more likely to both offer and receive alcohol as a gift we also observed that participants whose annual household income was more than one hundred thousand yuan were more likely to offer and receive alcohol than those with annual household income of less than 20000 similarly those whose annual household income was between 80000 and 100000 yuan were more likely to receive alcohol in addition we observed that married participants participants with an education level of junior high school and participants with a large social network had higher odds of receiving alcohol compared to those who were not married had education level of junior college college or higher and had a small social network association between gifting alcohol and drinking and smoking use status the results from table 3 demonstrated that receiving alcohol was associated with current alcohol use and current tobacco use while offering alcohol was only associated with current alcohol use adjusting for sociodemographic characteristics and social participation in addition both alcohol offering and receiving were still significantly associated with drinking and smoking status even when controlling for the other gifting behavior the household heads who offered or received alcohol had higher odds of being current drinkers than those who didnt offer or receive alcohol additionally those who received alcohol were more likely to be current smokers while those who offered alcohol were less likely to be current smokers discussion research on alcohol has generally only focused on its use or overuse as a psychoactive substance 335 meaning there are few studies on the behavior of alcohol gifting in this study two provinces in southern and northern china were selected to explore alcohol gifting associated factors and behavioral outcomes we also distinguished between actively offering and passively receiving alcohol gifts this study showed that nearly half of the participants had received alcohol and nearly onethird had offered alcohol suggesting that alcohol gifting is common in china there are some differences in alcohol gifting across sociodemographic characteristics our research showed that men were more likely to offer and receive alcohol than women we posit two potential explanations for this difference one there are sex differences in drinking alcohol behavior in china where drinking frequency in men is higher than in women 335 this higher drinking frequency in men might explain why alcohol gifting is more common among men two compared to women men are more likely to participate in social interaction where alcohol consumption is normative in the chinese sociocultural context especially on business occasions in addition the study also suggests that married people have higher odds of receiving alcohol consistent with this finding a previous study of chinese drinking behaviors showed that being married is associated with more alcohol consumption 36 we hypothesize that married people may be more invested in maintaining interpersonal relationships than those who arent married especially on special holidays when alcohol gifting is common married people may have more social and family ties that are accompanied by giftgiving expectations and therefore may be more likely to receive alcohol as a gift moreover chinese society emphasizes filial respect and giftgiving is a way for the younger generation to show respect for the elder generation as married people are generally more mature and have higher status within the family hierarchy they may be more likely to receive gifts such as alcohol the finding that participants with a high level of social participation were more likely to give and receive alcohol is consistent with the role that alcohol plays in chinese culture where alcohol consumption is commonly involved in social interaction chinese people traditionally consider drinking an important tool of social contact and emotional expression alcohol often accompanies business meetings social activities weddings funerals holidays and other special celebrations 37 gift giving can reduce uncertainty while producing positive emotions social cohesion and commitment 38 feelings of obligatory reciprocity often accompany giftgiving even when altruistic motives are also present 39 as consequence those who have received alcohol may feel obligated to reciprocate after receiving an alcohol gift by offering the giftgiver help strong emotional ties etc while social participation was found to be significantly associated with offering alcohol we did not find a significant relationship with cognitive social capital and social network social exchange theory holds that all human behaviors are exchange behaviors and giftgiving is also a social exchange behavior 40 in other words the cognitive perception of social capital and the extent of social network might not promote the occurrence of gifting behaviors perhaps giftgiving behavior can only be promoted through social engagement where there is real interaction with people in the context of social participation the behaviors of offering and receiving alcohol were also related to family annual income higher annual household income indicates higher economic status it was previously illustrated that individuals of higher economic status are more likely to offer expensive wines to demonstrate their prestige and high social standing 41 our results offer additional support for the relationship between higher ses and alcohol gifting this study found that compared with guangdong the southern coastal area in china the phenomenon of alcohol offering and receiving is more common in shaanxi an inland city in northwest china this may be partially explained by the regional differences in drinking prevalence according to a study on regional differences in alcohol consumption in china the prevalence of regular drinking in the northern region is higher than prevalence in the centralsouthern region 42 it is possible that northerners perceive drinking as an effective way to cope with cold weather and northern culture emphasizes hospitality with frequent gatherings and exhortation to drink 43 in addition guangdong has higher economic and cultural development than shaanxi due to the advantages of economic reform and being a coastal area which has more foreign trade activities with the outside this higher level of economic development may be associated with receiving more information about the harms of drinking leading to more concern about its effects on health and avoidance of alcohol 44 this difference may also be related to the cultural differences of gifting between the north and the south drinking status was also found to be strongly associated with giving and receiving alcohol behavioral susceptibility theory posits that behavior will gradually increase when that behavior is convenient 45 drinkers are more likely to approve of drinking than nondrinkers and may have more regular convenient access to alcohol drinkers may therefore be more inclined to choose alcohol as gifts in another study in china smoking outcomes were associated with cigarette gifting behaviors 22 notably a similar relationship was found in the current study where gifting alcohol was significantly associated with not only drinking but also smoking many studies have demonstrated that tobacco and alcohol were complementary products and couse is common 46 47 48 49 drinkers are also more likely to smoke cigarettes than nondrinkers 50 these findings may indicate that receiving alcohol as a gift may facilitate the consumption of addictive substances including tobacco and alcohol with regards to policy implications the result of the current study can be used to inform prevention and intervention first alcohol gifting is associated with higher odds of current drinking and current smoking previous studies have suggested that limiting alcohol advertising is an effective intervention to control drinking 5152 while it might be difficult to ban all alcohol advertising restrictions could be pursued that restricts advertising from using gifting themes and imagery interventions that teach people how to refuse alcohol as gifts and suggest alternative gifts could also be pursued such interventions should be targeted at specific populations that have higher odds of alcohol gifting for example people who are male married currently drink alcohol reside in the northern region have larger social networks and more social participation and people with higher economic status finally given the differences in alcohol giving in north and south local alcohol gifting culture should receive attention when formulating policies and interventions programs particularly in the northern region limitations some limitations should be considered first the crosssectional design prohibits causal associations additionally selfreported questionnaires are vulnerable to recall bias and social desirability bias second selection bias might misrepresent the prevalence of alcohol offering and receiving because the sample only included the household heads whose children were college students moreover results may not generalize to the entire country and the selected provinces might reflect northsouth cultural differences due to their geographical and economic characteristics conclusion in summary the present study used a multistage sampling design to study alcohol gifting through both offering and receiving alcohol as a gift the results showed that gender household annual income province drinking status social participation and authors contributions lz and lh drafted the manuscript dw participated in the conception and design of the project dw and ly participated in data collection for the study dw conducted statistical analysis lz lh cj and cw edited and revised the manuscript all authors reviewed and approved the final version of the manuscript competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

introduction alcohol gifting is a very common practice in china however little is known about the potentially adverse consequences of alcohol gifting this study aimed to investigate the prevalence of and factors associated with alcohol gifting and explore whether drinking and tobacco use were associated with alcohol gifting methods using a crosssectional multistage survey a sample of 982 household heads from guangdong province and 530 household heads from shaanxi province was collected online from 30 april to 30 july 2020 in china participants completed questionnaires regarding sociodemographic characteristics social capital drinking status and gifting alcohol behavior chisquare analysis and multiple logistic regression analysis were used to identify the factors associated with alcohol gifting and to identify its relationship with alcohol and cigarette use status results multiple logistic regression analysis showed that age gender household annual income province drinking status and social participation were prominent correlates of both offering and receiving alcohol participants who were married had an education level of junior high school or had a large social network had higher odds of receiving alcohol when both alcohol gifting behaviors were included in the models participants who offered alcohol had 215 95 ci 163285 times higher odds of current drinking than those who didnt offer alcohol and participants who received alcohol had 187 95 ci 145241 times higher odds of current drinking than those who did not receive alcohol those who received alcohol had significantly higher odds of current smoking aor 164 95 ci 125214 while those who offered alcohol had significantly lower odds of current smoking aor 07195 ci053095 conclusions social participation is an important correlate of alcohol gifting alcohol receiving behaviors were significantly associated with both current alcohol and tobacco use these associations can be used to inform alcohol gifting interventions in china

introduction family and friends are important sources of individuals health information using family and friends to obtain health information is particularly preferred by older adults many of whom are simultaneously managing multiple chronic conditions among rural adults social networks are particularly important to the exchange of health information individuals with similar life experiences or health conditions may share knowledge and experiences that others including family cannot understand acquiring health information can occur in both formal and informal social contexts that are not intended as venues for health information exchange yet the exchange arises through the social encounter examples of formal and informal contexts of health information exchange include obtaining health information before or after worship services in the workplace and while having lunch with friends these illustrations are consistent with the more general precept that people use wellestablished habits to acquire health information habits that frequently prioritize ease of access and interpersonal trust of the source research describing much less understanding older adults health information seeking behavior is generally absent from the welldeveloped literature documenting that informal sources of health information are preferred and widely used by older adults previous research clearly describes individuals frequently women as central nodes or informal sources of health information within a community whether it is for general health knowledge or more specific knowledge such as complementary therapies or traditional remedies less clearly delineated are the process and mechanisms by which older adults obtain and potentially become disseminators of health information understanding older adults health information seeking and sharing behavior has substantial theoretical and practical value theoretically the exchange of health information has both general and specific implications the potential differences in how different subpopulations exchange health information likely contributes to persistent health disparities observed by gender race or socioeconomic status more specifically the exchange of health information is one mechanism by which social networks are presumed to affect health outcomes thus a clearer understanding of how health information is exchanged can offer insight into health disparities including the mechanisms by which the social environment gets under the skin a better understanding of how health information is exchanged also has practical implications as it may inform strategies for minimizing the diffusion of poor or potentially threatening health information or improving the diffusion of useful health information this analysis has two central aims first this analysis aims to improve understanding of older adults health information seeking behavior second this analysis aims to enhance the understanding of cultural factors that can contribute to a meaningful design of geriatric health education programs to achieve this goal we emphasize two salient attributes of information seeking behavior breadth and intensity by breadth we mean the number and variety of venues or sources for acquiring information intensity refers to the level of effort expended by individuals in the acquisition or exchange of health information it is expected that the older adults in this study will vary on both the breadth and the intensity of their health information seeking the primary aims of the analysis are to document older adults sources of health information to describe the purposes for health information seeking and to describe the variation in effort given to health information seeking methods sample this study was conducted in three southcentral north carolina counties the counties represent variation on the urbanrural continuum such that one is in a metropolitan area of 250000 1 million population one is a nonmetropolitan county with urban population of 20000 or more adjacent to a metropolitan area and one is a nonmetropolitan county with urban population of 250019999 adjacent to a metropolitan area a sitebased procedure was used to implement the ethnographic sample design to recruit participants who reflect the range of knowledge beliefs and practices in the community we recruited 62 participants with approximately equal numbers of african american and white women and men from across the study counties that served different ethnic and social groups data collection occurred until saturation was reached and no new insights were gathered participants were recruited from 26 sites that included four congregate meal sites two homedelivered meals programs two senior housing sites four senior centers and clubs a local aarp affiliate three churches three county social service programs three county health department programs a local restaurant and two other research projects a gatekeeper at the various facilities or a project staff member presented information about the project to the older adults who were present at the facility based on the project information older adults would provide contact information if they desired to participate in the project once contacted by a project team member a time and location for an interview was decided upon attention was also paid to participants educational attainment and migration history in recruitment we asked participants about their migration history because living in different regions could shape social network size and individuals activities within those networks migration history has three categories nonmigrants return migrants and inmigrants nonmigrants had lived their entire life in the same community return migrants were born in the study area but had moved to other areas such as other cities in north carolina new york city new jersey and various other places in the us and abroad for work or military deployment before returning to their native communities inmigrants had lived in various places within north carolina this categorization method based on migration history has been applied in other research data collection data collection was completed over a nine month period by five trained interviewers interviewers conducted the interviews at a location of the participants choice usually their homes interviewers explained the project and obtained signed informed consent participants received a small incentive at the end of the interview indepth tape recorded interviews ranged in length from about one hour to three hours the wake forest school of medicine institutional review board approved all study activities interview content the main focus of the indepth interview was to capture information about the use of complementary therapies and the beliefs surrounding use of these therapies more detailed information about the interview content has been published a substantial component of the interviews sought to identify where individuals obtained information about health conditions and treatment as well as the extent to which people shared that information the context in which people shared health information was questioned in particular participants were asked what type of health information is shared with each other where these conversations take place who do people talk to other than a health care provider who are the people who talk about health and illness do men or women talk more about health and illness and are there lay people in the community who are asked for advice about health and illness to understand better community standards about the use of complementary therapies participants were asked to what extent people discuss different types of therapy use and where people learn about such therapies data analysis data analysis was based on a systematic computer assisted approach atlasti 60 software was used for qualitative data management systematic coding and analysis all interviews were transcribed verbatim and were edited for accuracy analysis was an iterative process initial case summaries were written for each participant and a coding dictionary was developed from the initial transcript review and case summaries each transcript was reviewed and coded by one member of the project team at the end of coding the initial case summaries were reviewed and revised by the project team member who coded the transcript a second team member then reviewed the coded transcript and suggested revisions to the coding and the case summary at the end of the process each transcript and case summary had been reviewed by at least two project team members there was a high level of interrater agreement in the coding process although no rate of interrater agreement was calculated instead discrepancies were discussed as a team during project meetings more often than not discrepancies were due to errors of omission not inclusion while data were not quantifiable relevant themes were highlighted and evaluated for salience results sources of health information friends were the dominant source of health information for older adults family was notably missing as a source of health information participants described how friends frequently shared information about health including basic information about illnesses or specific symptoms in most of the situations described participants talked about how conversations at churches or other recreation sites for older adults oftentimes shifted to health topics i think when you become friends with a different group of people and you know especially women womens groups i cant ever think of when i go to presbyterian womens group that something like that isnt discussed somebody doesnt show up because theyre sick or something you know oh wonder what shes taking or wonder if shes been to the doctor or you know i tried this or i tried that and maybe we ought to call her and see what shes taking thats the way its just like recipes however in some instances the transmission of health information within group social settings was purposeful and intentional for example one african american female described how her church provides health related seminars the most common social setting for older adults to ease the potential for discomfort men and women have separate meetings …women will have it seminars at church like on saturday and the next saturday men will have a seminar so they can get to ask about things that women wouldnt talk about around men and the men some things they wouldnt talk about around us so i carry my husband and leave him so he can ask questions health information was also obtained from several media sources the dominant media source for health information was television programming in most cases health information was disseminated as part of a broader message it typically was not focused on health content interviewer …do you know how its ltyrosine supposed to help your memory respondent no its supposed to just give your body the thing the natural substance that are low that cause the memory loss…i got it from a doctor on television dr perone on eye on health…well he just said these help restore our natural functions there are several things he advocates print sources of mass media were also sources of health information for older adults although several participants described how they obtained information about illnesses or disease from the newspaper comparatively more participants described books or magazines that were regularly used for health information many participants maintained and were eager to show interviewers their library of healthrelated resources respondent ive got a big library i love to read and i get a hold of a medical book husband shes got cases full of them respondent ill get a hold of a medical book and read it my husband had emphysema and i read up on that to see what that incurred and ive taken care of him for fifteen years and his doctor told me i made a good doctor although less widely used than television or print materials several participants expressed a general belief that computers and internet were sources of health information in large part because they allow individuals access to previously unavailable information on specific health topics of interest nevertheless there was a noteworthy absence of participants discussions about how they personally used the internet to gather health information …and i would think television and computer has brought a lot of information for people they never had before because they can access it especially computer older adults also rely heavily on health care providers for health information participants reported receiving health information from a wide variety of providers including doctors nurses physician assistants and pharmacists in most cases physicians were seen as the definitive source of health information especially about treatments for chronic conditions like heart disease or diabetes however there were also a noteworthy number of older adults who did not defer to health care providers as the definitive sources of information about health in some cases participants enacted alternative practices rather than modern medicine …i think i might refer to it as energy reception or something…i do know that i can receive energy from nature from being in nature…you know that old saying about tree hugging and stuff like that a tree will give you energy if you go to a tree and put your hands on it and ask for energy you can receive energy from a tree…when i was so confined with this knee i was in the house totally for a couple of weeks and got really stressed really depressed really out of my element…so i decided that what i needed to do was i had to get outside…so i had my son set up the porch in such a way so that i got outside and in contact you know everywhere you look theres nature…yeah and that reenergized me it centered me again in other cases participants questioned the providers motivation for sharing the information interviewer when you use these different remedies or tonics what do you tell your regular doctor respondent i dont tell him nothing theyd be surprised…well if he would ask me did that hurt or something i would tell him no and then he would ask me well wonder what stopped it from hurting then i might would tell him but since he dont ask i dont tell him…i feel like hes the doctor he should know but a lot of things doctors dont know about these old remedies and sometimes some doctors is against old remedies because thats going to cut their money off purpose of health information seeking there was variation in the reasons for health information seeking many older adults engaged in health information seeking when they were confronted with unfamiliar new or novel symptoms if the new symptoms were viewed as benign or nonthreatening older adults used their social networks typically friends and peers to obtain information …you know when you get to looking at me saying man whats wrong with you youre looking dull i say well my stomachs been bothering me…you come up with something i can do tell me to do it…well take this here and they describe something or other home remedy something that they say if this dont help it then you need to go to the doctor however if the symptom was viewed as being serious older adults were more likely to seek advice from a health professional although in most cases the advice seeking was more akin to fix me than give me information …the only time that i have any chest pains is when i get kind of aggravated and stressed that kind of stress causes you to have pain in your chest…whenever i get that and i know i have stress i try to see a doctor to see my regular doctor for that because i know i cant go on with the pain because sometimes it really hurts and it aint been long since i had that and i know stress will kill you quick as anything else… older adults also consulted a health care provider when they did not know of an appropriate or effective treatment or when a known treatment did not work if i have something on hand that i know will work ill use it otherwise ill go to the doctor less common was information seeking from friends and peers for treatment or ongoing management of chronic medical conditions more often than not participants turned to their health care providers for advice on treatment of chronic conditions as the health professional was presumed to be more knowledgeable of medical conditions ive always felt like he doctor knew what he was doing and i should follow his directions and not grandpas least common was information seeking for health promotion or strategies to reduce the likelihood of subsequent illness or disease when older adults talked about information for health promotion they frequently referenced historical information such as experiences during childhood respondent way way back my who was that my grandmother my grandmother used to say take a little teaspoon of vinegar itll help to keep your pressure down interviewer did she say why it help to keep your pressure down respondent no she didnt because back in them days you didnt ask your mother all these questions…you go on and take it the few individuals who did seek out this information on contemporary forms of health promotion were generally more health oriented or focused i think probably it goji juice gives you an extra edge against cancer and things like that because of the antioxidants and things…i read about it in one of my herbal magazines and ordered some and my son is on it in particular i make sure that he stays on it all the time and one of the things it does is supposedly helps you fight against depression and i think it helped him do that active versus passive information seekers participants expressed a clear range of effort put into health information seeking some older adults actively sought health information whereas others passively consumed this information active health information seekers deliberately sought information about health from a broad variety of sources and incorporated a large volume of health information relative to their peers i guess what you have a natural affinity for is what somehow you get led to if you are meditating and really trying to plug into that universal knowledge thats out there if youre really open youll be led to where you need to go and that was all a part of it i think i started reading you know certain articles in magazines that i would see would catch my eye or i would be at the bookstore and certain book would catch my eye and it was generally within a theme you know the meditation the natural living taking care of your own body herbs things like that within this group there were some women african american and white who portrayed themselves as nodes of health information they were contacted when others had healthrelated questions as they were known throughout the community for having health knowledge these women arrived at this status in different ways typically by way of medical education or life experiences these experiences across time made them better prepared to be nodes of health information i got a niece that shes the principal over here at name high and she said aunt name i just have so many hot flashes i cant hardly stand it i said well get you some sage and some sugar and put it in a bag and put it under your tongue… and let it dissolve… evaluation of acquired health information was imperative for health information seekers as a result of the increasing amount of available health information some participants expressed concern about the quality of information they received critical thinking about presented information was common among those who were actively engaged with the health information they received they evaluated and sometimes incorporated acquired health information into their health management a greater proportion of men than women were passive consumers of health information women versus men differences in information seeking behavior there were notable difference in the breadth and intensity of information seeking by gender several participants stated that older women regularly engaged in discussions about health information these discussions occurred across settings it was suggested by numerous participants that whenever older women gather the conversation inevitably addressed health issues …anywhere we go my wifes friends will be talking about some ailments conversations about health were less common among older men for a variety of reasons men typically chose not to discuss their health with other men reasons cited for this lack of discussion included its none of their business they dont want to hear it and others will tell you what to do instead they chose to discuss their health with only health care providers or their wives respondent ive heard women talk about their health i aint heard too many men talk about it i think theyre ashamed to interviewer why might they be ashamed discussion this qualitative analysis focused on the sources and strategies that older adults used to obtain health information a substantial portion of these older adults participated in health information sharing the association between health behaviors and social networks is well documented research describing the exchange of health information within these social networks however is generally missing our goal was to improve understanding of the variation in older adults health information exchange in order to inform future health education efforts our results suggest that friends are the primary source of health information for rural older adults unlike past research family was not a central source of health information for our participants an analysis of older adults with diabetes in the same counties indicated that they received more selfmanagement help from other relatives and friends than from children the one exception was a small group of men who turn to their wives for health information results from other studies suggest that family is a primary source of health information however participants in previous studies were much younger than participants in the present study therefore it is possible that older adults may have fewer family members to turn to or that family members may be primarily younger individuals with less experience than older adults seek however data to confirm this were not collected rurality should also be considered as a factor in the absence of family as a central source of health information for our participants for many older adults children have moved out of the area to attain employment because of difficulties finding work in rural areas as the number of proximal family members decreases older adults shift their focus to maintaining ties in social groups made up of friends and community peers the importance of peers and friends for health information is particularly salient among rural older adults who have less access to medical care and formalized sources of health information family and friends have been combined into a single variable in some research but among our participants these are clearly two independent sources of health information an important finding from this study is the enduring importance of traditional print media to the current generation of older adults yet among these older adults we find some also using electronic media the number of individuals using electronic media for health is far greater for those aged 5564 than among those 65 and older further those using electronic media for health information increases when there is a concern for a specific health problem while print media and television were the predominant media sources used some older adults commented that the internet has made it easier to obtain health information somewhat defying the stereotype of rural adults lacking knowledge or skills necessary for the internet yet even among those older adults who actively sought health information more traditional sources of media like books newspapers and television programming were preferred which should be taken into account by health educators while this study finds that older adults prefer other mediums of accessing health information than online it should be acknowledged that consistent with other research more older adults are accessing online health information a second finding from this study is the substantial passivity in older adults pursuit of health information these results indicate that when providing health education to older adults particularly rural older adults health educators should be direct and emphasize the importance of information because many older adults are not actively seeking information some past research described health information acquisition as an issue of access to information ramanadhan and viswanath try to explain information seeking within the context of communication inequality which they define as disparities among social classes and racial and ethnic groups in access to and use of information channels attention to health content recall knowledge comprehension of health information and capacity to act on relevant information contrary to other literature our data suggests that while many older adults have access to health information a portion of them simply are not engaged in acquiring synthesizing or applying that information this finding is compelling because it calls into question the general assumption that having health information is a desired end point it also raises questions about how to disseminate information to a market that does not demand it even if some of our participants who lack access to health information were provided access it is unclear whether or not they would utilize this access it has been shown that a sizable proportion of ailments experienced by older adults are attributed to old age thus passivity may reflect the notion that some health issues are not a condition requiring attention rather it is part of the body acting its age another potential explanation of passivity may be that as health literacy is positively associated with social support older adults lacking in social support have potentially lower health literacy than older adults who have adequate social support understanding the varying degrees of information seeking or nonseeking among these older adults may help bridge any existing gaps in health between those who are active passive or nonseekers of health information in this study health information sharing was not related to ethnicity about the same proportion of african american and white women and african american and white men participated in health information sharing highlighting the lack of ethnic differences among our study participants there were no differences in health information sharing related to migration status as past research indicates far more women than men in our study actively participated in health information seeking older women in this study comprise the informal health care system that many older adults utilize a partial explanation for this finding is that historically women have assumed the role of caretaker health information seeking for themselves or others perpetuates this role also it may reflect their desire to understand health information as a resource to support better quality of life or successful aging further men commonly neglect to visit a health care professional when ill or fail to report the symptoms of illness or disease women rely more on social ties for the acquisition of health information than men and this may delay their decision to seek health information from a health care provider delaying more effective treatments while women were more involved in health information seeking than men there was notable passivity among the majority of older adults in the study regardless of gender although consistent with previous research suggesting that watchful waiting is a common health selfmanagement strategy it is counter to the common notion that people are quick to begin searching for health information when symptoms or illnesses arise it is clear from this analysis that many older adults seek health information especially when presented with health problems this observation is consistent with the health selfmanagement literature and approaches like the selfregulatory model which posits that people are active in solving healthrelated problems however in contrast to the presumption that most individuals engage in active problem solving we found that older adults were relatively passive in their acquisition of health information this suggests that seeking health information via formal or lay networks may not be a dominant strategy for health selfmanagement while past research has focused on health information seeking for the treatment of chronic conditions older adults in this analysis primarily sought information in an attempt to manage a new or seemingly benign health condition taking more serious health concerns to a health care provider however little evidence in our data indicated that health care providers were seen as sources of health information per se as much as agents for change when older adults wanted to feel better they would visit a health care provider this study has several limitations first this study uses qualitative data from a small sample of rural older adults and the study design and analysis reflect the inherent limitations of qualitative studies second participants were representative only of rural older adults living in southcentral north carolina and we cannot generalize beyond this population third the central focus of the interviews was to gather information about older adults use of complementary therapies within this conversation participants were asked how they acquire or share health information it is possible that participant responses were influenced by the overall focus of the interview lastly participants were not randomly selected and statistics are not applied to these data however the sample of 62 participants was relatively large for qualitative analyses and participants were recruited from 26 sites this study considers health information exchange among rural older adults a subject that has not been well described in past research results indicated that friends not family were the most common source of health information and most older adults had a relatively passive approach to acquiring health information both these findings have important implications for health care professionals including health educators health information seeking was not related to ethnicity or migration history suggesting a common cultural influence that is more reflective of characteristics of their rural community than ethnicity results were also unrelated to educational attainment women in these communities are more invested in the acquisition of health information than men some are considered health experts or nodes of health information this has an important implication for the growing need of culturally competent geriatric health educators friendship networks or other leaders can be invaluable to the dissemination of health information understanding the reliance older adults have on social networks will prepare health educators to tailor programs to meet their needs help older adults help each other the nodes of health information in various communities act as lay health mediators and foster social cohesion equipping these nodes of health information with accurate health information or access to such information can create much needed lay geriatric health educators while they comprise only a small portion of the population these laypersons in the community play a role in the discussion of health information and have a vital role in the increasing importance of geriatric health education these results indicate that when providing health education to older adults particularly rural older adults health educators have three primary tasks first they should provide health information in forms that are most appropriate for their audience print media or otherwise second given the general passivity of many older adults health educators should be direct and emphasize the importance of active health information seeking lastly health educators should partner with the widely used friendship networks and lay intermediaries for a broader dissemination of accurate information nccam demographics white

this study documents older adults sources of health information describes the purposes for health information seeking and delineates gender and ethnic variation in health information seeking sixtytwo african american and white adults age 65 and older completed qualitative interviews describing their use of complementary therapies interviews identified how individuals obtained and shared health information friends not family were the dominant source of health information participants ranged from active seekers to passive consumers of health information information seeking was common for benign symptoms more women than men discuss health information with others friends are the primary source of health information for rural older adults there is substantial passivity in the pursuit of health information identifying health information sources of rural older adults can support the dissemination of information to those who share it with others

background the factors shaping the health of the current and largest generation of adolescents in human history are multidimensional complex and unparalleled 12 until recently adolescent health has been overlooked and misunderstood which is one reason why adolescents historically have had fewer health gains than any other age group 1 and hence are now central to a number of major current global health challenges 2 however addressing adolescent health potentially provides a triple dividend with benefits now later in adult life and for the next generation of children 1 further the period of adolescence may also provide a second chance to reduce or reverse earlylife disadvantage 3 in recent decades theorists have argued that understanding the factors driving growing adolescent health concerns requires a broad focus 4 clearly risk and protective factors of adolescent health include levels of physical activity substance use alcohol consumption tobacco usage 5 diet 1 adolescent abnormal weight and mental health 5 however it has been asserted that as well as focusing on an individuals health risk and protective factors the upstream social patterns and structures in which adolescents exist needs to be considered 4 ecological theorists 6 argue that an individuals social environment both present and past influence their health behaviors and health outcomes mediated by other factors including their demographics and physical and psychological makeup social environments are multifaceted and include peer school community societal cultural new media influences and family dynamics 7 adverse childhood experiences such as psychological physical or sexual abuse violence parental substance abuse parental separationdivorce parental incarceration or death of a parent close relative or friend may also influence health behaviors and health outcomes in adolescents 8 9 10 11 conceptual frameworks have been developed to represent the complex web of causal pathways through which social factors interact with an individuals health risk and protective factors throughout the life course 12 however these models have not been tested among adolescent populations selfrated heath is a legitimate and stable construct used in adolescent populations 13 14 15 16 17 18 19 20 21 reviews by idler and benyamini 19 proposed that an individuals health status cannot be assessed without the srh measure as it captures an irreplaceable dimension of health status spanning past present and future physical behavioral emotional cognitive 22 and social 20 dimensions of health widespread agreement in the literature 15 23 24 25 recognizes that srh is a complex parameter affected by multifarious determinants specifically shr is influenced by higher body mass index 17 mental health select health behaviors 20 demographics and social factors many of these factors have complex interrelationships 23 directly or indirectly affecting selfperception of health status 15 while an increasing number of studies have been reported on srh among adolescents 13 most research in this field 13 14 15 16 17 18 24 25 26 address only select factors fig 1 conceptual framework for determinants of health affecting health status and thus yield only partial or confounded information on the determinants of adolescent health 23 investigations need to assess concomitantly the factors associated with this multifaceted health measure 23 utilizing structural equation modeling and srh as a measure of health status this study aimed to explore concomitantly the complex relationships between srh and social environments health behaviors and health outcomes among adolescents attending a faithbased school system in australia methods study design and participants in 2012 1734 students aged 12 to 18 years of age responded to a health and lifestyle survey that was administered in 21 seventhday adventist private secondary schools in australia the database created by this survey has been used in previous studies 2728 seven hundred and eighty eight students from this database met the inclusion criteria for this study which included useable data for the following domains srh bmi mental health and vitality notably bmi data were not collected on over 900 students in the database hence these cases did not meet the inclusion criteria the study was approved by the avondale college of higher education human research ethics committee and participation in the study was voluntary and anonymous a hypothesized model informed by ecological theory and the conceptual framework for determinants of health 12 is presented in fig 2 the dependent variable was the measure srh in order to concomitantly explore factors associated with srh yet retain a parsimonious model we delimited the study by restricting the explanatory variables to the following health outcome variables health behavior variables and demographic and social variables religious affiliation survey instrument the survey instrument recorded the participants srh as well as bmi measures of mental health and vitality selected health behaviors personal demographics and social influences selfrated health status srh status was assessed with a single item involving a fivepoint likert scale ranging from excellent very good good fair and poor body mass index height and weight were selfreported and used to calculate bmi using the standard equation bmi weight in kg 2 mental health and vitality mental health and vitality were measured using the validated and reliable 29 fiveitem mental health and fouritem vitality subscales from the sf36 30 these subscales measure general mental health status and assess the individuals energy and fatigue each item in the mental health and vitality subscales has six response options ranging from all of the time to not at all standardized scores for these subscales were calculated creating a 0100 scale according to the standard procedure for calculating the mental health and vitality scores 31 higher scores indicated better mental health and vitality internal reliability of the mental health and vitality subscales have been reported at α 78 to 87 and α 72 to 87 respectively in studies across eleven countries 32 as seen in fig 2 hypothesized model for factors associated with selfrated health in adolescents table 1 the reliability of vitality in this study was comparatively lower than in these reports selected health behaviors sleep hygiene was assessed by an item that asked how many hours do you usually sleep per night with eight response options ranging from 3 h or less to 10 h or more physical activity was measured by an item that asked how many times per week do you usually do any vigorous or moderate physical activity for at least 30 minutes with seven response options ranging from none to 6 or more times 33 fruit and vegetable intake was assessed using food frequency questions adapted from items previously used in adolescent studies 34 fruit consumption was measured by an item that asked how many serves of fruit do you usually eat each day response options ranged from i do not eat fruit to 6 serves or more vegetable consumption was measured by an item that asked how many serves of vegetables and salad vegetables do you usually eat each day response options ranged from i do not eat vegetables to 6 servers or more the fruit and vegetable items were summed to provide an overall fruit and vegetable intake score as a measure of the respondents overall diet an item asked how would you describe your usual diet response options included 1 total vegetarian 2 lactoovo vegetarian 3 pescovegetarian 4 nonvegetarian for the purpose of this study this item was dichotomized as a vegetarian or nonvegetarian diet this item was included in the study because a high proportion of adventists adhere to a vegetarian diet 35 alcohol consumption tobacco and marijuana use were assessed with frequency questions ranging from none to 60 for alcoholic drinks drunk and cigarettes or marijuana smoked in the last four weeks religion religious affiliation was included in this study due to the special nature of the sample previous studies report associations between religion and srh 36 with some reviews reporting that this association is unaffected when controlling for demographic variables 37 religious affiliation was assessed by asking the participants which of the following best describes your religious belief now options ranged from 1 seventhday adventist christian 2 other christian 3 other religion 4 no formal religion and 5 dont know this item was dichotomized to nonadventist and adventist social factors in this study an adverse childhood experiences score 8 9 10 11 was generated by collating responses from the following nine items 1 one or both of my parents were in trouble with the law 2 my parents were separated or divorced 3 one or both my parents died 4 one or both parents were absent from home for long periods 5 there were times when family violence occurred 6 there were times when i was physically abused 7 there were times when i was sexually abused 8 one or both parents smoked tobacco and 9 one or both parents drank alcohol weekly or more often each of the nine items included noyes response options which were given a corresponding value of zero or one responses from each item were summed to calculate an overall aces score childhood family dynamics were assessed by creating a cfd score from six items namely 1 as a child my parents showed me love 2 as a child my parents understood me 3 while i was a child my family had a lot of fun 4 as a child my parents didnt trust me 5 as a child my parents didnt care what i did and 6 as a child i enjoyed being at home with my family each item included five response options ranging from strongly disagree through to strongly agree each response was given a corresponding value from one to five and was recoded so that higher scores represented positive outcomes responses from each item were summed to calculate the overall cfd score analysis the objective of this study was to simultaneously analyze all paths of the hypothesized model in order to explore the complexity of the associations between multiple factors and srh hence structural equation modeling 38 was used to estimate the model fit of the data and analyze the direct and indirect effects of the multiple factors in the hypothesized model overall model fit was examined using multiple goodnessoffit indices namely chisquare statistic relative x 2 baseline comparisons fit indices of nfi rfi ifi tli cfi and rmsea structural equation modeling was carried out using amos the bootstrapping method 39 was applied to verify statistical significance of indirect and total effects at p 05 the data were imported into spss to calculate means standard deviations distributions and internal reliability results descriptive statistics a summary of descriptive statistics and reliability estimates is shown in table 1 sixtyone percent of the students in the study reported very good to excellent health this is comparable with the 201415 australian bureau of statistics survey 40 which reported that 63 of young australians rated their health as very good or excellent unique to the study cohort was that 49 of the students reported an affiliation with a christian faith and low rates of alcohol consumption tobacco use and marijuana use the model for factors associated with selfrated health in adolescents the hypothesized model based on theoretical considerations was submitted for analysis using techniques developed by jöreskog and sörbom 41 utilizing an iterative process of inspection of the statistical significance of path coefficients and theoretical relevance of constructs in the model to derive an optimal sem that best fit the dataset and were theoretically meaningful the items that asked the participants about alcohol tobacco and marijuana use were removed from the model due to their nonsignificant contributions generating a final structural model modification indices suggested that the health behavior variables be allowed to covary as well as the health outcome variables mental health and vitality the final structural model as a whole fitted the data very well as indicated by the goodnessoffit indices cmindf statistic below three is considered good model fit 42 as are baseline comparisons fit indices above 09 43 the rmsea value was less than 006 which indicated a close fit between the data and the model 44 in fig 3 the standardized path coefficients are presented as singleheaded arrows and all shown paths are statistically significant including all indirect and total effect pathways the final structural model describes the upstream associations of bmi mental health and vitality health behaviors demographics and social factors on srh as well as their interactions the squared multiple correlation calculated for srh was 020 which indicates that the model explained 20 of the variance in selfrated health based on standardized path weight coefficients the health outcome variables bmi mental health and vitality had a direct association with srh this indicates that adolescents who reported a higher bmi reported a poorer srh and adolescents who reported higher mental health and vitality scores reported better srh the health behavior variables sleep hours physical activity fruitvegetable consumption and a vegetarian diet had a direct association with srh this indicates that adolescents reporting more sleep each night more physical activity greater consumption of fruit and vegetables and a vegetarian diet also reported a better srh the health behavior variables were also associated with srh indirectly through the health outcome mediating variables sleep hours was associated with srh indirectly through the mediating health outcome variables bmi mental health and vitality physical activity was associated with srh indirectly through the mediating health outcome variables mental health and vitality fruitvegetable consumption was associated with srh indirectly through the mediating health outcome variables mental health and vitality a vegetarian diet was associated with srh indirectly through the mediating health outcome variable vitality of the health behavior variables sleep hours had the strongest combined direct and indirect association with srh followed by fruit vegetable consumption physical activity and then vegetarian diet of the demographic and social variables aces was the only variable that had a direct association with srh with the other demographic and social variables indirectly associated with srh age was associated with shr through the mediating health behavior variables sleep hours and physical activity and through the mediating health outcome variables bmi and mental health gender was associated with shr through the mediating health behavior variables sleep hours physical activity fruitvegetable consumption and vegetarian diet and through the mediating health outcome variables bmi mental health and vitality aces was fig 3 structural equation model predicting selfrated health status associated with shr directly and through the mediating health behavior variable sleep hours and the mediating health outcome variable mental health and vitality cfd was associated with shr through the mediating health behavior variable sleep hours and through the health outcome variable mental health religious affiliation was associated with shr through the mediating health behavior variables sleep hours fruitvegetable consumption and vegetarian diet notably of the demographic and social variables in the model aces had the strongest association with srh hence more aces were associated with lower srh gender had the second strongest association with srh of the demographic and social factors and also interacted with the greatest number of the mediating variables in the model the association of age on srh demonstrated that older adolescents reported poorer srh however overall males rated their health better which is in line with other studies 13 the association of cfd on srh demonstrated that adolescents reporting better cfd also reported better srh finally the model indicated that although the respondents religion did have indirect links to srh its association was small adolescents who identified as adventist were more likely to report higher srh and better health behaviors than those who identified themselves as not affiliated with the adventist church discussion this study explored concomitantly the relationships between factors associated with srh in adolescents attending adventist schools in australia by including a number of variables into one conceptual model and analyzing them simultaneously the study is unique in that it was able to describe a complex network of associations between the factors that influence srh this study supports the need for a broad multicomponent approach to the study of adolescent health the findings in this study demonstrate the association between mental health and srh which is in line with findings from previous studies 2022 the mental health measure used in this study had the strongest association with srh of the three health outcome variables measured and was associated with the most health behaviors demographics and social variables in the model several health behaviors as well as demographics and social factors had a direct association with mental health notably the association between the adolescents childhood upbringing and mental health demonstrates how social factors early in life are associated with mental health status years later in adolescence the vitality metric used in this study had the second strongest association with srh of the health outcome variables all health behaviors in the model along with gender and aces directly associated with the measure vitality research on vitality is limited however one study found that up to 30 of healthy teens experience symptoms of fatigue that affect their normal functioning 45 the observed influence of health behaviors on vitality in this study highlights the importance of targeting healthy behaviors for improving the energy levels and lessening fatigue among adolescents there is a wealth of literature supporting the importance of health behaviors on adolescent health 3 however a unique aspect of this study was the simultaneous assessment of the association of four health behaviors with srh this allowed the health behaviors to be ranked according to their strength of association with shr while all health behaviors had a direct association with srh and an indirect association through one or more of the health outcome variables sleep had the strongest association with srh followed by fruitvegetable consumption physical activity and vegetarian diet this finding highlights the value of prioritizing healthy sleep hygiene among adolescent cohorts 46 although clearly interventions that address all health behaviors are likely to be most efficacious and therefore desirable in the sem analysis the items measuring the health behaviors consumption of alcohol and the use of tobacco and marijuana had nonsignificant pathways to srh it is well documented 5 that these health behaviors influence adolescent health negatively a possible explanation for the nonsignificant effect of these health behaviors in this study may be that the study cohort reported a low prevalence of these behaviors while this low prevalence was expected given the adventist community proscribes such behavior further exploration as to what motivates the use of alcohol tobacco and marijuana in a low using cohort would be of interest of the selected demographics and social factors included in the model predicting srh aces presented as having the strongest association indeed it is remarkable that adolescents who reported higher incidents of adverse experiences in their earlier childhood reported poorer srh in their adolescent years although children may have no choice in the aces they experience this study reinforces the necessity for childhood human rights health promotion and resilience building 47 to be at the forefront of global policy and intervention development to provide benefits not only in childhood but also later in adolescent life of the five demographic and social factors assessed gender had the second strongest association with srh and was associated with the most number mediating variables interacting with all health behavior and health outcome variables in the model this suggest that interventions targeting improving general health of adolescents may be more effective if they were gender specific the influence of cfd and religion on srh in this model is noted albeit not as strong as aces and gender strengths and limitations the strength of this study is that it concomitantly explored a number of factors associated with srh and describe the complex interaction between these factors and srh it is acknowledged however that model presented in this study although strong represents only part of the big picture of the overall influences of srh for example socioeconomic status is a wellknown predictor of srh 17 and this was not assessed in this study as no data on socioeconomic status was collected another limitation of this study is that it focused on a comparatively homogeneous group of adolescents who were exposed to a faithbased community namely adventist christians who place a strong emphasis on health and a wholistic lifestyle since its inception in 1863 the adventist religion has promoted the adoption of a healthy lifestyle to its members that includes regular exercise a vegetarian diet and rest alcohol caffeine tobacco and illicit substances are also proscribed the adventist population has been the focus of numerous health studies as they tend to experience good health and lower rates of disease 48 adventist schools espouse the health practices of the adventist church hence while approximately half of this study cohort did not identify themselves as adventist they were likely influenced the by health focus of the adventist church it is possible that the adolescents in this study potentially underscored their selfrated health status compared to adolescents in the general population due to the high health ideals advocated by the faithbased schools they attend this may have resulted in these adolescents perceiving and judging very good or excellent health against a more rigorous standard this limits the generalization of the findings to other populations the crosssectional nature of this study means that only associations could be measured it is not possible to say whether these relationships were causal although srh has been established as a legitimate and stable construct for use in adolescent populations 13 14 15 16 17 18 19 20 21 to measure general health status objective measures of health including biomedical testing as represented in the conceptual framework for determinants of health 12 may improve the validity of the findings in this study conclusion this study presented a conceptual model that described the complex network of factors concomitantly associated with srh in adolescents the results highlight the association of mental health with shr gendersensitive interventions prioritizing modifiable health behaviors such as sleep healthy diet and physical activity may achieve a greater combined effect in improving adolescent health status than select single factor interventions the association between aces and adolescent srh reinforces the necessity to address childhood human rights resilience family dynamics and health promotion in children for lasting benefits later in adolescent life further research into what influences the variables interacting with srh may provide insight into more effective interventions to improve adolescent health abbreviations abs australian bureau of statistics aces adverse childhood experiences bmi body mass index cfd childhood family dynamics cfi comparative fit index cmin chisquare statistic cmindf relative x 2 ifi incremental fit index nfi normed fit index rfi relative fit index rmsea root mean square error of approximation sem structural equation modeling srh selfrated health tli tucker lewis index x 2 chisquare authors contributions bc dm lk pr and bg conceived of the study participated in its design and coordination tb and kp coordinated the data collection bc and pm performed the statistical analysis and data interpretation bc drafted the manuscript and dm pm lk bg pr assisted in critical revision of the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background the factors shaping the health of the current generation of adolescents are multidimensional and complex the purpose of this study was to explore the determinants of selfrated health srh of adolescents attending a faithbased school system in australia methods a total of 788 students attending 21 seventhday adventist schools in australia responded to a health and lifestyle survey that assessed srh as well as potential determinants of srh including the health outcomes mental health vitality body mass index bmi select health behaviors social factors and personal demographics structural equation modeling was used to analyze the data and examine the direct and indirect effects of these factors on srh results the structural model developed was a good fit with the data the health outcome mental health had the strongest association with srh β 017 several upstream variables were also associated with higher srh ratings the health behavior sleep hours had the strongest association with srh β total 0178 followed by fruitvegetable consumption β total 0144 physical activity β total 0135 and a vegetarian diet β total 0103 of the demographic and social variables measured adverse childhood experiences aces had the strongest association with srh β total 0125 negatively influencing srh and gender also associated with an increase in srh β total 0092 with the influence of these factors being mediated through other variables in the modelthis study presents a conceptual model that illustrates the complex network of factors concomitantly associated with srh in adolescents the outcomes of the study provide insights into the determinants of adolescent srh which may inform priority areas for improving this construct

m any studies in the disaster science literature have addressed disasters and mental health 12 relatively few studies have examined health outcomes after multiple backtoback disasters 3 4 5 6 residents of the us gulf coast have had a decade of catastrophic disasters in rapid succession with the 2005 hurricanes katrina and rita and the 2010 bp deepwater horizon oil spill considered the worst humanmade environmental disaster in us history the bp oil spill has been a significant stressor for coastal residents struggling with hurricane recovery 78 moreover the oil spill has threatened the economy commercial fishing industry and cultural heritage of those whose livelihood depends on natural renewable resources 9 10 11 understanding the longterm health consequences of consecutive catastrophic events is a pressing challenge from both psychological and public health perspectives for instance elevations in the prevalence of symptoms of depression and posttraumatic stress among residents of disasteraffected communities highlight the need for coordinated responses among mental health professionals local officials and urban planners to promote resilience and prepare for future disasters 46 there is ample evidence of health vulnerabilities among commercial fishers with recent trauma related to the bp oil spill 471012 cherry and her colleagues have shown that katrinarelated stressors and prior lifetime traumatic events predicted different styles of coping with oil spill stress for commercial fishers although only avoidant coping was associated with increased risk of depression and posttraumatic stress 13 cherry et als first findings suggest that multiple disasters are devastating for coastal residents particularly residents with economic ties to the commercial fishing industry 413 however these findings are limited because they did not examine agerelated differences in postdisaster health or healthrelated quality of life prior research has shown that health and wellbeing are sensitive to demographic variables including age gender education and income 1415 there is a small but growing literature on the impact of disasters on older 16 17 18 19 20 21 and oldestold adults 2223 from an epidemiological perspective older adults are less likely than younger adults to survive disaster 24 however older adults who live through disaster may fare better than their middleaged and younger counterparts on mental health indicators possibly due to prior experience or more effective coping strategies born of experience 1521 other evidence has shown that older survivors including nonagenarians and their younger counterparts were comparable across preand postdisaster measures of psychosocial and cognitive health 23 although further research is necessary the primary objective of the present study was to directly examine adult age differences in healthrelated quality of life in a sample of disaster survivors from south louisiana who ranged in age from 18 to 91 years a second objective was to examine the impact of social engagement on postdisaster physical and mental health outcomes many epidemiological studies document the associations among social relations and health a topic of interest in the scientific community for many years 2526 in this study we conceptualized social engagement as an umbrella construct encompassing 2 social behaviors namely charitable work done for others and perceived social support ample evidence has shown that perceived social support 27 and communitylevel support 28 may lessen postdisaster distress cherry and colleagues 4 found that social support was a protective factor for symptoms of depression and posttraumatic stress at least 5 years after hurricanes katrina and rita in the present study we extend the literature by focusing on katrinarelated disruptions in charitable work done for others and the social support in the years before and after the 2005 hurricanes while controlling for the known influences of group gender education income objective health and prior lifetime trauma on the basis of previous literature 20 we expected that disruptions in social engagement activities would be inversely associated with healthrelated quality of life to summarize the goals of this study were to examine the impact of multiple disaster exposures on healthrelated quality of life in younger and older disaster survivors and determine whether social engagement is associated with healthrelated quality of life taken together the anticipated findings extend the literature on the longterm consequences of multiple disasters and may have noteworthy implications for the development of agesensitive interventions to lessen distress among coastal residents exposed to a decade of disasters methods participants in all 219 people participated in this study sampling recruitment and testing are reported in greater detail elsewhere 4 noncoastal and former coastal residents were 30 indirectly affected residents and 62 former coastal residents who relocated permanently in 2005 to baton rouge louisiana there were 63 current coastal residents with catastrophic property damage and stormrelated displacement in 2005 they returned to rebuild and had restored their lives in their original coastal communities current coastal fishers were 64 commercial fishers and their family members fishers were also coastal residents who were displaced for up to 2 years or more but who returned to rebuild after katrina fishers had an additional layer of stress related to the 2010 bp oil spill that is fishers are a particularly vulnerable group given their economic dependency on the gulf of mexico which was severely impacted by the oil spill fishers could not work in the commercial fishing industry for up to 1 year or more after the spill 71113 independent measures all participants had completed a storm impact questionnaire with 4 modules hurricane exposure and threat to self family disruption and stormrelated stressors social support and lifetime exposure to potentially traumatic events 4 in this article we utilized original data from the last 2 modules with separate questions that assessed disruptions in charitable work done for others perceived social support and prior lifetime trauma respectively to be precise we recoded the original data from the third module in a binary manner where 0 either no difference in or more charitable work after the 2005 hurricanes relative to before and 1 a decline in charitable work after the hurricanes similarly perceived social support 0 if there was no difference or more social support and 1 there was a decline in social support after the storms our rationale for the binary recoding of these data here relative to an earlier report 4 was to capture disruptions in these 2 social behaviors in a parsimonious manner that we could model in logistic regressions data from the third module included charitable work and availability of help if needed which included instrumental support appraisal support and emotional support data from the fourth module were the sum of 5 events where each event was scored as 0 1 or 2 dependent measures the medical outcomes study short form36 29 comprises 8 indicators of general health including physical functioning role limitations due to physical health problems bodily pain perceptions of general health vitality social functioning role limitations due to emotional health problems and mental health the psychometric qualities of the sf36 include construct validity 30 and high internal consistency reliability for the 8 subscales 31 subscales are combined to form composite physical and mental health component scores that range from 0 to 100 normative data yield a mean of 50 and a standard deviation of 10 for the pcs and mcs scores 32 thus we dichotomized these scores at 50 for the logistic regressions reported here statistical analyses all statistical analyses were carried out by using sas version 94 statistical software prior research 21521 has documented the potentially confounding influences of demographic factors physical health and lifetime traumatic events on postdisaster health and wellness indicators therefore bivariate logistic regression analyses were run on all variables that might be expected to covary with health based on the outcomes of the bivariate analyses and prior literature 6 variables were selected for inclusion as covariates in multivariate regression models as follows group gender education income chronic physical conditions and lifetime prior trauma all outcomes were dichotomous results psychosocial demographic and health characteristics table 1 presents a summary of the psychosocial demographic and selfreported health characteristics of the sample the groups differed in prior lifetime trauma so these variables were controlled in the logistic regressions that follow gender composition was comparable across groups but group membership was significantly associated with educational attainment by a chisquare test noncoastal and former coastal residents reported holding a college degree or masters degree more often than expected more than half of the fishers reported having a high school degree or less participants selfreported income level fell short of statistical significance with group by a chisquare test the groups did not differ statistically in number of chronic conditions logistic regression analyses odds ratios appear in table 2 for 2 dimensions of social engagement changes in charitable work done for others and perceived social support before and after the 2005 storms inspection of table 2 indicates that age was significantly and inversely associated with higher pcs scores which is consistent with the literature on postdisaster physical health in later life 22 among the covariates group and objective health status were significantly inversely associated with higher pcs scores furthermore low income was inversely associated with sf36 mcs scores with respect to social engagement only the decrease in perceived social support after the 2005 storms relative to a typical year before the storms was inversely associated with higher sf36 mcs scores this aspect of the data indicates that participants were 60 less likely to have higher than average mental health with each additional point dropped on the social support ratings contrary to expectation the drop in charitable work done for others since the 2005 storms was not associated with physical or mental health discussion and conclusions our primary objective in the present study was to examine adult age differences in healthrelated quality of life after a decade of consecutive disasters in support of our hypothesis we found that age was negatively associated with a higher than average sf36 pcs composite score which is composed of several subscales that measure of perceptions of physical functioning ability to fulfill roles because of physical health problems bodily pain and general health the age effect observed here was obtained after controlling for the known influences of group gender education income chronic conditions and prior lifetime trauma this finding joins others in the literature documenting lower perceptions of physical health among older persons compared to their younger counterparts 33 interestingly age was not associated with the sf36 mcs composite score implying that perceived mental health was no different for younger and older disaster survivors to address the possibility that the null effect of age in the analysis of sf36 mcs scores was an artifact of dividing the sample at the median we conducted sensitivity analyses where we first treated age as a continuous variable and then as a dichotomous variable using a higher cutoff age both analyses yielded the same null effect of age the most conservative conclusion to be drawn based on these data and the followup sensitivity analyses is that older persons may not be differentially vulnerable to adverse postdisaster psychological sequelae although further research would be desirable before firm conclusions are warranted participants in this study were communitydwelling adults and nearly all had prior hurricane and other natural disaster experience 4 older adults with prior hurricane experience may possess effective problemsolving skills and coping strategies that could be positively impactful in future disaster preparation and relief planning 1334 frail older adults in the community and those with reduced health status in assistedliving or nursing home facilities may need special assistance for evacuation safety and postdisaster relocation 3536 an important consideration for future disaster and emergency preparedness planning a second objective in this study was to examine the impact of social engagement on postdisaster healthrelated quality of life we conceptualized social engagement as hurricanerelated disruptions in charitable work done for others and perceived social support after the storms relative to a typical year before the 2005 storms disruption in charitable work was not significantly associated with physical or mental health in contrast the drop in perceived social support was significantly and inversely associated with sf36 mcs scores this aspect of the data is compatible with other findings showing that disruptions in social network characteristics have a deleterious effect on older hurricane katrina survivors 20 our findings among others in the disaster science literature imply that perceived social support 27 and communitylevel support 28 may lessen postdisaster distress on a broader note the group variable was treated as a covariate here to allow a clearer assessment of agerelated differences in healthrelated quality of life however the inclusion of commercial fishers is a noteworthy strength of the study that deserves further comment because commercial fishers have been doubly affected by katrinarelated losses and the more recent economic impact of the bp oil spill disaster they are at greater risk of adversity 911 the finding that group was a significant predictor of sf36 pcs scores is suggestive of selfperceived health vulnerabilities among commercial fishers and their families with stressors related to the experience of natural and technological disasters in rapid succession relatively few studies have examined the mental and physical health consequences of natural and technological disaster exposures although inherent differences between these f value for lifetime total trauma and healthrelated quality of life chisquare for all other variables b lifetime trauma with fear from cherry et al 4 c sf36 health survey which includes composite indexes of physical and mental health 29 d based on the presence of 6 chronic conditions e p ≤ 005 f p ≤ 001 g p 005 and ≤ 010 healthrelated quality of life in older coastal residents after multiple disasters disaster medicine and public health preparedness different types of disaster are noted in the literature for instance natural disasters may bring sudden catastrophic damage and loss of life although uncontrollable events of nature do happen from time to time and are generally not considered controversial 37 38 39 in contrast technological disasters involve failure of a humanmade system that is presumed to be controllable 37 for those directly impacted by technological disaster a lengthy process of litigation may follow as well as anger hostility and blame directed toward an individual or corporate entity at fault 4041 accordingly technological disasters may have longerlasting impacts on mental health and wellbeing for those directly affected although further research to address different types of disaster and their longterm effects is necessary last we included chronic conditions and prior lifetime trauma among the covariates here based on the assumption that survivors current health status and developmental history may shape postdisaster wellbeing after multiple consecutive disasters the number of chronic conditions was predictive of sf36 pcs scores as expected this finding supports the notion that survivors chronic conditions impact healthrelated quality of life a potentially important consideration for future disaster planning with older adults further prior lifetime trauma was a marginally significant predictor other evidence has shown that cumulative adversities including life stressors and prior lifetime traumatic event exposures affect the trajectories of mental and physical health in later life 2142 consideration of survivors current health status and prior lifetime trauma is relevant for the design or implementation of programs in connection with disaster relief efforts future research to systematically explore the role that survivors current health and developmental histories may play in the success of communitywide disaster relief programs would be valuable at least 4 methodological limitations of this study warrant brief mention first the sample size was small and may not be representative of the population second a crosssectional design was used so causal inferences are not warranted healthrelated quality of life is likely to be dynamic varying over time as people adapt to new life circumstances future research that includes longitudinal comparisons is needed to measure trajectories of change in health and psychological wellbeing among older disaster survivors third we did not estimate the impact of variations in the temporal intervals between exposures to the 2005 hurricanes and 2010 bp oil spill and participants responses on the outcome measures included here the present results should be considered in light of this methodological limitation fourth we did not include biological indicators of stress responses a potentially important direction for future research to permit a more precise estimate of the longterm health consequences after a decade of disasters in closing the present findings add to a growing literature on the human impacts of natural and technological disaster bringing attention to older disaster survivors physical and mental health risks in the years after these events interventions to address health challenges and healthrelated quality of life may be especially critical for commercial fishers in the years after disaster and are a potentially important direction that awaits future research correspondence and reprint requests to katie e cherry department of psychology louisiana state university baton rouge la 708035501 about the authors

objective exposure to multiple disasters both natural and technological is associated with extreme stress and longterm consequences for older adults that are not well understood in this article we address age differences in healthrelated quality of life in older disaster survivors exposed to the 2005 hurricanes katrina and rita and the 2010 bp deepwater horizon oil spill and the role played by social engagement in influencing these differences methods participants were noncoastal residents current coastal residents and current coastal fishers who were economically affected by the bp oil spill social engagement was estimated on the basis of disruptions in charitable work and social support after the 2005 hurricanes relative to a typical year before the storms criterion measures were participants responses to the sf36 health survey which includes composite indexes of physical pcs and mental mcs health results the results of logistic regressions indicated that age was inversely associated with sf36 pcs scores a reduction in perceived social support after hurricane katrina was also inversely associated with sf36 mcs scores conclusions these results illuminate risk factors that impact wellbeing among older adults after multiple disasters implications of these data for psychological adjustment after multiple disasters are considered

introduction criticism of donor funding and research grants schemes processes and practices is common among applicants complaints are often related to the cost of wasted efforts and concerns around various forms of biases including einsider bias personal bias dominant group bias and bias related to the incentive to do research that please the interests of those dispensing the funds 1 while different ways to allocate researchfunding are associated with different issues global health research funding carries additional challenges due to unequal power dynamics related to the coloniality of power of knowledge and of being 2 3 4 while the studies are designed to address health challenges in the global south the financial power including decisionmaking around delivery remains concentrated in the global north 5 6 in may 2021 in an open letter african scientists called for the decolonisation of global health research funding after a usled malaria initiative favoured partnering with western institutions over african institutions 7 they argued that funders continue to favour western institutions by dismissing global south expertise and undermining local agencies 7 8 while funders deny favouritism this paper introduces approaches to systematically interrogate the processes and practices that enable and maintain the dominance of euronorth americancentric ways of doing by presenting some of the unacknowledged barriers between the researchers whose application summary box ⇒ global health research funding is affected by unequal power dynamics rooted in global coloniality that manifest in the prioritisation of outsiders perspectives over local needs ⇒ this practice paper investigates why global south actors research funding applications are less likely to be successful than applications from global north actors ⇒ it outlines a threestep decolonial approach to epistemic injustice analysis of research funding processes and practices ⇒ findings suggest that epistemic wrongs occur when common biases and ethnocentrism are not mitigated during the review process ⇒ global north and global south funders can address current funding asymmetries by ensuring that pose and gaze are aligned from the design of the call for proposals to the review process bmj global health are being assessed and the funders and reviewers of their application 4 it aims to guide global health financing actors including member states united nations agencies and nongovernmental organisations to identify discrimination and coloniality in their work adopt a decolonial approach and recognise the critical need to disrupt power asymmetries and promote ownership participation and equity 5 9 10 the role of research funders in decolonising global health given their central position in the processes involved in knowledge production research funders have an important role to play in driving efforts towards equitable and decolonial research 2 11 12 epistemological colonialism refers to the way in which the expansion of colonial power enabled the expansion of colonial knowledge the colonial way of understanding and acting in the world to the detriment of local knowledge systems 13 14 with the overwhelming majority of funding being located in the global north organisations that issue calls for proposals can intentionally or unintentionally disadvantage and constrain global south applicants through research priorities language eligibility criteria due diligence rules and other expectations that can generate ethical and practical research issues 15 16 several studies have shown that global health research practices are currently geared towards the interests of certain socialepistemic groups over others 11 1719 this situation translates into less priority being placed on the knowledge and perspectives of certain groups and what is of pronounced interest and consequence to them in addition to affording less credibility to the knowledge they hold 20 21 22 23 24 decoloniality is a movement focused on untangling the production of knowledge from a primarily euronorth americancentric lens by challenging the perceived universality of western knowledge and practices and the superiority of western institutions and paradigms of research 4 17 21 25 applying a decolonial approach to research funding can therefore be defined as a process to acknowledge understand and address euronorth americancentric norms and structures inherited from colonialism that continue to act as a barrier to nonwestern applicants during calls for proposals 4 17 20 26 lack of awareness and reflexivity on existing structural inequalities directly impacts resource allocation and ultimately knowledge production 12 15 27 research funders have reported lower number of successful proposals from global south applicants despite the burden of global health challenges being situated in the global south 4 the resulting asymmetries manifest as both higher access to financial resources for applicants based in the global north and the generation of inadequate incomplete or not fitforpurpose evidence to meet the needs of global south communities 4 16 18 28 there is growing pressure to drive substantive changes in funding practices and ensure that the definition of global health interventions is embedded in the broad social cultural economic and political contexts that underpin the issues being addressed 29 30 31 as an example in the humanitarian sector the interagency standing committee 2016 grand bargain pledged to get more means into the hands of people in need and improve the effectiveness and efficiency of humanitarian action 29 this paper outlines a decolonial approach to epistemic injustice analysis of research funding processes and practices the overall aim is to guide practitioners towards greater equity in research funding and partnership and inform the development of transformational processes the article is divided in four sections after defining the key principles of epistemic injustice the author will show how the design of a research call for proposals can favour foreigndominant epistemic groups over local groups then the author will discuss the influence of pose and gaze during a review process using the epistemic injustice framework created by bhakuni and abimbola 18 finally the author will introduce different approaches to address current asymmetries in the research funding architecture understanding the epistemic injustice of colonialism in global health research funding epistemology is a branch of philosophy that focuses on the nature origin and scope of knowledge it is concerned with the way in which knowledge is defined and validated the intended receiver of the knowledge produced and the standpoint from which knowledge is produced directly impact the way it is understood and creates opportunities for epistemic injustices 16 20 32 an epistemic wrong occurs when knowledge produced by a group is misinterpreted or undervalued by others epistemic groups 18 it manifests when 18 18 this paper uses bhakuni and abimbolas epistemic injustice framework and the concept of global coloniality centred around the coloniality of power knowledge and being to develop a threestep approach for investigating the presence of epistemic wrongs inherited from colonialism in global health research funding schemes 5 step 1 coloniality of power and analysing the aim of a call for research proposal practising decoloniality in research funding starts at the definition of the grant objectives analysing the aim of knowledge production systems can reveal our expected audience and our positionality and inform why some bmj global health groups remain mostly represented as bystanders in knowledge production 4 16 19 33 when a call for proposal bears the implicit assumptions that the primary purpose of knowledge production is to be used elsewhere it highlights an expectation that knowledge produced in the grants to be funded must be a universal one that is easily transferable 16 while publicprivate funders in euronorth american settings may not insist that knowledge produced to answer national public health concerns be transferable generalisable to population outside of the country and publishable in a peerreview journal those expectations are often maintained as an essential requirement to fund research conducted in the global south 16 the notion that knowledge that is contextualised is of limited value because it would not have impact in other settings is a common fallacy that stem from global north institutions distance from the issues being addressed and unchallenged colonial legacies that continue to present nonwestern communities as a singular group context 16 34 the resulting academic literature imply that large or multisite studies are inherently more valuable than small or single sites studies which leads to more support given to knowledge producers and systems that can claim to be universal 16 35 in reality health systems challenges are complex and require deeply local perspective to be responsive to local systems and realities 36 consequently what is robust for generating decontextualised generalisable knowledge may not be robust enough for generating contextualised and necessarily local knowledge 16 28 when the objective of a call for proposal is mostly focused on addressing gaps in the literature and finding universal truths it can clash with global south researchers focus on making sense of and altering the social structures that disadvantage communities in their context such a call for proposal therefore ultimately advantages global north applicants 3 16 step 2 coloniality of knowledge and acknowledging the influence of gaze and pose during the review process after submission a funding committee makes an informed decision on the outcome of proposals using technical reviewers feedback on the potential impact of the research findings the scientific robustness the feasibility the value for money and in certain cases the strength of a research consortium these criteria and the associated comments directly influence the committees decisions even though they are not completely responsible for the outcome while these criteria are often considered neutral and universal the way funders and reviewers define them and the background of the reviewers can have an impact on the review process especially when funders and reviewers associate euronorth americancentric ways of doingincluding structures methods processes and practicesas the only legitimate and scientific ways of producing knowledge and of knowing and understanding the world 3 5 15 the author will use bhakuni and abimbolas framework to present how the extent to which the review process accounts for and mitigates epistemological differences within the review criteria can systematically favour global north over global south applicants potential lines of analysis are organised in two categoriestestimonial injustice and interpretive injusticedrawing on examples from commonly known discussed and anticipated reviewer comments 18 testimonial injustice credibility deficit and excess testimonial injustice is defined as the act of prejudicially misrepresenting a knowers meanings or contribution to knowledge production it leads to the undervaluation of ones status and the overvaluation of others 18 global south groups have relatively few interpretive tools in circulation available to be used or recognised as equal to those designed by foreigndominant groups that have a monopoly on both knowledge production and development of interpretive tools 4 18 21 25 26 37 this situation directly impacts the credibility of global south epistemic groups if reviewers are not familiar with their interpretive tools and physically distant from their context 18 37 the following examples show how testimonial injustice during a reviewing process can discount the credibility of global south applicants as holders and producers of knowledge while increasing the credibility of global north applicants when the need to produce knowledge is based on what is globally known or not known rather than on what is locally known or not known a credibility deficit is imposed on local applicants it occurs when global south applicants are encouraged to justify a study or publication based on a gap in the literature as if the literature could be considered the sum of all available knowledge 16 it implies a presumption that knowledge on issues about which people have daytoday experience does not exist because it is not in the literature 38 when the value of a proposal to generate local knowledge is determined using what is known or deemed valuable elsewhere then local knowledge and needs are sidelined and credibility deficit is imposed on local knowers it occurs when the definition of novel knowledge is applied at the global level rather than the specific context it seems to imply that local expertise is only valued in comparison to evidence from elsewhere even though knowledge that is relevant in a given context may not be deemed new or of value elsewhere bmj global health it occurs when the assumptions used in the review process do not match local practices in global south contexts and are based on common global north structures and processes 39 testimonial injustice reduces the success rate of global south applicants lack of acknowledgement of what is often described as an expat bias will continue to systematically impact global south applicants success in calls for proposals 40 41 42 43 interpretive injustice interpretive marginalisation interpretive injustice is a form of epistemic injustice that prevents certain groups from being able to efficiently communicate knowledge to other perhaps more powerful groups 44 an interpretive marginalisation occurs when foreign dominant groups prejudicially impose or only recognise their interpretive tools as valid thus preventing other groups from sharing their experience of the world 18 when it manifests it contributes to the illusion that prejudicial low credibility judgements are epistemically justified 23 in the absence of available legitimised collective interpretive tools global north groups often assume that their own approach to knowledge production and sensemaking is universal 18 consequently the experiences of global south groups can be misunderstood because they do not fit concepts known to global north groups 26 the following examples show how interpretive injustice during a review process can discount the credibility of global south applicants as holders and producers of knowledge while increasing the credibility of global north applicants when the ability of local applicants to interpret their own reality for their own people is taken away interpretive marginalisation is imposed on them it occurs when decontextualised findings and needs are deemed more desirable in the selection criteria it demands that global south applicants proposal needs to be aligned with the needs of a global north audience and signals that only knowledge that claims to be universal is considered valuable when foreigndominant interpretive tools are expected to be used or imposed it leads to interpretive marginalisation it occurs when review criteria assume that global south applicants wouldshould justify conducting a study in their own setting similarly to how an applicant might justify conducting a study in a foreign settingfor example by using structured research or information available in the literature in practice the kind of insight available to global south applicants which then influence how they frame and justify their work is inherently different local interpretive tools ways of making sense of reality in data analysis ways of deciding whether a study is necessary or an intervention is appropriate are not allowed to flourish risk remaining marginalised and at worse disappearing 21 23 when a foreigndominant group places its understanding of local realities above local groups perspective interpretive marginalisation is imposed on local actors local practices and realities shape the way a project is proposed the physical proximity or distance of a reviewer can affect the reviewers interpretation of what is being proposed 16 28 global south applicants see the complexities of their setting and are compelled to engage with it given what they know and how they make sense of it 23 25 whereas global north applicants see from afar and are prone to simplify complex realities in ways that global south applicants tend not to 16 26 global south applicants are more likely to go for methods and approaches that allow them to make sense of the full complexity of their setting system or reality 17 28 interpretative marginalisation reduces the success rate of global south applicants and can lead to epistemic violence and epistemicide instead of the stated social transformation when global south applicants are denied the opportunity to use approaches that challenge euronorth americancentric research paradigms 5 21 step 3 coloniality of being and addressing asymmetries in global health research funding this analysis of calls for proposals and review processes from a decolonial perspective highlighted the ways in which the project definition and the pose and gaze of the reviewers can legitimise the inferiority of global south applicants and influence their success rate compared with global north applicants due to entrenched assumptions and expectations in the field 18 20 in reality despite calls for localisation stated commitment to decolonise research funding and the added logistical constrains created by covid19related restrictions research funders expectations seem to remain strongly centred around euronorth americancentric processes structures practices and norms 21 for example there is a tension in the way lived experience and contextual understanding is valued relative to training and institutional affiliation consequently applicants from or who trained in the global north are often implicitly afforded credibility excess due to their proximity to euronorth american practices 18 27 meanwhile one can argue that global south applicants timeefforts ratio during proposal writing is systematically underestimated as it is unclear whether funders take cognizance of the numerous logistical constraints including poor internet connection unpaid labour limited electricity limited access to academic journals and libraries etc 45 46 as long as commonly used evaluation criteria remain perceived as neutral their colonial epistemic foundations will continue to legitimise existing inequalities and oral histories or other forms of local knowledge may not be citable but if the information does not exist in academic literature it does not mean that it doesnt exist or it is weaker when the bulk of the academic knowledge is written by and from the perspective of the global north the exclusion of that knowledge can be intentional and reflect a different perspective and understanding of the local challenges funders mayinclude funding for rapid scoping research to support the generation of evidence create tools or invite global south actors to create tools to formally introduce their knowledge or acknowledge the experience of local actors rather than assume that what is not in western academic literature does not exist or is not valid a statement of why western academic research was not used or a rationale for the inclusion of only western academic evidence may also be included how is the rationale for the study being assessed recognising who is driving the need for the study is key when objectives are defined from the global north with little inputs from local communities the problem definition inherently favours global north applicants funders should aim to align their study rationale with national or regional research priority over international agenda feasibility does the analysis of the proposal consider the dynamic nature of global south context and institutional differences time and resources to write proposal are often scarce and logistical constraints including lower access to academic journals can negatively impact the final output funders should consider having different timelines for submission between global north and global south applicants and offering temporary access to key academic journals during the application process for equity reasons to support global south applicants in their academic evidence assessments how is the ability of the local team to deliver on the activities proposed being evaluated a deeper understanding of local context and needs often lead to more complex proposals limited institutional funding in the global south can act as an incentive for local knowers to try to conduct multiple activities in one research proposal rather than being an indicator of unrealistic planning funders should acknowledge these differences between global north and global south applicants building from experience of global north applications in the global north the presence of global south experts in the design of a call for proposal could allow funders to anticipate these situations value for money bmj global health hinder the evolution of nonwestern epistemic groups with the risk of epistemicides 45 4749 redefining evaluation criteria towards knowledge equity rather than hampering the production of contextualised knowledge existing inequalities should be used as opportunities to design innovative and equitable processes to reduce funding access gap 45 46 50 to do so research funders need to move away from unidimensional diversity and equity criteria that are often focused on geography alone and instead systematically account for common biases and ethnocentric tendencies during the proposal review process of international grant schemes 51 table 1 presents key questions and considerations that highlight how knowledge equity objectives can be attained by adjusting for epistemological colonisation power dynamics positionality and logistical barriers 22 28 35 47 49 51 for instance lower access to institutional funding in the global south might results in lower experience managing large grants while this is often an important criterion it can be addressed by providing a grant management training or inviting global south applicants to include one in the proposal similarly prioritising lived experience requires research funders to place greater value onoftenunpaid community work experience and balance potential technical skills gap with inviting global south applicants to include nationalregionalinternational training that would be complementary to their project and their professional development 45 50 funders should consider asking reviewers to attach a reflexivity statement to their comments to highlight how they accounted for their gaze and positionality when reviewing the applications 52 further including local civil society organisations in the definition of the call for proposal and the review process should also be considered to ensure that applications meet the needs of the communities aligning pose and gaze towards local knowers and fostering knowledge plurality epistemic injustices are also facilitated by the current disconnect between the pose and gaze of funders reviewers and local researchers 18 as demonstrated by our analysis in the absence of clear commitments to epistemic diversity actors positionality and interests can influence the outcome of a proposal review 4 19 22 26 37 to reduce epistemic wrongs actors pose and gaze should be perfectly aligned when actors from global north groups or applicants from the global south legitimise a single knowledge framework they impose epistemic injustice on other groups while also omitting to consider the possibility that euronorth americancentric interpretive tools can be rigid imperfect and inappropriate especially regarding the experiences of those in the global south 4 16 19 20 26 it also raises questions around the ethics of analysing work conducted in the global south with a dominant euronorth americancentric framework rather than prioritising the voices of experts who use local approaches or have lived experience 4 bmj global health supporting the production of the knowledge needed to accurately understand global south issues craft appropriate interventions or design projects that are responsive to global south applicants culture context and needs requires research funders and global south applicants to show clear commitments to the inclusion of diverse perspectives accounts and ways of thinking and doing through practical transformational change 4 6 21 it starts with being transparent about the grant objectives by clearly defining the preferred epistemic frameworks and the intended audience and receiver of the knowledge to be produced in practice research funders should increase opportunities for global south applicants to develop alternative interpretive tools by allowing them to either adapt euronorth americancentric tools to their context use existing but marginalised tools or develop and disseminate novel contextualised methods to reach equity goals funding scheme guidelines and reviewers need to embody and acknowledge past and ongoing asymmetries and promote the coexistence of different research paradigms that reflect local needs rather than outsiders perspectives 4 15 17 20 conclusion while proposal definition and reviewing processes may differ across funders the primary objective of this practice paper was to challenge euronorth americancentric perspective and provide guidance to address the impact of global coloniality on epistemic diversity the current research funding architecture is skewed towards global north applicants limited analyses are conducted to better understand this phenomenon redressing current asymmetries will require deliberate analysis to identify existing unjust defaults and assumptions the lack of understanding of the ways in which euronorth americancentric epistemic domination hinders the success of global south epistemic groups applications legitimises funding asymmetries and the exclusion of local voices to address local challenges 6 8 10 49 this article presents a decolonial approach to analysing global health research funding processes and practices this should inform novel perspectives to funding prioritisation that enable funders to move from thinking about how to make international funding more accessible to global south actors to exploring ideas around the development of appropriate decentralised and locally led funding mechanisms that increase the success rate of global south applicants in the future these reflections should also be taken into consideration by global south funders twitter emilie s koum besson emilieskb

epistemic injustice is a growing area of study for researchers and practitioners working in the field of global health theoretical development and empirical research on epistemic injustice are crucial for providing more nuanced understandings of the mechanisms and structures leading to the exclusion of local and marginalised groups in research and other knowledge practices explicit analysis of the potential role of epistemic injustice in policies and practices is currently limited with the absence of methodological starting points this paper aims to fill this gap in the literature by providing a guide for individuals involved in the design and review of funding schemes wishing to conduct epistemic injustice analysis of their processes using a decolonial lens placing contemporary concerns in a wider historical political and social context and building from the intertwined issues of coloniality of power coloniality of knowledge and coloniality of being that systematically exclude nonwestern epistemic groups this practice paper presents a threestep decolonial approach for understanding the role and impact of epistemic injustices in global health research funding it starts with an understanding of how power operates in setting the aim of a call for research proposals then the influence of pose and gaze in the review process is analysed to highlight the presence of epistemological colonisation before discussing methods to address the current funding asymmetries by supporting new ways of being and doing focused on knowledge plurality expanding research on how epistemic wrongs manifest in global health funding practices will generate key insights needed to address underlying drivers of inequities within global health project conception and delivery

introduction mathematical modeling of infectious processes is not recent having been used since the late 17th century to understand the dynamics of contagion and to support control and mitigation strategies however the use of frequency of social contacts in these models even today is not usually present this is largely explained by the lack of adequate estimates that reflect the reality of contacts in each population under study recent advances in epidemiological data collection have shown that the predictive and explanatory power of models is enhanced through the quantification of social contacts in epidemiological studies it is common to use systems of differential equations called compartmental models which includes the sir model the construction of these traditional epidemiological models requires the estimation of certain parameters of the system to adequately capture the dynamics of a disease in a population one of these parameters is the daily contagion rate which indicates how many secondary cases an infectious individual generates per day in a susceptible population and measures the rate of interaction between the susceptible and infected compartments of the model usually when estimating this rate the contexts in which the contacts are taking place are not measured1 using the assumption that the parameter is the same or converges towards this in all population subgroups or social contexts in which contacts occur in this regard its possible to treat the case of groups of different age as compartments in a sir like model modifying the estimated daily contagion rate to construct an age specific rate using the product between the rate of social contacts and the rate of contagion of the pathogen given the occurrence of contact some examples of the use of contact rates for compartmental epidemiological models are present in the work of chin et al and prem et al the contact rate understood as the average number of daily contacts of a population segment is known to be a function of both individual attributes and the environment in which the contacts are made in a pandemic scenario the promotion of nonpharmacological actions such as restrictions on the function of economic activities to promote greater social distancing requires an understanding of how contacts develop a sine qua non condition for the construction of reliable epidemiological scenarios and the evaluation of public policies the aim of this article is to present the significance of contact rates as a vital instrumental measure for epidemiological analysis to this end we present the general aspects of designing a contact data collection survey and then demonstrate how epidemiologically relevant contact rates can be used to improve traditional epidemiological models furthermore we present an analysis of the sociodemographic constraints of epidemiologically relevant contact rates these were obtained through field research carried out in a sector of the city of belo horizonte in june 2021 the contact rates collected also made it possible to simulate the dynamics of covid19 through the parameterization of a sir model firstly the paper describes the methodological field on epidemiological social surveys that aim to collect social contact rates highlighting the main approaches with their challenges and limitations secondly it presents the application of the former methodology in the universe of a slum community in belo horizonte brazil including sample size strategy for data collection and poststratification procedures thirdly we present the statistics describing the social contact rates collected fourthly aiming to test the heuristic power of social contact rates we include a comparison of two sir models one informed with parameters that consider the social contact rates observed and another one using social contact rates projected for brazil in international studies fifthly via a loglin model we explore social determinants of social contact rate considering an epidemiological perspective a proxy variable density of cliques2 was constructed to operationalize the social contact rate as a dependent variable finally as for practical recommendations we present the advantages of informing sir models with social contact rates just like the identification of some relevant determinants of social contacts development of survey methodology on social contacts the first largescale quantitative survey was carried out in 2008 on contact patterns relevant to respiratory and closecontact infections the study improving public health policy in europe through the modeling and economic evaluation of interventions for the control of infectious diseases involved 7290 people from eight european countries and used the epidemiological diary to record participants contacts in one day providing data on different age groups and different interaction environments such as school home work among others other smallerscale research has explored patterns of social interaction to understand the transmission of infectious diseases an example was conducted in the province of san marcos in the northern highlands of peru involving rural communities another study carried out called bbc pandemic was an innovative research experiment conducted through the pandemic app specially created to identify the human networks and behaviors that spread infectious diseases their data were used by researchers at the university of cambridge and the london school of hygiene and tropical medicine to build a map of social interactions in the uk recently chin et al studied the contribution of age groups to the dynamics of sarscov 2 in the united states to this end they performed a longitudinal study with sixwave data from the berkeley interpersonal contact survey they worked with social contact information collected between march 2020 and february 2021 in six metropolitan areas in the united states other studies regarding the action of subjects during a pandemic involve the measurement of mobility during the covid19 related to the dynamics of the subjects on spatial structures whereas in this case we are interested in the patterns of contacts especially the frequency of contacts between individuals belonging to different age groups however the structures of the patterns of mobility describe the dynamics of the epidemic on a mesoscopic scale whereas with the contact process we see the phenomenon at the microscopic scale the former approach has been preferred in several studies one suggested by the anonymous referee which uses google covid19 community mobility data all these studies have contributed to filling the gap in the production of empirical data about social contacts relevant for modeling the dynamics of infectious disease transmission in the same direction the present work a result of the research covid19 epidemiological model that incorporates structures of social contacts seeks to advance in the field of social contact research and includes the main recommendations pointed out by hoang et al regarding sampling instruments and data collection methods especially with the elaboration of a complex sample design taking into account on the one hand the relevant sociodemographic parameters and on the other hand the structural parameters of an unobserved network of contacts sampling design and data collection data collection for the estimation of social contacts we implemented a survey in an impoverished sector of belo horizonte capital of one the largest federated states of brazil located in the centersouth region of the city the aglomerado da serra comprises a contiguous space of eight villages located on the slopes of the serra do curral an old urban occupation with a complex environmental degradation situation it is an occupied area on the fringes of public planning with a lowincome population in which the public power recognizes the need to organize the occupation through housing programs urbanization interventions and land regularization actions this population was chosen with the aim of observing the rates of social contact in a high vulnerability area in this region with a high population density people share reduced housing units rendering social distancing impractical in addition many houses present characteristics of precariousness and insalubrity such as lack of adequate ventilation poor sunlight and excess humidity these factors increase housing insalubrity and reflect on peoples health especially children and the elderly the sample size calculation of the survey considered sociodemographic and network structure parameters which due to network sampling resulted in a larger sample size than would be necessary for a conventional survey this presented several challenges firstly a study on social contact rates relevant for the spread of infectious diseases in a brazilian slum higgins sss et al r bras est pop v40 120 e0241 2023 the unavailability of an updated demographic census as the last one available dates from 2010 according to this the total population of aglomerado da serra was 38405 inhabitants who lived in 10900 households secondly we estimate network parameters so we assume as a population target a large but unobserved network for this universe of people to calculate the minimum size of nodes to get credible estimates for the network we assume as a sampling target a complete but unobserved network for this universe of people to do so we simulated 500 networks of 5000 and 10000 nodes using a test power of 8 and a significance level of 95 which allowed us to estimate the average number of cliques of sizes 2 3 4 and 5 giving us a sample size of at least 1000 nodes we use the ergm and graphlets packages built and made available in the r package both are part of the statistical network analysis library of r given the total number of individuals in the sample and the plausible frequency of cliques we designed a threestep stratified sample at first the sample was stratified following a proportional estimate of households according to the neighborhood where they are located and the number of residents in a second stage the households were randomly selected in each neighborhood according to a previously established systematic agenda in the third stage a respondent was drawn at random from each household this provided a unit of information collection which we call the observation unit it consists of the individual drawn within the household as well as several units of analysis that feed the explanatory models some at the individual level such as the contact rates aggregated by age groups and others at the collective level such as the size of the household measured in number of inhabitants and the social circles where relationships are held inside and outside the home based on a confidence level of 95 and a sampling error of 2 we determined a first sample of households of size 1000 to apply the instrument to correct the demographic census lag and the availability bias at the time of collection we returned to the field and collected a second sample following the stratified design of the first survey with 450 households with this we subsequently calibrated the data taking into account two basic variables sex and age group to obtain the values of the standard deviation and confidence intervals for the estimators a simple resampling procedure of 100 copies of the original database was applied with replacement plus a column with the calibrated weights for each resampled observation an epidemiological diary adapted from the instrument used by polymod in the united kingdom was applied due to the application time and costs the interview method was chosen a selfadministered questionnaire along several days in a week as applied in europe would require a great followup effort given the social conditions of the target population while at the same time potentially compromise the response rate necessary to attain the optimal sample size the questionnaire was designed in three blocks of questions the first one identified the number of people living in the house and their sex with this information the respondent was drawn by lot then it was decided if the drawn respondent was qualified to give the information asking if in the last twentyfour hours heshe talked face to face or had any physical contact with one or more people at the same time the second one asked about sociodemographic characteristics of respondents the third inquired in detail about the social circle where the contacts took place in house outside neighborhood church work school the number of people grouped together which for the purpose of the analysis we call cliques the sex and age of the alteri the duration the frequency among other characteristics 3 this research considered qualified respondents as adults aged 18 or over as well as children and young people who gave their consent under the guidance of a responsible adult regarding the consent that the epidemiological diary assumes the study was approved by the research ethics committee of the federal university of minas gerais results sociodemographic data it was found that the adult population predominates in aglomerado da serra in the range of 20 to 59 years with a significant presence of children and adolescents from 0 to 14 years and the elderly which comprise the socalled dependent population the presence of young people between 15 and 19 years old is not very expressive as expected for the brazilian case the vast majority of the population declared to identify as black and brown this is due to the fact that poverty affects mainly these population segments in aglomerado da serra the data indicate the greater presence of households with up to 3 residents within the limit of the average size of households projected for brazil in 2020 30 residents another 198 of households have up to 4 people and only 147 have more than 4 people confirming the trend towards smaller households as a result of demographic changes that have taken place in recent decades household income in aglomerado da serra is low 760 of households have a monthly family income of up to 2 minimum wages and of these almost 390 of households live with up to 1 minimum wage however only 369 of households received emergency aid in 2021 confirming the limited scope of social protection measures to reduce impact in times of health crisis a study on social contact rates relevant for the spread of infectious diseases in a brazilian slum higgins sss et al 401234567891011121314151617181920e02412023 social contact rate and their characteristics from this sample it was possible to identify the social contact rate by age group as well as the distribution of these contacts by meeting place and their duration it was found that children and adolescents from 0 to 14 years old reported a higher average of contacts compared to other age groups young people and adults between 20 and 34 years old were the second group to report more contacts whose average also exceeds that of the other age groups the age group of 60 years and over showed the lowest rate r bras est pop v as for contacts through social circles 623 of the reported contacts took place at home followed by contacts made in the neighborhood 193 contacts in other circles were greatly reduced only 082 of contacts were made in school environments the data are consistent with the period in which the research was conducted when belo horizonte had measures to restrict circulation and ban school attendance the data also showed differences in the duration of each contact by social circles contacts were reported to last longer at home at work and leisure shorter contacts occurred mainly in commerceservices and neighborhood it is important to note that in addition to the average number of reported contacts location and duration the dynamics of contagion also depend on the interaction between different age groups more specifically on knowing which age groups interact with each other which corresponds to the rates of transmission intraand interband contacts when we see the contact process as a poisson process then the contact rate of the process is estimated by the average number of contacts the contact rates or average number of contacts between age groups can be seen in the figure 1 source research data note the matrix is read in the direction of the line to the column for example if we want to know the observed rate of contacts between people aged 014 and those aged 3559 we look for the respective vertex which indicates it is 099 contacts per person per day in other words on average each child or adolescent reported one contact with an adult in the age group in question we then looked at the line for the 35 to 59 age group to see how many contacts they indicated with a child or adolescent and found that it was 05 on average the rates do not match because within the sample the alteri do not necessarily coincide with those indicating this makes it necessary to symmetrize the matrix using the arithmetic mean to include it in the sir models sir model by ages using contact rates to simulate pandemic behavior incorporating the effect of the structure of social contacts a sir epidemiological compartment model was applied susceptible infected and recovered by age five age groups were used corresponding to individuals with ages in the ranges in complete years from 0 to 14 15 to 19 20 to 34 35 to 59 and 60 years or older this set of intervals was obtained by grouping adjacent age groups in the contact rate matrix until it was reduced to five age groups the system of differential equations describing the evolution of the number of individuals in each compartment in the aged sir model is j i i j i j j i t ds t s t t dt n β σ j i i j i j i j i t di t s t t i t dt n y β σ i i dr t i t dt y here β is the infection rate and 1γ is the recovery rate s i the number of susceptibles i i the number of infected e r i the number of recovered at time t if n is the total population being considered then s i l i r i nsince the formulas consider age groups the subscripts i and j designate the ith and jth age group respectively thus t ij means the contact rate between the i age group and the j age group the covid19 infection rate at the time of the survey was β 0 005 and for the calibration of the model we adjusted this rate taking into account the average of the contacts which is also the average of rates of the matrix of contact rates using the estimated matrix for brazil in polymod we obtain t and then to simulate the results in belo horizonte we use the estimated contact matrix for aglomerado da serra obtaining t β β this value corrects the effect of contacts in estimating the rate β 0 the recovery rate 1γ 17 corresponds to the inverse of the average recovery time for covid19 three values were used for the rates corresponding to the estimated average rates and the upper and lower limits of the confidence intervals for the rates rate matrices were symmetrized to reduce bias 4 the system of equations implementation was done using the epimodel package from r to assess the consistency of the model proposed here two simulations were carried out using epidemiological parameters of the reference week of data collection as reference one using the adjusted contact rate data for brazil derived from the polymod and the other with the empirical rates of aglomerado da serrabh both with a projection horizon of one week 5 the results are shown in figure 2 where we plot in a graph the simulated and observed proportions of infected by age group 4 the nonsymmetry present on contact matrices was observed on several studies and evaluated recently on the work by hamilton this study compared symmetric versus nonsymmetric contact matrices via simulation of sir type models using polymod estimates and comparing also with observed data according to the study models with nonsymmetric matrices underestimated the basic reproduction number had delayed timing of peak infection incidence and underestimated the magnitude of peak infection incidence nonsymmetric matrices also influenced cumulative infections observed per age group and the projected impact of agespecific vaccination strategies 5 prem et al performs sophisticated demographic projection work to find social contact rates by age group in three social circles in 152 countries covering 959 of the worlds population they use three data sources polymod demographic and health survey and national data from different countries the projection process starts with a hierarchical bayesian model that estimates contact rates by age and social circles in each of the eight european countries covered by polymod and for the whole set this first exercise allows for the construction of three matrices with contact rates by age groups one for each social circle subsequently the contact rates of each matrix are projected for the countries that were not part of polymod considering the following demographic parameters available in national databases population profile by age groups labor force participation studentteacher ratio school enrollment rates the estimates produced by the model proposed in this research from the survey of contact rates by age groups offer a better approximation between predictions and observations than the approximation that uses estimated rates of the polymod in both simulations the average contact rates for brazil from polymod were used as a correction factor contact rates and their conditions a clique approach next we present the main determinants of contact rates collected in aglomerado da serra since this is the most epidemiologically relevant data from the perspective of contact structures it is pertinent to explore it from the perspective of some sociodemographic factors that were raised at the time of collection first it should be explained that we approach contact numbers using a proxy variable the cliques or groupings declared by respondents each respondent was asked about the contacts he had in the last 24 hours according to the specific place where they happened but also asked to indicate how many other people they had been in contact with simultaneously as well as the age and sex of these alteri given that we conducted a basic sir model on diseases that are transmitted persontoperson such as respiratory diseases it is useful to understand which covariates are associated with these agglomerations of variable size where the contagions happen to this end we must highlight that we chose to name the variable of interest as clique density due to the sociometric concept that defines a clique as a group where all its members are adjacent to each other that is where all are in contact with each other we assume that a clique is a cluster with k contacts where k is the number of vertices which in this case corresponds to number of people in contact respondents declared cliques with a minimum size of 2 and a maximum of 11 people6 at this point two clarifications are necessary first we use the concept of clique in the mathematicalformal sense that it has in graph theory ie a grouping where all nodes are adjacent to each other it does not have the substantive sense of a cohesive group by a common identity recognized by the members secondly the contact rate we have discussed is nothing but an average of the relationships considering all the cliques in which a person takes part for example if a respondent declared that in the last twentyfour hours he or she was grouped into three cliques of size 3 5 and 7 respectively then his or her average number of contacts is σ 2 σk which corresponds to 16 the frequency distribution of the clique size variable presents a concentration in the smaller size cliques only contacts declared in the first contact situation were used for the purpose of this analysis as the memory bias delivered a decreasing valid data frequency 994 in the first situation 305 in the second situation and 25 in the third situation since the number of contacts in the cliques of k size follows a geometric progression the natural logarithm of this progression was used as a scale for our independent variable clique density 7 in this way we tested using a loglin model the associations between the response variable and its determinants with explanatory power we interrogated our data using two loglin models following the expression used by gujarati and porter the general equation is lny β 0 βx 1 r in both models the response variable is clique density we use two treatment criteria social circle and age group to see how a set of determinants impact the fact that an individual clusters in cliques with different numbers of social contacts these are the main independent variables both variables were transformed from categorical into a set of binary ones where each category corresponds to a new variable in the first model only the social circle home was included while the last age group was used as the omitted reference category in the second model home is the omitted reference category keeping all other variables including age group in the same way we should remember that at the time of our data collection the brazilian federal government had already implemented economic aid for lowincome families to allow them to subsist during the social isolation measures the models assume the point of view of the interviewee members and on the other hand of the orientation of the relationship the latter means that we can consider or not the direction of the relationship for example if two people are married their relationship is not oriented it does not make sense to say that a is married to b but that b is not married to a in the case of contagious relationships we must consider that a can infect b but that b does not necessarily infect a or vice versa if the nonorientation perspective of the relationship is adopted the number of contacts will be k2 but if orientation is adopted as we have done in this article the number of contacts will be k 7 considering k as the number of contacts in the clique of size k we have a variable with a geometric progression and with a nonlinear distribution that is in a clique of size 3 we have 6 contacts if the size is 4 we have 12 contacts and so on up a clique of size 11 which has 110 contacts since the scale of the dependent variable is the natural logarithm the coefficients are percentage proportions of how much each explanatory variable increases the response higgins sss et al est pop v40 120 e0241 2023 variable in the first model where the contact situation is the house one more resident in the household increases the clique size by 284 gender has no significant effect the contact situation within the household reduces the clique density by 60 in the opposite case when we invert the binarization recording the situation outside the home there is a 60 increase in clique density neither the emergency aid nor the fact of using public transport had significant effects children aged 0 to 14 and young adults aged 20 to 34 had 41 and 39 respectively more contacts in the clique group than people aged 60 and over the age groups from 15 to 19 and 35 to 59 did not present a significant coefficient at the conventional value of 5 r bras on the second model there are several contact situations that correspond to forms of socialization that take place outside the home the number of residents maintains its aggregation effect on clique density gender emergency aid and public transport like in the first model do not present a statistically significant effect among the contact situations two were not significant namely commerce and school it is important to remember that on the date of data collection the belo horizonte school system had suspended activities due to the pandemic it is possible that the contacts declared at school correspond to occasional visits to pick up some study material to work on at home the other contact locations show important impacts on the size of the clicks compared to the home groupings at church generate 186 more contacts than those at home followed by leisure workplace and neighborhood the only age groups with predictive power over clique size correspond to the same age groups as in the first model children and young adults taken together the previous results demonstrate that the size of households in terms of number of residents is an important determinant in the formation of epidemiologically relevant clusters however the formation of cliques within the household does not mean that they took place in the respondents household in fact crosstable analyses show only a 65 correspondence between the number of residents and the size of the declared cliques a percentage obtained by dividing the total diagonal values between values 2 and 10 for both the number of households and for the size of cliques by the total of reported cliques in the case of cliques located outside the home the correspondence is only 10 the formation of intrahousehold cliques appears as a phenomenon formed by children and caregiversparents between 20 and 34 years old something to be expected when the school system was closed figure 3 explains the distribution of clique size according to age groups and contact location in the latter greater variability in the clique size can be observed in the situation outside the home as evidenced by the interquartile range and the amplitude of the clique size this is consistent with the results of the second model which showed how church leisure work and neighborhood are spaces that encourage people to meet this is something we can expect if people are outside the more controlled environment of the home physical spaces contain vital socialization circles for people and we assume a margin of randomness in social encounters discussion following the current pandemic triggered by sars cov 2 a wide range of work has undertaken the challenge of monitoring the expanding course of the pandemic some global initiatives turned to technological devices to identify the mobility of human populations almost in real time the google platform provided data on the mobility of its users by making use of smartphones geolocation to this end the google covid19 community mobility report was made available with data from 131 countries this initiative with specific research purposes ended in 20221015 oliveira et al used the gccmr data in ten latin american countries to associate mobility indexes with the covid19 stringency index from oxford without undervaluing the advantages of the previous analysis strategy it is important to point out several limitations imposed by the baseline data when working with conventional sir models as the authors themselves rightly acknowledge the mobility data provided by gccmr in various social circles constitute a digital proxy for facetoface human interactions the attribution of an individual to a place depends on whether the user has activated their phones location history furthermore google reserves the right to provide data about social circles where there is low frequency of visits as this may compromise the anonymity of the information however the two most serious limitations marking a substantial difference with our strategy are the absence of relational information between human beings and the no disaggregation of age groups we know nothing about physical contacts nor about one of the most important behavioral determinants age in summary having to refine parameters in mathematical sir models imposes the rigorous collection of primary data through surveys that provide social contact rates when comparing our work with other studies inspired by the polymod strategy and carried out in developing countries we found some important convergences and differences johnstonerobertson et al conducted a survey of social contacts in a township of just under 20 thousand inhabitants near cape town a rural population with a welldefined census this allowed for a random sampling of individuals considering age groups the results accurately demonstrated that the young population between 5 and 19 years of age was at the highest risk of infection by respiratory diseases endemic to that community thus confirming that by disaggregating the data by age groups an epidemiologically relevant determinant of social behavior is identified in turn the work of grijalba et al highlights the difficulties of collecting data on social contacts in several population universes at the same time wanting to cover 54 rural communities in peru they had to give up probabilistic sampling to settle for convenience samples in which the members of at least two households per community were interviewed costs and logistics make probability sampling plans less feasible furthermore when estimating infection rates of pathogens the incorporation of social context is extremely important to determine the evolution of the epidemic especially in the case of airborne viruses such as sars as already pointed out by other research factors such as household size and age are intrinsically linked to sarslike virus infection rates and these factors are linked to socioeconomic conditions that need to be evaluated in situ to have a more realistic determination of what infection rates mean in turn the exploration of the sociodemographic conditions of contact rates in this study through two loglin models showed that research of this type is also useful for the determination of covariates associated with the formation of small agglomerations that result in epidemiologically relevant contacts in this case we saw how the demographic size of the household is a fundamental covariate when planning mitigation or epidemic control scenarios as it increases the density of groups between people understanding social circles is important to understanding how forms of socialization increase the risk of contagion in popular communities places of worship neighborhoods and places of leisure among others are favorable scenarios for forms of socialization that substantially increase contact rates the low coverage of emergency assistance provided by the brazilian federal government was not associated with the reduction of social contacts when we interpret this finding together with the statistically significant effect of the work circle we can infer that government aid in the case of the sars cov 2 pandemic in urban areas was useful for the survival of families and less effective in pandemic control families from popular sectors that survive on up to two minimum wages have no other option than to seek their livelihood in a job market with a high rate of informality beyond methodological divergences this finding has been reinforced by research that digitally captured social mobility indexes this study also indicated as already demonstrated in specialized literature that compartmental epidemiological models combined with social contact rates have greater ability to describe epidemiological dynamics because they incorporate interaction between ages in this regard we observed the social contact rates collected in aglomerado da serra provided a better fit in the sir model relative to the demographic projection made by prem for brazil therefore this study reveals the importance of investing in epidemiological diary research that provides information on the covariates associated with the formation of epidemiologically relevant clusters and informs compartmental models better improving their fit and allowing projecting the effect of mitigation processes such as vaccines or isolation in different age groups which increases the relevance of their use conclusions the crisis triggered by sars cov 2 was a significant opportunity to adapt the technique of epidemiological dairy in the context of health surveillance in brazil this study demonstrates how the empirical in situ estimation of social contact rates improves the descriptive power of compartmental models widely used in epidemiology in general these models work at average levels of contact rates disregarding the heterogeneity of contacts between social groups in this work we estimated the rate of social contact by age and the results are more sensitive to the reality of the pandemic the technique of epidemiological diaries adapted as an interview makes it possible to gather information on rates of social contacts as well as on factors of the sociodemographic structure that affect the rates of social contacts with greater clarity on one hand about the morphological factors of social life such as the demographic size of households and age composition of the social universe and on the other hand about socialization circles we can broaden our comprehension of the infectious processes in terms of the different structures of interaction between human beings resumo um estudo sobre as taxas de contatos sociais relevantes para a difusão de doenças infecciosas em um aglomerado brasileiro inspirado no estudo polymod foi realizado em junho de 2021 um survey epidemiológico num dos setores de maior densidade populacional e vulnerabilidade social de belo horizonte uma amostra de 1000 domicílios permitiu identificar num período de 24 horas as taxas de contatos sociais por faixas etárias o tamanho e a frequência de cliques do qual participou o respondente assim como outros fatores sociodemográficos associados os dados foram analisados em duas fases na primeira foram comparados os resultados entre dois modelos sir que simularam um processo pandêmico de oito dias um incluiu parâmetros ajustados a partir das taxas de contatos observadas o outro operou com parâmetros ajustados a partir de taxas projetadas para o brasil na segunda fase mediante uma regressão loglin modelamos os principais determinantes sociais das taxas de contato utilizando o adensamento de cliques como uma variável proxy a análise dos dados mostrou que o tamanho da família a idade e os círculos sociais são as principais covariáveis que influenciam a formação dos cliques também demonstrou que modelos epidemiológicos compartimentais combinados com taxas de contato social têm melhor capacidade de descrever a dinâmica epidemiológica fornecendo uma melhor base para medidas de mitigação e controle de doenças que causam síndromes respiratórias agudas palavraschave survey epidemiológico polymod taxa de contato social cliques resumen un estudio sobre las tasas de contactos sociales relevantes para la propagación de enfermedades infecciosas en un barrio popular del brasil con inspiración en el estudio polymod se hizo una encuesta epidemiológica en junio de 2021 en uno de los sectores más densamente poblados y socialmente vulnerables de belo horizonte una muestra de mil hogares permitió identificar en un período de 24 horas el tamaño y la frecuencia de los cliques en los que participó el encuestado las tasas de contactos sociales por grupos de edad así como otros factores sociodemográficos asociados los datos se analizaron en dos fases en la primera se compararon los resultados entre dos modelos sir que simularon un proceso pandémico de ocho días uno incluyó parámetros ajustados a partir de tasas de contacto observadas el otro operó con parámetros ajustados a partir de tasas proyectadas para brasil en la segunda mediante una regresión loglin se modelaron los principales determinantes sociales de las tasas de contacto utilizando la densificación de cliques como una variable proxy el análisis de los datos mostró que el tamaño de la familia la edad y los círculos sociales son las principales covariables que influyen en la formación de camarillas también demostró que los modelos epidemiológicos compartimentados combinados con tasas de contacto social son más capaces de describir la dinámica epidemiológica proporcionando una mejor base para las medidas de mitigación y control de las enfermedades causantes de síndromes respiratorios agudos palabras clave encuesta epidemiológica polymod tasa de contacto social cliques received for publication in 02122022 approved for publication in 19042023 about the authors

inspired by the polymod study an epidemiological survey was conducted in june 2021 in one of the most densely populated and socially vulnerable sectors of belo horizonte brazil a sample of 1000 individuals allowed us to identify within a 24hour period the rates of social contacts by age groups the size and frequency of clique in which respondents participated as well as other associated sociodemographic factors number of household residents location of contact use of public transportation among others data were analyzed in two phases in the first one results between two sir models that simulated an eightday pandemic process were compared one included parameters adjusted from observed contact rates the other operated with parameters adjusted from projected rates for brazil in the second phase by means of a loglin regression we modeled the main social determinants of contact rates using clique density as a proxy variable the data analysis showed that family size age and social circles are the main covariates influencing the formation of cliques it also demonstrated that compartmentalized epidemiological models combined with social contact rates have a better capacity to describe the epidemiological dynamics providing a better basis for mitigation and control measures for diseases that cause acute respiratory syndromes

introduction physical inactivity is increasing across europe threatening human health and costing the european economy over e80 billion per year raising the physical activity levels of the less active members of the population is a public health priority and promoting walking is potentially the most effective means of achieving this in part because it is low cost and even normal walking pace can be healthenhancing importantly natural environments appear to be locations which may be effective at encouraging healthenhancing bouts of walking survey research for instance suggests that individuals tend to spontaneously engage in longer episodes of physical activity including walking in natural rather than urban settings and thus expend more energy on visits to these environments while experimental research has demonstrated that people are more likely to conduct uninterrupted bouts of brisk walking in natural environments than in urban locations further walking in natural environments can heighten affective benefits of walking compared to walking in urban settings leading to a greater likelihood that the activity will be repeated combined these findings suggest that greater systematic efforts to promote walking in natural settings may play an important role in enhancing sustainable improvements in physical inactivity this is certainly the perspective of the uks national institute for health and care excellence which identified the need for public health professionals to collaborate with colleagues in countryside management and park services in promoting walking among inactive individuals importantly nice also specified that there was a need to ensure programmes are based on an understanding of factors influencing peoples behaviour such as their attitudes existing habits what motivates them and their barriers to change and develop walking programmes for adults who are not active enough based on an accepted theoretical framework for behaviour change in commenting on how these programmes should be promoted nice stated that programme directors should ensure programmes include communications strategies to publicize the available facilities and to motivate people to use them the aim of the current research was to investigate the extent to which a sample of brochures promoting specific walks in natural environments in england contain the kind of theoretically derived messages to motivate walking in natural settings that nice recommends in the uk brochures advertising recreational walking in natural environments are commonly produced by local authorities councils charities and tourism organisations and are aimed at both local residents and touristsvisitors although we recognize that such walking leaflets may not have been produced as health promotion materials per se it is nonetheless informative to investigate whether they already contain many of the techniques suggested by theory and whether such an investigation could provide insights into how future leaflets could be developed to include more theorybased techniques in line with nices recommendations to motivate people to undertake more walks in the future an examination of walking brochures in particular makes sense because written materials are a widely used medium for communicating persuasive messages and promoting behaviour change they have also been found to be among the most effective tools in promoting walking programmes nevertheless there is evidence that written materials advertising physical activity more generally are not always informed by behaviour change theory for instance one content analysis of 22 physical activity brochures identified a lack of messages relating to goalsetting planning and affective benefits of physical activity the omission of such messages may mean these materials only motivate active people and may deter inactive people from taking up physical activity which may be especially important in the case of walking a relatively simple and costeffective way to become less sedentary nevertheless to our knowledge no content analysis of persuasive messages in recreational walking brochures has yet been undertaken consequently our main task was to develop a relevant taxonomy of potentially persuasive message categories that could feasibly be contained within such brochures and then to identify their prevalence among a selected sample to do this we adapted a preexisting taxonomy developed for the analysis of health promotion materials our two main research questions were a can the content of recreational walking brochures be reliably categorized and b if so what persuasive messages tend to be included in recreational walking brochures methods specifically we used the content analysis approach to theoryspecified persuasive educational communication to inform the development of our coding taxonomy caatspec is an approach to quantitative content analysis of persuasive texts and can be used to outline messages used in health promotion materials it uses mutually exclusive coding categories to classify content and was suited to this study as recreational walking brochures are persuasive texts that promote a change in a healthrelated behaviour this is the first known application of caatspec to materials in which health promotion may not necessarily have been the primary aim sampling brochures were collected from july to december 2013 in the county of devon uk convenience sampling was employed sourcing brochures from councils holiday parks visitor information centres and supermarkets this involved visiting as many of these places as was feasible in three principal holiday destinations and one major city the following inclusion criteria were applied a the brochures existed in printed and digital form and advertized recreational walking in natural environments including mixtures of urban and natural environments and b brochures had to be available free of charge to ensure they could have the widest readership while convenience sampling results in an unrepresentative sample it is justified here as all possible printed recreational walking brochures in the county were difficult to obtain it would have been extremely labourintensive to have even attempted to do so and the current selection of brochures is still useful for generating hypotheses about the effectiveness of content in recreational walking brochures three conditions necessary for selecting convenience sampling for quantitative content analysis in total twentysix brochures were collected brochures had a range of 54 to 712 paragraphs and 524 to 17126 words they were associated with 29 different organisations and printed by nine different production companies two pages from a specific brochure are displayed in the supplementary materials for illustrative purposes taxonomy following initial readings message categories corresponding to specific messages included in the brochures were devised all categories were arranged under five superordinate headings which encompassed the key components of behaviour change in a variety of evidencebased theories namely providing information highlighting potential consequences and opportunities establishing normative beliefs promoting intentions and planning and enhancing selfefficacy in a previous application of caatspec the latter two superordinate headings were collapsed but are separated here to highlight their exclusivity in conceptions of behaviour change the final taxonomy had three further levels of specificity arranged hierarchically and can be viewed in figure 1 we attempted to categorize brochure text into message categories using established taxonomies of behaviour change techniques a taxonomy emerged where each category represented a distinct potentially persuasive message however categories warranted greater specificity than techniques defined in general taxonomies to take an example abraham and michie identified the general change technique provide information on consequences as derived from explanatory theories the authors defined the technique as information about the benefits and costs of action or inaction focusing on what will happen if the person doesdoes not perform the behaviour this technique was rendered domainspecific by michie and colleagues who identified the technique as comprising health social environmental and emotional consequences in the present study we further adapted the technique to better represent persuasive messages found in recreational walking brochures specifically consequences of recreational walking in the present taxonomy comprised health social environmental financial heritage aesthetic and recreational consequences in a similar way to previous applications of caatspec categories were created to classify pictures of people walking and graphics of maps listed below are details of categories under each superordinate from the finalized taxonomy the full coding manual can be viewed in the supplementary materials providing information category 1 reflected information on pa recommendations or the prevalence of pa or walking in a population categories 27 detailed characteristics of the route such as the terrain or distance categories 811 concerned amenities such as public transport or refreshments on the route highlighting potential consequences and opportunities categories 1217 concerned general consequences of pa or walking including financial environmental physical and mental health and social categories 1826 described opportunities on the advertised route such as heritage aesthetics social and recreation establishing normative beliefs categories 2734 outlined normative information about pa or walking or the consequences of these including expert recommendations on pa and financial environmental health and social consequences in a similar way to highlighting potential consequences and opportunities categories 3543 detailed normative information about opportunities related to walking the advertised route promoting intentions and planning categories 4447 prompted behaviours related to pa or walking including setting goals based on distances or times reducing barriers or prompting activity maintenance categories 4857 identified messages specific to the advertised route such as prompting goals based on distance attending to signage or managing the terrain enhancing selfefficacy following caatspec most categories under this superordinate were dichotomized as encouraging or guiding behaviour encouragement categories conveyed that behaviour was easy to execute and guidance categories instructed on how to execute behaviour categories 5868 related to building confidence for pa or walking in general and included guidance on reducing barriers to activity for example not knowing where to walk encouraging setting walking goals based on time or modelling walking pictorially categories 6987 related to building confidence for completing the advertised route and included guidance on maintaining recreational walking behaviours encouraging the use of appropriate equipment or guidance on direction taking as can be imagined this last category was likely to be central to recreational walking brochures coding procedures a pilot coding manual was tested by two coders but demonstrated insufficient reliability to improve the manual categories were added and deleted definitions were revised and coding procedures were modified with the revised manual and in accordance with previous research a linebyline coding procedure was utilized to facilitate intercoder reliability testing sentences acted as units of analysis and coders were instructed on how to detect semantic changes within and across sentences and how to code these categories were exclusive text could only be coded under one category the manual also provided guidance on distinguishing semantically similar categories for example some messages prompted behaviours whilst others provided guidance on the same behaviours eg category 53 refers to messages suggesting ways to deal with the terrain on the advertised route whereas category 79 refers to messages explicitly providing guidance on how to deal with these coders were instructed that any category prompting behaviour will refer to specific behaviour but any category guiding behaviour will inform them on how to execute that behaviour coding instructions can be seen in the supplementary materials coding a brochure took approximately 90 minutes reliability intercoder reliability was assessed using the ac1 statistic the prevalence of some categories was very small and ac1 adjusts reliability accordingly where alternatives would not the protocol for reliability testing was as follows two brochures were selected by the first author on the basis that they varied in style length and publisher thus potentially encompassing the broadest range of categories two coders would code the brochures linebyline as described above if reliability was established at all hierarchical levels testing would stop providing that individual categories demonstrated reasonable reliability too this generous alpha level was selected so that categories with only one agreed instance were judged reliable despite the lack of more instances to determine reliability at conventional alpha levels this is because coders selecting one piece of text and identifying it as the same category of a possible 87 was unlikely to be due to chance if any individual categories did not meet this criterion consensus would be sought using an independent coder and the category removed if agreements on disagreed instances were not reached if any level of the hierarchy demonstrated unsatisfactory reliability the manual would be revised and testing repeated with two further brochures if any individual categorys ac1 exceeded the alpha level or if there were no instances of a category found the category was deemed a potential category of persuasive message but with insufficient data to determine reliability analysis strategy to examine frequently employed persuasive messages only categories which appeared in more than three brochures were included in the main analysis categories which appeared in more than three brochures but had insufficient data to determine reliability in the testing phase were noted as requiring further reliability testing we examined frequencies and proportions of content firstly across and then within superordinate categories results reliability consult supplementary materials for reliability statistics 476 category instances were doublecoded coders agreed on the same categories for 363 of these satisfactory reliability was achieved at all levels of the hierarchy there were only 35 categories that contained enough instances to confirm reliability with a statistically significant ac1 value we believe this reflects the lack of diverse persuasive messages used in brochures and not inadequate sampling the number of additional categories for which reliability could have been established through doublecoding more brochures did not justify the labour involved in further linebyline doublecoding there were six categories that did not meet our reliability criteria all instances coded under these categories were discussed between the first and second author and categorisations agreed for all so no categories were removed afterwards 448 of the 476 category instances were agreed upon and the reliability of all levels of the hierarchy had improved significantly as a consequence of this resolution phase two further categories did not meet our reliability criteria in total these categories only comprised five disagreements so in line with previous content analyses decisions of the first author were accepted as they had the benefit of coding all brochures in the sample content analysis all percentages reported reflect subordinate categories which were included in more than three brochures in the sample using this criterion 33 of the original 87 categories formed a useful taxonomy of potentially persuasive messages frequently used in recreational walking brochures descriptive statistics for these 33 categories are displayed in table 1 the supplementary materials contain descriptive statistics for all categories of these 33 seven had insufficient data in reliability phase to determine reliability and another was category 53 which as discussed earlier did not meet the 0 6 ac1 threshold after the resolution phase interpretations on all of these categories should therefore be considered cautiously of the 25 with sufficient data in the reliability phase ac1s ranged from 069 to 100 so good reliability can be assumed for the rest of the categories included here there were 4800 instances of coded text within these 33 categories messages providing information accounted for 30 92 of all coded content messages highlighting consequences accounted for 2694 messages promoting intentions and planning accounted for 558 messages enhancing selfefficacy accounted for 3656 no categories pertaining to messages establishing normative beliefs appeared in more than 3 brochures messages providing information the most prevalent messages under this superordinate were those categorized as information about the overall course of the advertised route accounting for 2648 of all content which provided information all content refers to the percentage of all content which is accounted for by the category of superordinate refers to the percentage of superordinate content which is accounted for by the category and 819 of content overall this included summaries of where the route would take the reader eg this walk explores an inland section of the bude canal on the devoncornwall border or information on the location eg exmouth is a gateway town other widely used categories included information about public transport options related to the advertised route eg many of the trails have convenient parallel public transport routes bus or train information about the terrain of the advertised route eg mostly level and easy although there is one steep climb on an inclined plane and information about the distance of the advertised route eg a 13km8 mile circuit messages highlighting potential consequences and opportunities the most frequently occurring types of messages were those categorized as viewing historical points of interest as consequences of walking the advertised route accounting for 5128 of content which highlighted consequences and 1381 of content overall this was also the only category to appear in every brochure this incorporated descriptions of geology eg celebrating 95 miles of internationally important rocks displaying 185 million years of the earths history the jurassic coast is a geological walk through time it also detailed historical facts about the advertised route eg in 1861 the arrival of the railway linking the town with exeter brought with it a dramatic population explosion other common categories included viewing scenery as a consequence of walking the advertised route eg the south west coast path is a superb way to experience a range of fine devon scenery from cliff tops to wide estuaries sandy bays to wooded valleys and leisure opportunities as consequences of walking the advertised route eg the estuary is a hub of activity for recreational activities such as sailing canoeing windsurfing fishing and scuba diving messages promoting intentions and planning prompting repeated recreational walking similar to the advertised route was the most utilized message category responsible for 3918 of promoting intentions and planning content and 219 of content overall this included the promotion of related brochures without instruction on how to obtain these eg an introductory leaflet and a detailed route book on the tarka trail are both available it also included ways to enjoy the advertised walk again without instruction on how to do so eg why not try your hand at geocaching when on the trail it further included contact details on guided walks eg why not join one of a number of free guided tours another often used category was prompting ways to overcome difficulties with the terrain on the advertised route this included directions to be aware or take care eg care should be taken at all times when walking on roads or take care crossing the exe river over bickleigh bridge another common category was prompting barrier reduction on the advertised route eg you can pick up short sections of the trail from a number of easily accessible points messages enhancing selfefficacy the most often used category was guidance for direction taking on the advertised walk this category was present in 23 of the brochures and accounted for 9020 of all selfefficacy content and 3298 of content overall it embodies the nature of walking brochures instructing on how to progress through a route this is different from the provision of route information as it builds confidence for wayfinding examples include just before you reach a cattle grid turn left alongside a bank or go through the gate at the top left corner of the next field to the road in a similar way to messages promoting intentions and planning other common categories included guidance on repeated recreational walks similar to the advertised route this is different from the promotion of repeated recreational walks as it provides means by which the reader can access further walking information for example free booklets about devons coast and countryside including walking trails cycling horse riding and wildlife can be ordered through the devon county council website at or leaflets on all of these walks are available from exeter city council and the visitor information centre other frequently used message categories were guidance on ways to overcome difficulties with the terrain on the advertised route eg this route is closed during the shooting season from 1st october to 1st february and walkers should follow the alternative route along the quiet road instead at that time or aim to walk this part of the route within two hours of low tide and modelling walking on the advertised route pictorially uncategorized content 404 of all content was unable to be categorized under any of the 87 categories this equated to 206 instances of uncategorized text compared to 4893 instances of categorized text the proportion of text which went uncategorized per brochure ranged from 0 to 1071 examination of this text revealed no systematic exclusion of content related to recreational walking the majority of this text related to authorship credits website addresses unrelated to walking and advertisements for holiday attractions the only recurring behavioural message types that went uncategorized concerned the advertisement of cycle routes and the prompting or instructing of environmental behaviours eg support local shops and services or take your litter home and recycle it where possible discussion this is the first known study to develop a specific coding taxonomy for and conduct a content analysis of recreational walking brochures acceptable reliability of this taxonomy was established at each hierarchical level and for most frequently occurring categories the content analysis suggested that brochures promoted walking in natural environments through messages which provided information on the route highlighted potential consequences and guided on wayfinding however they lacked variety in message types frequently omitting information which could raise normative beliefs promote intentions or enhance selfefficacy for walking how do brochures encourage recreational walking in natural environments brochures often provided information that aimed to facilitate easier access to a walking route as opposed to information about pa more generally they also provided information on the course distance duration and terrain of a route seemingly in order to detail the amount of time and level of expertise required to undertake the walk in contrast to traditional pa promotion messages highlighting consequences often framed scenic features as reasons to walk rather than potential health gains importantly previous research has demonstrated that for people who visit natural environments infrequently subjective qualities like this are more important motivators for visiting than the achievement of physical fitness thus highlighting these may persuade less frequent visitors who are also more likely to be less active to visit natural environments promoting intentions and enhancing selfefficacy in the brochures mainly drew the readers attention to other recreational walking materials and how to access them this could support walking maintenance behaviours but the aim of those messaging strategies may have been simply to drive further interest in a destination or organisation do brochures conform to nice guidance on walking promotion a public health priority is to encourage those who are least motivated to engage in recreational walking and natural environments could support this considerable investment has been directed towards improving environments and opening walking routes but little is known about how to sell these opportunities through printed media to those who are less motivated to walk in the present study walking brochures lacked general and normative information about pa for health behavioural prompts and efficacy information messages containing such information can be effective in motivating inactive people to set better plans to undertake pa most brochures and much of the content therein whether intentionally or not was therefore intended for people who already do recreational walking in the natural environment this is at odds with guidance on walking promotion while further research is needed to explore which messages are most effective there appears to be more scope in the brochures to change cognitions about recreational walking and encourage behavioural strategies doing so would help meet nices recommendation that local authorities develop walking programmes for adults who are not active enough based on an accepted theoretical framework for behaviour change an example of how to achieve this is illustrated in one of the brochures in the sample exeter walking map stood out as the brochure having both the highest categorytoinstance ratio and the most even distribution of categories across superordinate content areas this brochure was also devoted to the promotion of walking more generally as opposed to its related recreational walking routes for example it outlined physical health consequences eg walking can help you live longer helps protect you from heart disease diabetes cancer osteoporosis and much more and included four references to mental health consequences eg walking can activate the happy hormone which makes you feel good improves your mood and reduces stress it contained normative information on benefits to children eg children like to walk to school so they can chat to their friends furthermore it included text reducing general barriers to walking eg walking need not require any special equipment and provided guidance on walking goals based on time management eg by walking to work school the shops or the station you can get your daily exercise as part of your normal routine it was also one of only two brochures in the sample to state pa guidelines in this case providing guidance on how someone could achieve them doing 10000 steps per day will contribute to the recommendation of moderateintensity physical activity for at least 30 minutes on 5 or more days per week this brochure demonstrates how a variety of theoryderived persuasive messages can be incorporated into a recreational walking brochure naturally many more considerations are involved in creating a brochure the overall layout typesetting language style and numerous other features are important in attracting or deterring a potential reader from picking up a brochure or persuading them to change their behaviour nonetheless the selection of appropriate behavioural antecedents to write into messages remains important strengths limitations and future research the main strength of this study is that it produced a flexible taxonomy for analysing materials that advertise recreational pa in a variety of different communication channels such as websites or mobile applications furthermore it has identified for the first time the range of messages used in walking brochures which attempt to attract people to recreate in certain landscapes the coding taxonomy was designed to facilitate easier analysis of other recreational pa materials by maintaining stable superordinate content areas within which users could define individual categories to suit different environments pa conventions and cultures notwithstanding their geographical specificity the sample of brochures did nonetheless cover a variety of environments near smaller and larger conurbations some of the brochures detailed longdistance trails while longdistance trails traverse many settlements they tend not to locate near to larger conurbations meaning that they may not facilitate everyday recreational walking for populations such as those living in urban areas of high deprivation who experience a greater burden of inactivityrelated poor health focusing on how to best promote shorterdistance recreational walking in urban green spaces may be more effective in ameliorating the relative lack of greenspace use by these populations while convenience sampling was employed to generate hypotheses about the effectiveness of brochure content if feasible future content analyses of recreational walking materials may wish to employ probability sampling methods to ensure better representativeness although the taxonomy was reliable at all levels of the hierarchy reliability for eight frequently occurring categories could not be established while this suggests inadequate sampling not one of these categories alone accounted for more than 1 of all content suggesting that further reliability testing may still not have yielded enough instances for confident reliability assessments perhaps in the future a combination of traditional presenceorabsence methods supplemented by linebyline procedures could improve reliability protocols in comparable content analyses nevertheless categories may need to be omitted or revised in any future applications of the taxonomy should they fail to meet acceptable reliability criteria developing the categories in the present taxonomy was achieved in part by expanding behaviour change techniques from other taxonomies this suggests that in any contextspecific content analysis especially those examining materials where health promotion is perhaps a secondary aim such taxonomies could possibly only be used to derive more relevant message categories even with the present taxonomy categories such as mental health consequences of walking could be subdivided into affective benefits restorative benefits and spiritual benefits for instance each may be differently persuasive for different readers in the future researchers must consider the strengths of comprehensiveness and parsimony when deciding upon message categories in future controlled trials could use the taxonomy prospectively as a guide to creating intervention materials that target different antecedents of behaviour change and test with more precision which ingredients are most effective and appealing to different groups future research might also wish to test different types of brochure in terms of their ability to alter attitudes towards walking or intentions to walk for example controlled studies could administer brochures which were identical in style but varied in terms of the type of message employed this would allow researchers to test how original vs tailored information could be differently persuasive and thus inform guidelines on how to produce recreational walking brochures conclusion content in recreational walking brochures sampled from devon uk was coded for the presence of potentially persuasive messages using the coding taxonomy developed here these brochures principle persuasive strategies are to guide wayfinding provide information on amenities and access and enhance the appeal of various properties of natural environments whilst highlighting attractive properties could motivate inactive people omitting messages related to the promotion of intentions or selfefficacy and failing to raise normative beliefs may fail to encourage inactive people to engage in recreational walking in natural environments in future brochures could utilize a wider variety of message strategies in their text in order to engage such populations public health bodies could support the creation of recreational walking brochures to achieve this supplementary material supplementary material is available at health promotion international online

although walking for leisure can support health there has been little systematic attempt to consider how recreational walking is best promoted in the uk local authorities create promotional materials for walking networks but little is known about whether they effectively encourage walking through persuasive messaging many of these materials pertain to walks in natural environments which evidence suggests are generally visited less frequently by physically inactive individuals consequently the present study explores whether and how recreational walking brochures use persuasive messages in their promotion of walks in natural environments a coding taxonomy was developed to classify text in recreational walking brochures according to five behavioural content areas and 87 categories of potentially persuasive messages reliability of the taxonomy was ascertained and a quantitative content analysis was applied to 26 brochures collected from devon uk brochures often provided information about an advertised route highlighted cultural and aesthetic points of interest and provided directions brochures did not use many potentially effective messages text seldom prompted behaviour change or built confidence for walking social norm related information was rarely provided and there was a general lack of information on physical activity and its benefits for health and wellbeing the limited range of message strategies used in recreational walking brochures may not optimally facilitate walking in natural environments for inactive people future research should examine the effects of theoryinformed brochures on walking intentions and behaviour the taxonomy could be adapted to suit different media and practices surrounding physical activity in natural environments

introduction several studies suggest that individuals with more social connections tend to live longer and healthier lives than those with less social connections 1 2 3 4 several plausible pathways link social relations to health 5 for example supportive social relations may buffer the impact of stress by promoting less threatening interpretations of adverse events and providing cues for better coping strategies and emotional and instrumental social support 6 moreover it has been suggested that social relations affect physiological outcomes such as resting blood pressure heart rate stress hormone levels and immune function 7 social relations may also affect health risk behaviours such as heavy alcohol use smoking and low physical activity 89 an individuals personal social network may affect their health behaviour by shaping norms and enforcing patterns of social control by providing healthrelated information and by improving an individuals sense of responsibility for their own as well as others health and wellbeing 8 although not all social relations are beneficial and some can even lead to risky health behaviour compared to small social networks larger social networks may have the potential to offer more diverse social relations with relatively more positive influences on health behaviours 1011 previous studies among american middleaged and older adults for example have found that a higher number of social ties being married 1213 and participation in religious activities 14 are all associated with healthier lifestyles such as higher levels of physical activity nonsmoking and low levels of alcohol use a crosssectional study among patients in cardiac rehabilitation showed a positive association between the number of most important members in a social network and healthy life style as well as coping efficacy 15 similarly crosssectional studies among lowincome adults 16 and adults at a higher risk of diabetes and cardiovascular disease 17 have found larger social networks to be positively associated with physical activity however prospective evidence on the role of social network size in predicting longterm health behaviour among adult populations remains scarce thus little is known about how persistent the associations between social network size and health risk behaviours are in the present study based on two occupational cohorts and one populationbased cohort of workingaged adults we used repeated measurements on health risk behaviours over a 1520year followup to examine whether the size of social network at baseline was associated with persistent differences in health risk behaviours over time we hypothesized that compared to participants with large social networks those with smaller social networks would be more likely to have unfavourable patterns of health behaviours over time as indicated by heavy alcohol use smoking and low physical activity we also hypothesized that health risk behaviours would accumulate among those with a small social network since sociodemographic factors are also associated with both social networks and health behaviour we also examined the association of network size with health risk behaviours by gender agegroup and educational level 5 18 19 20 methods measurement of social network size social network size was assessed in all cohorts at baseline using the social convoy model described by antonucci 23 participants were asked to write the initials of their social network members on three concentric circles the people who were closest and most important to the respondent without whom life would be hard to imagine were placed in the innermost circle the people who were not quite that close but still important were placed in the middle circle and those not already mentioned but who were close and important enough to belong to their personal network were placed in the outer circle the total number of members in these circles was calculated and classified into three categories based on the data distribution 010 1120 and at least 21 members similar categorization of social network size has been used previously 24 the convoy model has been used successfully among people of different age ranges and from different countries 18 and has been shown to have relatively good testretest reliability over time 24 measurement of health risk behaviours baseline and followup information on health risk behavioursheavy alcohol consumption smoking and low physical activitywas drawn from the questionnaires three dichotomous variables of health risk behaviours were created on the basis of similar questions used in all cohorts and over time alcohol use expressed as absolute ethanol in gramsweek was estimated on the basis of the reported average consumption of beer wine andor spirits the cutoff point of heavy alcohol use was set at 288gweek for men and 192gweek for women as proposed by the finnish guidelines 25 these limits also correspond with the medium risk levels of daily consumption presented by the world health organization 26 smoking status was categorized into nonsmokers and current smokers information regarding average time spent in physical activities with different intensities was used to estimate average metabolic equivalent hoursweek 27 participants whose physical activity corresponded to less than 14 met hoursweek were regarded as having a low level of physical activity 27 in addition a summary variable was created at each wave by summing up the total number of each participants health risk behaviours into a measure of none to three risk behaviours measurement of potential confounders age gender education and chronic conditions at baseline were selected as potential confounders on the basis of an a priori assumption that these factors are associated with both social relations and health behaviours 5 18 19 20 28 information on education was based on the highest selfreported vocational education classified into three categories basic intermediate and high information regarding chronic conditions at baseline was obtained from the national drug reimbursement register and diagnosis of cancer from the finnish cancer registry the total number of these conditions was calculated and classified into no chronic conditions and at least one chronic condition statistical analyses descriptive statistics were calculated to evaluate baseline characteristics of all study participants in each cohort and by social network size differences in these characteristics by social network size were assessed using the kruskallwallis test for continuous variables and the chisquare test for categorical variables relative risks with 95 confidence intervals of health risk behaviours across the followup periods were calculated in each cohort by means of repeatedmeasures logbinomial regression analysis using the generalized estimating equations method 29 the gee method enables the analysis of correlated data arising from a longitudinal study with repeated measurements on the same subject those with at least 21 members in their social network at baseline were used as a reference group three types of models were performed in each cohort 1 age gender and survey year adjusted models with each health risk behaviour as a dependent variable 2 models further adjusted for education and chronic conditions and 3 cumulative logistic regression models with the total number of health risk behaviours as the dependent variable adjusted for age gender survey year education and chronic conditions trends in health risk behaviors according to baseline social network size were examined over the 10year period treating year as a continuous variable to assess whether the potential changes in risk differed between the groups after separate analyses in each cohort fixedeffects metaanalysis 30 was used to pool the cohortspecific results into summary estimates fixedeffect analysis was chosen because the number of studies was small which results in poor precision of the betweenstudies variance estimate in such cases the randomeffect model may not be applied correctly 31 however randomeffect models were also performed in order to verify the consistency of the results with both of these methods finally stratified analyses of the associations between baseline social network size and health risk behaviours over time were performed by gender age group and education in order to test whether the selective dropout during the followup affected the results we performed sensitivity analysis including only those participants who had answered both to the first and the last questionnaires statistical analyses were performed with the use of sas software version 94 and the r statistical package results table 1 shows the baseline characteristics of the three cohorts the followup period extended up to 20 years including on average 35 repeat measurements depending on the cohort figure 1 shows the results from metaanalyses of each health risk behaviour separately and a summary variable of overall unhealthy lifestyle score with summary estimates for pooled results of the three cohorts adjusted for age gender survey year chronic conditions and education compared with participants with at least 21 network members those with 010 members in their social network were at a significantly higher risk of heavy alcohol use smoking hours less than 14week c cumulative odds ratio for overall unhealthy lifestyle score there was no clear difference in trends of health risk behaviours over time between those with 010 members and those with at least 21 members in their total social network appendix c figures c1c3 if anything the risk of heavy alcohol use increased slightly more among those with at least 21 members in their social network as compared with those with the smallest social network examined over the tenyear period on the other hand additional analyses of participants with healthy lifestyle at baseline showed that health risk behaviours accumulated differently according to the size of social network compared with participants with at least 21 members in their social network those with 010 members were at a higher risk of overall unhealthy lifestyle over the followup period table 2 trends in health risk behaviours according to social network size examined over the 10year period treating year as a continuous variable relative risks with 95 confidence intervals are derived from repeatedmeasures logbinomial regression analysis using the generalized estimating equations method summary estimates pooled from cohortspecific results discussion our findings from two occupational cohorts and one populationbased cohort from finland suggest that smaller social networks are associated with persistently more unhealthy behaviours over the adult life course compared with individuals with at least 21 members in their social network at baseline those with up to 10 members were at a significantly higher risk of being heavy alcohol users smokers or physically inactive over the followup period extending up to 1520 years in addition these individuals were at a higher risk of having multiple risk factors as part of an overall unhealthy lifestyle score our findings are consistent with previous mainly crosssectional studies on the association between social networks and health risk behaviours 1213 15 16 17 20 32 33 34 previous studies have shown for example that individuals who drink heavily report decreased levels of social activities worse social anchorage and low contact frequency 32 our results are also in line with those reporting a significant association between smoking and social isolation low levels of social support participation and network heterogeneity 3334 it has been suggested that for some people smoking provides a means of managing negative moods and stress that might result from having inadequate social relations 35 none of these studies however have addressed the question of the persistency of the associations between social network size and smoking or heavy drinking an association with physical inactivity has previously been reported for various measures of low social engagement such as low social integration and a small number of friends and close network members 1213161720 similarly our results highlight the importance of social network size on physical activity the strongest and most robust association observed in the present study potential mechanisms linking social network and physical activity include the higher levels of social support offered by a larger network the establishment of social norms the provision of resources and encouragement for activity 36 on the other hand it could be speculated that those who are more physically active obtain more social contacts through their participation in leisure activities however as the difference in the risk of being physically inactive according to social network size persisted over the followup period it is also possible that having a larger social network promotes a physically active lifestyle over time it is noteworthy that social relations may also discourage a healthy lifestyle for example those who are closely connected to smokers are more likely to smoke themselves and conversely a decision to quit smoking is affected by the choices made in groups of interconnected people 34 drinking habit is also largely influenced by the drinking habit of a social network 37 in the present study no information regarding the attitudes or health risk behaviours of social network members was available yet the social network size at baseline was a robust predictor of these health risk behaviours over time women tend to have larger social networks than men as do better educated people compared with the lesseducated and to a lesser extent younger adults compared with the elderly 5 some studies have reported the associations between social relations and health behaviour to be stronger among people with lower as compared to those with higher socioeconomic positions 20 in line with this observation we found a tendency toward a stronger association between social network size and health risk behaviours among participants with basic or intermediate education compared with those with high education yet these differences could not be proven statistically the effects of social relations are likely to accumulate and create a growing advantage or disadvantage for health 5 however with respect to health risk behaviours we found no evidence of accumulation according to social network size over time the change in the prevalence of separate health risk behaviours did not differ significantly between participants with small networks and those with larger networks it is possible that the age phase of the study members of the present study is relatively stable with respect to social relations potentially diminishing the likelihood of clear differences in separate health risk behaviours between the groups followup periods extending over critical life transitions such as changes in marital status or retirement might provide more specific information regarding the contribution of social relations to trajectories of separate health risk behaviours in addition more detailed information on the various dimensions of social networks might be more efficient in predicting separate health risk behaviours strengths and limitations the strengths of this study were that we were able to use data from three large cohorts of workingaged adults with long followup periods and repeated measurements of health risk behaviours information regarding sociodemographic factors and chronic conditions was also readily available however some limitations should be considered first behavioural outcomes were assessed by selfreporting which may be subject to bias and underreporting in some and overreporting in other health behaviours the information regarding social network size was similarly based on selfreporting and may thus not correspond to the actual number of members in the social network but depend on the persons willingness to provide details of their social network on the other hand the importance of social relationships is always more or less based on subjective assessment and may be difficult to evaluate objectively another limitation was that social network size was only assessed at baseline and therefore it was not possible to evaluate how changes in network size may have contributed to the changes in health risk behaviours over the followup period however previous studies have shown that social relations are relatively stable across adulthood 38 which is also likely to be the case among the workingaged study population of the present study selective drop out during the followup was also a possible important limitation of the study however our sensitivity analyses including only those participants who provided information about their health risk behaviours in both the first and last questionnaire showed unchanged results compared to the whole study population further although we controlled for major potential confounders eg chronic conditions and education confounding can never be ruled out in observational studies such as ours finally clustering of participants in geographic regions could potentially affect the results if the participants remain in the same regions however during the two decades of followup of health behaviours many cohort members moved from their baseline residential regions the fact that the same pattern was found in the occupational cohorts and the population cohort which was not drawn from geographic regions further suggest that clustering of participants in geographic regions is an unlikely source of major bias conclusion in conclusion the data from three longitudinal cohort studies of workingaged adults suggest a sustained association between small social networks at baseline and an increased likelihood of persistent risky alcohol use smoking and low physical activity over a followup of up to 1520 years as compared with those who had large networks the findings of the present study may serve as a rationale for designing public health interventions that focus on strengthening social networks in order to support beneficial health behaviour patterns however further followup studies are needed to assess the specific factors of social networks that have the most affect and whether the changes in these factors have an impact on the trajectories of health risk behaviours and ultimately on health outcomes competing interest the authors have no competing interests to report

to determine the associations between social network size and subsequent longterm health behaviour patterns as indicated by alcohol use smoking and physical activityrepeat data from up to six surveys over a 15or 20year followup were drawn from the finnish public sector study raisioturku cohort n986 hospital cohort n7307 and the health and social support study n20115 social network size was determined at baseline and health risk behaviours were assessed using repeated data from baseline and followup we pooled cohortspecific results from repeatedmeasures logbinomial regression with the generalized estimating equations gee method using fixedeffects metaanalysisparticipants with up to 10 members in their social network at baseline had an unhealthy risk factor profile throughout the followup the pooled relative risks adjusted for age gender survey year chronic conditions and education were 115 for heavy alcohol use 95 ci 106124 119 for smoking 95 ci 112127 and 125 for low physical activity 95 ci 121129 as compared with those with more than 20 members in their social network these associations appeared to be similar in subgroups stratified according to gender age and educationsocial network size predicted persistent behaviourrelated health risk patterns up to at least two decades

background nutrition has a big impact on peoples health and is closely tied to social and cognitive development particularly in childrens formative days 12 children cannot receive their complete recommended ageappropriate nutrition in environments with low income and social resources 1 in children suboptimal infant and young child feeding practices remain serious public health problems 3 to overcome these concerns complementary feeding should be started in children who are 6 months of age and above 2 complementary feeding is the introduction of liquids and other foods along with breast milk for 623 months age children 4 world health organization defines minimum acceptable diet practices for 623 months age children as a combination of both minimum meal frequency and minimum dietary diversity in both breastfeeding and nonbreastfeeding children 56 in many countries less than onequarter of children are reported not getting the nutrition they need to grow well particularly in the crucial first 1000 days 78 child undernutrition is a major public health problem in many resourcepoor communities in the world 3 among children aged 6 to 23 months from low socioeconomic status only one in five can feed the minimum recommended diverse diet which is one component of mad 8 the first 2 years of age of the childs life provide an opportunity to ensure the growth development and survival of the child through optimum infant and young child feeding practices 4 therefore inappropriate iycf practices during this period result in significant threats to child health by compromised educational achievement impaired cognitive development and low economic productivity which become difficult to reverse later in life 4910 inappropriate feeding practices during the first 2 years of life are a cause for more than twothirds of malnutritionrelated child deaths 11 malnutrition is linked to just half of all deaths of under five children in each year 48 optimal complementary feeding practices prevent approximately onethird of child mortality 12 research has shown that in subsaharan africa children lost up to 25 years of schooling if there was a famine while they were in utero and during their childhood 8 even though the minimum acceptable diet problem has multiple causes it is widely agreed that inadequate iycf due to socioeconomic inequalities is one of the most immediate determinants 113 socioeconomic inequalities in child nutrition are a concern for health differences since it is resulting from factors considered to be both avoidable and unfair 14 the global burden of childhood undernutrition is concentrated in lowincome and lowermiddleincome countries and becomes a vicious cycle with their economic status 15 in countries with low socioeconomic status with inadequate food and resources children can not have full growth and developmental possibilities 1 subsaharan africa is loaded with half children living in extreme poverty among 385 million around the world whereas over a third live in south asia 8 according to the global nutrition report in 2020 there were inequalities in dietary diversity meal frequency and minimum acceptable diet children from the richest households do far better as do a more educated mother or those who live in urban areas 1516 there were an 115 wealth gap 49 location gap and a 77 education gap of minimum acceptable diet intake 16 a lot of interventions have been taken to overcome these problems 1617 the united nations secretarygeneral launched the zero hunger challenge in children by fulfilling objectives such as 100 access to adequate food all year round zero stunted children under 2 years and sustainability of all food systems 17 world health organization set as strategies for complementary feeding practice by using multiple micronutrient powders for home fortification of foods and vitamin a for children 623 months of age 18 despite these lots of interventions that have been taken the minimum acceptable diet usage is still low 8 therefore identifying and reducing the avoidable socioeconomic inequalities of minimum acceptable diet intake and its contributing factors are an important issue in improving the overall health and wellbeing of the child 14 there have been studies reporting the burden and determining factors of childhood mad usage in different program that endorses women empowerment such as income generation cash assistance for mothers who have under 2 years of children and women employment using affirmative actions and nutrition education such as media campaigns and promoting breast feedings longterm plans are also needed for those ssa countries with lower income status through programs to enhance their countrys economy to the middle and higher economic level and to improve the wealth index of individual households to narrow the poorrich gap in the minimum acceptable diet intake keywords minimum acceptable diet socioeconomic inequalities and subsaharan african countries of subsaharan africa but those studies were used regionally varied local food items to assess mad intake among children which makes it difficult to make pooled estimates and regional comparisons however this study used the most recent standard dhs dataset which was collected in a similar design and standardized parameters makes easy to have pooled prevalence of mad intake among children therefore this study aimed to assess the pooled prevalence the level of socioeconomic inequalities of mad intake and contributor factors for the inequalities among children aged 623 months in ssa countries it will be the crucial point for policymakers to know child nutrition status in the region and draft child nutrition policy and take actions based on the evidence methods study design setting and period the data source for this study was the recent standard dhs data of subsaharan african countries conducted within 10 years which was a crossectional study conducted every fiveyear interval to generate updated health and healthrelated indicators the subsaharan is the area in the continent of africa that lies south of the sahara and consists of four geographically distinct regions namely eastern africa central africa western africa and southern africa 19 but economically according to the 2019 world bank list of economies classification categorized as low income lower middle income and uppermiddleincome country 20 together they have a total population of 11 billion inhabitants 21 the datasets are publicly available from the dhs website dhspr ogram com 19 dhs collects data that are comparable across countries the surveys are nationally representative of each country and populationbased with large sample sizes all surveys use a multistage cluster sampling method 22 population the source population was all children aged 623 months preceding 5 years of the survey period across 33 subsaharan african countries whereas the study population was children aged 623 months preceding 5 years the survey period in the selected enumeration areas and the mother or the caregiver was interviewed for the survey in each country mothers who had more than one child within the 2 years preceding the survey were asked questions about the most recent child 23 sampling procedures and sample size a total of 47 countries are located in subsaharan africa of these countries only 41 countries had demographic and health survey report from these five countries that did not have a survey report after the 20102011 survey year were excluded these countries are central africa republic eswatini sao tome principe madagascar and sudan as well as three subsaharan countries were excluded due to the dataset not being publicly available then after excluding countries that had no dhs report after 2010 and countries where the dhs dataset was not publicly available a total of 33 countries were included in this study typically dhs samples are stratified by geographic region and by urbanrural areas within each region dhs sample designs are usually twostage probability samples drawn from an existing sample frame enumeration areas were the sampling units for the first stage of sampling in selected eas households comprise the second stage of sampling following the listing of the households a fixed number of households is selected by equal probability systematic sampling in the selected cluster 22 the detailed sampling procedure was available in each dhs reports from the measure dhs website 22 weighted values were used to restore the representativeness of the sample data and were calculated from childrens records or kids records dhs datasets finally a total weighted sample of 78 542 children in the age category of 623 months from all 33 countries were included in this study table 1 study variables dependent variables the outcome variable of this study was taking minimum acceptable diet of children 623 months which is combined from children who had minimum meal frequency and minimum dietary diversity in both breastfeeding and nonbreastfeeding children during the survey their mother was asked questions about the types and frequency of food the child had consumed during the day or night before the interview 22 if a child is taken four out of seven food groups fed during the day or night preceding the survey the following food items are considered as getting minimum dietary diversity these are grains roots and tubers legumes and nuts dairy products flesh foods eggs vitamin arich fruits and vegetables and other fruits and vegetables whereas minimum meal frequency is the provision of two or more feedings of solid semisolid or soft food for 68 months three or more feedings for 923 months breastfeed and four times for nonbreastfed children the data of the above variables were collected similarly across all ssa countries 622 since minimum meal frequency has a different cutoff value for different age groups and breastfed and nonbreast feed children so as the overall meal frequency computed after computing for each group independent variables sociodemographic factors such as marital status and household family size socioeconomic factors such as educational attainment of women occupation of women and country income status health behavior factors such as media exposure and breastfeeding status and geographical factors such as place of residence and subregion in ssa are all taken into account the countries income status was categorized as low income lower middle income and uppermiddleincome country based on the world bank list of economies classification since 2019 20 world bank calculated country income based on gross national income per capita which categorized as low income 1025 or less lower middle income 10263995 upper middle income 399612375and high income 12375 or more 20 data processing and analysis this study was performed based on the dhs data obtained from the official dhs measure website measu redhs comafter permission has been obtained via an online request by specifying my objectives data from the dhs dataset were downloaded standard dhs data in stata format then cleaned integrated transformed and append to produce favorable variables for the analysis microsoft excel and stata 16 software were used to generate both descriptive and analytic statistics of the appended 33 countries data to describe variables in the study using statistical measurements the variance inflation factor was used to detect multicollinearity and all variables had vif values less than 10 and the mean vif value of the final model was 157 the pooled estimate of mad intake among children in subsaharan africa and subregions was estimated using the metan stata command model building concentration curve and index the concentration index and concentration graph approach are used to examine socioeconomic inequalities in health outcomes 2425 the concentration curve is used to identify whether socioeconomic inequality in some health variables exists and whether it is more pronounced at one point it displays the share of health accounted for by cumulative proportions of individuals in the population ranked from the poorest to the richest 2526 the two key variables underlying the concentration curve are the health variable and the distribution of the subject of interest against the distribution of the variable capturing living standards 27 the concentration curve plots the cumulative percentage of mad usage against the cumulative percentage of children 623 months ranked by living standards beginning with the poorest and ending with the richest households 27 a 45 0 line running from the bottom lefthand corner to the top righthand corner concentration curve would be indicated the absence of inequity furthermore the concentration curve lying above the equality line indicated that mad intake is disproportionately concentrated between poor and whereas below the equality line indicated concentrated on rich 28 to quantify and compare the degree of socioeconomic related inequality in mad intake concentration index is used 2629 and it is twice the area between the concentration curve and the line of equity with the range of 1 to 1 the sign indicates the direction of the relationship between mad intake and the distribution of living standards 2527 where hi is the health outcome μ is the mean of hi and n is the number of people ri represents the fractional rank of individual i in the living standards distribution used with i taking the value of 1 for the poorest and the value of n for the richest 272930 as a result c 0 showed that mad intake was disproportionately concentrated on the rich and ci 0 revealed that the mad intake is disproportionately concentrated on the poor 2728 whereas c 0 indicated that the distribution is proportionate accordingly c 1 showed that the richest person had children taken mad whereas c 1 indicated that the poorest person had all of the children taken mad 2730 but the outcome variable in the present study is binary the bounds of c depend on the mean of the outcome variable and do not vary between 1 and 1 thus the bounds of c vary between μ1 and 1μ and the interval shrink when the mean increases as a correction the present study applied the wag staff normalization to calculate the concentration index by dividing c by 1 minus the mean 2730 c 2 nµ n i1 hiri 1 wag staff decomposition analysis wag stafftype decomposition analysis was performed for those variables that were screened statistical significance based on multilevel analysis and clinical significance after the concentration index and curve were assessed and showed incomerelated inequality to the magnitude of mad usage the wag stafftype decomposition analysis quantifies the degree of incomerelated inequalities of the minimum acceptable diet intake and explains the contribution of each factor to the observed inequality 31 concentration index decomposed based on regression analysis of the relationship between an outcome variable and a set of determinants the overall concentration index can be decomposed into k social determinant contributions in which each social determinants contribution is obtained by multiplying the sensitivity of the outcome related to that determinant and the degree of incomerelated inequality in that factor 2732 based on a linear additive regression model the concentration index for minimum acceptable diet intake can be expressed as follows where μ is the mean of y x ̅ k is the mean of xu ck is the concentration index of xk and gcε is the generalized concentration index for the error term the overall concentration index of mad intake includes the explained part which is the sum of the contributions of k determinants and the unexplained part based on the wag staff normalization the normalized decomposition of the concentration index obtained by dividing the concentration index by 1μ 30 absolute contribution is expressed in the same unit as the c whereas relative contribution was the percentage of the c of each covariate to the total observed incomerelated inequality in mad data quality control the dhs data are comparable across countries the missing values were clearly defined by the dhs guideline if there were missing values and dont know in breastfeeding assumed as not breastfeeding but if there were in specific foods excluded from further analysis 22 the magnitude of mad usage among children in each country was compared with the respective dhs reports c normalized c 1 µ c k ck gc ε µ results socio demographic characteristics of mothers or caregivers a the pooled magnitude of minimum acceptable diet intake among children aged 623 months the overall pooled estimate of the minimum acceptable diet intake among children aged 623 months in subsaharan african countries was 987 with i 2 978 and ranging from 310 in guinea to 2040 in kenya moreover the pooled magnitude of mad intake across country income levels was determined the pooled estimate of mad intake in lowincome countries was 899 lowermiddleincome countries 1175 and 1096 across upper middleincome countries wealth related inequality in minimum acceptable diet usage concentration index and curve the concentration index is used to quantify the degree and show the direction of socioeconomicrelated inequality in a health variable the value of negative sign indicates the more concentration of mad intake among the poor where a positive value indicates concentration among the rich in this study the overall wag staff normalized concentration index analyses of the wealthrelated inequality of mad showed that the prorich distribution of mad intake with c 0191 95 ci 0189 0193 this shows that mad intake among children aged 623 months was disproportionately concentrated on the richer groups the concentration index is twice the area between the concentration curve and the diagonal line then when multiplying the c by 75 1433 which showed that 1433 of the mad intake would need to be redistributed from the richer half to the poorer half of the population to arrive at a distribution with fig 1 the forest plot showed that pooled magnitude of mad intake among 623 children in ssa based on income status an index value of zero the finding from the indices is in agreement with the results of the concentration curves in fig 2 similarly the concentration curve in the following figures showed that the concentration graph of minimum acceptable diet usage was below the line of equality which indicated that the distribution of minimum acceptable diet used children was concentrated in rich households fig 2 the wealthrelated inequality of mad intake was significantly higher among the urban residents than rural and similarly the concentration curve showed that the concentration graph of mad intake among children aged 623 months who were live in urban residence was below the graph of rural residence the wag staff decomposition analysis after the concentration index and curve were assessed and showed incomerelated inequality to the mad intake wag stafftype decomposition analysis have been fitted for those variables that were statistically significant during multilevel analysis and clinical important variables for wealthrelated changes the wag stafftype decomposition analysis is used to decompose the overall incomerelated inequalities of the mad intake by variables and explains the contribution of each factor to the observed inequality table 3 reveals the wag staff decomposition analysis for the contribution of the various explanatory variable for wealth inequalities of mad intake among children aged 623 months in subsaharan african countries the table contains information about coefficient elasticity concentration absolute contribution and percent contribution elasticity is the sensitivity of mad intake for each factor the concentration index in each variable is the degree and direction of socioeconomicrelated inequality in mad intake corresponding to specific explanatory variables the value of negative sign in c indicates the more concentration of mad intake among the poor where a positive value indicates concentration among the rich absolute contribution is calculated by multiplying elasticity with the concentration index of each factor and indicates the extent of inequality contributed by the explanatory variables whereas percent contribution means the contribution of each variable to the overall concentration index in this study more than half of the wealthrelated inequalities of mad intake in children were explained by the combination of variables fitted in the model geographicalrelated factors contribute most of the prorich wealthrelated inequality on the usage of mad among children more than onethird of the prorich inequalities in mad taking among children is explained by the residents having media exposure also explained nearly onefourth of the prorich wealthrelated inequality for children who had taken mad the other 1163 of the estimated prorich inequalities in mad usage are explained by maternal secondary educational status table 3 discussions inadequate infant and young child feeding practices are the major determinants of undernutrition optimal growth and development especially in the first 2 years of life is a major problem both globally and in developing countries 33 identifying and reducing avoidable socioeconomic inequalities and other determinants of malnutrition is a critical step toward improving childrens overall health and wellbeing 14 this study aimed to determine the pooled estimate socioeconomic inequalities of minimum acceptable diet intake and contributor factors among children less than the lowest magnitude of mad intake in our study is in line with research conducted in india which was 9 34 but lower than a multisite study conducted in america asia and africa 21 35 south asia countries 36 bangladesh 20 37 and indonesia 40 38 of children aged 623 can access a minimum acceptable diet the discrepancy might be due to geographical variation population growth and socioeconomic status of the countries 35 cultural beliefs and knowledge paradigms about mad are also known to influence feeding practices 434 studies showed that growth faltering among subsaharan african children becomes evident from early infancy and is sustained through the second year of life which is the period with the highest reported prevalence of overall malnutrition 39 but our finding is higher than a study conducted and in the philippines 67 40 of children aged 623 can access a minimum acceptable diet this is due to the that the current study included a large population from different geographic subsaharan african regions with various cultures beliefs and traditions which make it a real estimation of the magnitude in ssa in this study a significant variation of mad usage of children among ssa countries was observed in which kenya had a significantly higher whereas guinea had a statistically significant lowest magnitude of mad usage am children this is in line with a study in india 34 indonesia 3 south asia 36 and west african countries 41 which reported regional variation in mad usage this might relate to the difference in governmental actions toward the application of national nutritional programs and addressing cultural beliefs around complementary feeding 42 for instance the better magnitude of mad intake in kenya was achieved by implementing a health platform which is called the babyfriendly community initiative platform and by integrating wash into complementary feeding sessions 42 the availability and accessibility of foods in the region may have also a contribution children in agrarian dominant and city dwellers were more likely to have mad 34344 for instance guinea is among the poorest countries in the world which ranks 179 of 187 countries with 10 population were food insecure 45 therfore this low magnitude mad intake might be associated with it evidence also showed that there is an ecological association between dietary diversity and child nutrition in ssa due to ecologyspecific crops production and livestock farming 39 in this study we found that the concentration index and curve result showed that the mad intake was disproportionately concentrated on the rich households c 0191 95 ci 0189 0193 this is in line with a study conducted in india 4647 south asia 36 tanzania 48 it is known that children from a family of higherincome can feed diversified foods and frequently as their families could be more likely to afford to have diversified foods as compared to children from a low household income 49 in this study the prorich inequalities in mad intake were explained by maternal educational status having media exposure of household and living in a rural residence the contribution of secondary and above maternal education towards explaining wealthrelated inequality of mad intake in this study was positive the result was consistent with studies in india 464750 the study in new york also showed that the association of maternal education and child nutrition was positive in intermediate and high socioeconomic conditions 51 the global nutrition report 2020 also pointed out that the education gap contributes 77 of child nutrition inequalities 16 this is might be due to those children of educated mothers having health advantages due to their higher socioeconomic status 47 maternal schooling can help to foster the positive association between household wealth and child linear growth 52 media usage of the household also has a large contribution to explaining prorich wealthrelated inequality of mad intake among children aged 623 mo in ssa this might be due to that those media user households have more likely to be the richest and eventually to feed mad for their kids in this study the concertation of the rural residence was negative for prorich wealthrelated inequalities of mad intake this is in line with studies conducted in india 4753 according to the global nutrition report 2020 the location gap contributes 49 of child nutrition inequalities 16 this is due to that factors that determine nutritional status differ between urban and rural areas nutrition in urban children is characterized by life events of their residence which have a greater dependence on cash income but lower reliance on agriculture and natural resources 54 it is also supported by the multilevel result of this study which showed rural areas had a lower likelihood for mad intake and only 415 of children from rural areas belonged to the richest household wealth status whereas was twofifths of the urban which resulted in a negative contribution the main strength of this study was the use of the weighted nationally representative data of each subsaharan african country with a large sample which makes it representative at subsaharan and regional levels therefore it has appropriate statistical power that can be generalized of the estimates in minimum acceptable diet intake in the study setting to all children 623 during the study period furthermore the concentration index and curve and wag staff decomposition analysis are appropriate statistical models to shows the direction and degree of socioeconomic inequality of mad between the poorest to the richest household since the data were collected crosssectional at a different point in time by selfreported interview would be prone to recall and social desirability bias the drawback of the secondary nature of data was inevitable the heterogeneity of the pooled estimate of mad intake was not managed by further analysis conclusion and recommendations the proportion of minimum acceptable diet usage among children aged between 6 and 23 months in subsaharan africa was relatively low minimum acceptable diet intake was disproportionately concentrated on the rich households secondary and above maternal education having media exposure of household and rural residence were positively contributor whereas breastfeeding was a negative contributor for prorich socioeconomic inequalities in mad intake to increase minimum acceptable diet intake among children age 623 months in subsaharan africa policymakers in nutritional projects and other stakeholders should work as an integrated approach with other sectors and give prior attention to modifiable socioeconomic factors such as promoting womens education and employment increase wealth status and media exposure of the household and promoting breastfeeding behavior the government of subsaharan african countries should plan and work in short terms through the program that endorses women empowerment such as income generation cash assistance for mothers who have under 2 years of children and women employment using affirmative actions and nutrition education such as media campaign and promoting breastfeedings longterm plans are also needed for those ssa countries with lower income status through programs to enhance their countrys economy to the middle and higher economic level and to improve the wealth index of individual households interventions to improve mad practice should not only be implemented factors at the individual level but also be tailored to the community context ssa especially in east africa regions needs equityfocused interventions to curb the inequalities and low magnitude of mad intake not only by taking measures for economic equity but also need the balance by supporting the marginalized group such as uneducated women households with no media usage and rural residence competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more 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background child undernutrition is a major public health problem in many resourcepoor communities in the world more than twothirds of malnutritionrelated child deaths are associated with inappropriate feeding practices during the first 2 years of life socioeconomic inequalities are one of the most immediate determinants though subsaharan africa ssa shares the huge burden of children undernutrition as to our search of literature there is limited evidence on the pooled magnitude socioeconomic inequalities of minimum acceptable diet intake and its contributing factors among children aged 6 to 23 months in the region this study aimed to assess the level of socioeconomic inequalities of minimum acceptable diet intake and its contributor factors among children aged 623 months in ssa using recent 20102020 dhs data methods a total of 78542 weighted samples from demographic and health survey datasets of ssa countries were used for this study the data were cleaned using ms excel and extracted and analyzed using stata v16 software the concentration index and curve and wag staff type decomposition analysis were applied to examine wealthrelated inequalities in the outcomes pvalue 005 was taken to declare statistical significancethe pooled magnitude of mad intake among children age 623 months in ssa was 989 95 ci 857 1121 ranging from 310 in guinea to 2040 in kenya mad intake in ssa was disproportionately concentrated on the rich households prorich c 0191 95 ci 0189 0193 residence 3617 media exposure 2393 and womens education 1163 explained the prorich inequalities in mad intake the model explained 5555 of the estimated socioeconomic inequality in mad intake in ssaminimum acceptable diet intake in ssa is relatively low there are moderate socioeconomic inequalities in mad intake in ssa mainly explained by residence media exposure and womens education the government of subsaharan african countries should plan and work in short terms through the

m arianna fotakis analysis of the role of compassion in good quality healthcare is helpful and challenging 1 it is helpful because she makes clear that promoting compassion on an individual level can never be a solution for a healthcare system that fails to be humane as regards the atmosphere it creates for individual caregivers and patients suggesting that the crisis in contemporary healthcare can be solved by blaming individual caregivers only increases the stress these people already are subjected to therefore fotaki proposes one needs to look at both the professional and organisational side of the coin her analysis is challenging because there are a number of causes that make it very hard to give compassion the place healthcare it should have in this commentary i would like to reflect on fotakis contribution from a care ethical perspective fotaki rightly refers to care ethics in her editorial as a movement with feminist roots since carol gilligans seminal work in the beginning of the 1980s however care ethics has developed into an interdisciplinary field of enquiry in which insights have been articulated that help understanding the deeper causes of why we do not seem to manage developing a more humane healthcare drawing on these insights i would like to raise three issues that may help understanding why changing our culture is so hard the 3 issues are the relation between the moral and the political the role of neoliberalism and the absence of reflection on what care essentially is the boundary between the moral and the political one of the central critical insights of care ethics coined by joan tronto is that the virtual boundary between the moral and the political in our culture has made it possible that unjust political systems may continue to exist next to highly moral individual practices 2 this is precisely what happens when individual care givers are promoted to be more compassionate in order to held up a healthcare system that in return is not compassionate to their workers and patients trontos insight that the moral is political and vice versa means that we cannot consider compassion to be a feature of isolated individuals we should look more deeply into an analysis of why compassion is so hard to reinstall nowadays when we think of the story of the good samaritan the western role model of compassion par excellence and its widespread use still in contemporary culture we are reminded of the fact that once compassion was one of the most important foundations of healthcare grit and dolfsma 3 eg analysed the different rationalities underlying the developments in healthcare during the last century in the netherlands and list 4 discourses with their own logics that shift from a central role of compassion to a central role of the market according to their analysis in the beginning of the 20th century healthcare was organised from institutions with a religious mainly christian identity many of the religious people serving as healthcare givers in these institutions lived and worked in a world in which compassion was both an individual virtue reflected in the public policy of their healthcare institution and part of a meaning frame that was shared by both professionals and patients this unity of discourse expressed in a continuity between the individual and the institutional the moral and the political was changed when a new paradigm and discourse was developed in the 1950s due to the great developments of medical science a medical discourse began to dominate healthcare in which an idea of professionalism was developed replacing the central value of compassion in the 1970s a political discourse was introduced into healthcare in which accessibility of healthcare and participation of all citizens began to dominate in the 1980s the netherlands as many other north atlantic countries were confronted with a new discourse economy began to reign over healthcare managers were introduced and the market was seen as the best way to reduce costs the role of compassion shifted from a central organizing value to a commodity to enhance low quality care 4 neoliberalism in order to understand why it is so hard to change this situation we have to dig somewhat deeper into the cultural climate change that set off in the 1980s and has had an enormous effect on every segment of society neoliberalism as wendy brown has shown neoliberalism extends market values to social politics and all institutions that uphold our society including healthcare 5 the effect of this on our society can hardly be underestimated because it is so pervasive and omnipresent it even influences the way we look at ourselves and the world around us all aspects of economic life are subjected to an economic rationale including the way individual subjects see themselves and organize their lives in order to have a viable existence citizens are forced to adopt entrepreneurial habits and be prepared to always be high performing this creates calculating individuals subjected to economic rationalism the instrumental logic of neoliberalism also transforms the way we look at care 6 as according to the laws of the market all human capital must bear fruit care is considered as an activity by which human beings deploy their human capital taking care of oneself is seen as an individual responsibility whereas taking care of someone else is regarded as an economic transaction in a logic like this human beings are not seen as the vulnerable corporeal beings they basically are neoliberalism holds a reductionist view of mankind as composed of rational selfsupporting creatures that all strive for wealth and freedom compassion can only have a place in this logic if it is cut to an instrumental size the roots of compassion as a premoral unpredictable and disruptive experience that opens up and connects human beings is to be avoided for its uncontrollable and irrational nature 7 in the logic of neoliberalism compassion appears as a commodity a trick to manipulate vulnerable patients at a deeper level in order to gain profit from them understanding care one should not be romantic about restoring compassion in healthcare neither does nostalgia bring us any further compassion cannot play the fundamental role it has played for centuries without the meaning frame that had accompanied it in those days and the institutional and political structures that went with it what can be done within our neoliberal society however is change the way we look at things by working on the concepts we use to organize our society no society can do without healthcare the more care is generally understood and agreed upon as a multidimensional human practice that is intrinsically contributing to a more humane world the less we need a concept as compassion to provide good quality healthcare how can this be realised one of the most inspiring stories in 20th century healthcare is the way dame cicely saunders contributed to transforming the way we care for the dying being denied and marginalised in a society traumatised by the second world war and hypnotized by the promises of modern technology care for dying people was often limited to physical support if at all 8 by introducing the concept of total pain and founding an institution st christophers hospice in london that played a leading role in developing a new approach to terminal care she helped developing a new way of understanding what care for the dying should be like worldwide palliative care is now seen as care for the whole person and his or her family intrinsically multidimensional including physical psychosocial and spiritual support and thus essentially non reductionist although of course culture can never be changed by one single person and the complexity of these changes involve a long and slow cultural process of patients and relatives learning to reorient their hopes and perspectives on living and dying saunders helped influencing policy making up to the level of the world health organization and changed the face of care for the dying the lesson we can learn from saunders is that healthcare can be changed but only then when our thinking about healthcare is changed as well saunders installed new practices of care accompanied with research and education that articulated a new way of looking at reality and by changing the way we look at the dying person it became impossible to accept any form of reductionism any longer palliative care is not only a specific practice of caring for people in a specific state but also an approach a philosophy including an anthropology that sees patients as relational beings embedded in a family context and asking for support in all dimensions of human life just as neoliberalism has entered our inner lives and deeply influences our perception of reality other ways of looking at the people and world around us may touch and motivate us to shape different practices that asks for reflective spaces in healthcare in which daily reality is analysed and reflected upon in order to understand why healthcare itself can be so unhealthy most healthcare professionals are trained to care for people for many years without ever reflecting upon the question what caring is and how it relates to a humane society they are trained to perform actions without thinking about the systems their actions are embedded in and the degree to which these actions contribute to a society that threatens the dignity of many of its weakest members good philosophical reflection on caring makes clear that this practice in whatever context or form it is performed is aimed at building a humane world in which people can live together in sustainable relational webs that compassion does play a role in such a practice goes without saying but it is neither the foundation of this practice nor the decisive element which makes the difference between good and bad quality care the real foundation of caring is our readiness and willingness to deal with our vulnerable and mortal human condition in a humane way the philosophy that helps spelling this out should be part of any healthcare curriculum ethical issues not applicable competing interests author declares that he has no competing interests authors contribution cl is the single author of the manuscript

although marianna fotakis editorial is helpful and challenging by looking at both the professional and institutional requirements for reinstalling compassion in order to aim for good quality healthcare the causes that hinder this development remain unexamined in this commentary 3 causes are discussed the boundary between the moral and the political neoliberalism and the underdevelopment of reflection on the nature of care a plea is made for more philosophical reflection on the nature of care and its implications in healthcare education

native american individuals have a higher 12month prevalence of alcohol use disorder relative to nonhispanic white individuals and are twice as likely to meet criteria for a severe aud they also have higher alcoholrelated consequences and morbidity and mortality rates including alcoholrelated motor vehicle accidents and suicides relative to nonhispanic whites however it also is important to note the wide variability of alcohol consumption patterns within any ethnic minority group while lifetime substance use is often lower among native american groups relative to other adults of the native americans that do consume alcohol there tends to be increased frequency and severity of use these variations in alcohol consumption and consequences may be associated in part to drinking cultural norms in a landmark article macandrew and edgerton argued that culture influences how people behave during and after drinking alcohol for example within group cultural differences have been found based on factors such as religious beliefs and religious commitment individuals who identify with religions that promote abstinence generally report higher rates of abstinence however those who drink alcohol have an increased risk of aud most southwestern tribes promote abstinence and prohibit alcohol such that alcohol is illegal to sell buy or consume on their reservation land given the impact of cultural norms and proscriptions against drinking alcohol crosscultural applicability of the aud criteria is warranted only one previous study has examined the construct validity of the aud criteria in native americans gilder and colleagues examined the validity of 10 aud lifetime symptoms except for legal concerns outlined in the diagnostic and statistical manual for mental disorders fourth edition among a native american community sample that endorsed drinking more than 4 drinks at least once in their lifetime they found support for a unidimensional construct in this sample suggesting that the abuse and dependence symptoms represent a single diagnosis social and interpersonal problems related to use and tolerance were associated with lesser severity whereas physical and psychological problems related to use and activities given up to use were associated with greater severity in terms of ability to detect who meets criteria for an aud and who does not social and interpersonal problems related to use had the highest discrimination ability and tolerance had the lowest discrimination ability gilder and colleagues did not include the criterion of craving that was added to dsm5 thus to our knowledge no previous work has examined the construct validity of the full dsm5 aud criteria in a treatmentseeking sample of native americans most previous factor analytic studies of dsm criteria for aud replicate the work by gilder and colleagues demonstrating that these criteria represent a single continuous latent factor these findings also have been incorporated into the newest version of the dsm 5 th edition in which the alcohol abuse and dependence disorders were combined to reflect a single disorder yet many of the studies used to justify the transition from two disorders in dsmivtr to one disorder in dsm5 relied on data from predominantly nonhispanic white samples that were not treatmentseeking thus we found it important to examine the unidimensional nature of the aud criteria in dsm5 in a sample of treatmentseeking native americans our study builds on previous research in several important ways one we are assessing the unidimensional nature of this construct using the dsm5 rather than the dsmivtr as previous studies have done specifically the current study included a measure of craving and was testing the validity of this criterion in a diverse sample two although gilder and colleagues found support for a single construct in native americans different clinical assessment measures were used gilder and colleagues used the semistructured assessment for the genetics of alcoholism to assess aud whereas the current student assessed aud using the structured clinical interview for the dsm lastly in contrast to gilder and colleagues our sample is treatment seeking and it is currently unclear whether the dsm items are discriminative within those seeking treatment for and meeting diagnostic criteria for aud as defined by the dsm5 the current study used baseline assessment data from a randomized clinical trial examining the efficacy of a culturally adapted evidencebased substance use disorder treatment to evaluate the construct validity of the dsm5 criteria for aud in a sample of native americans seeking treatment for alcohol and drug concerns specifically we sought to test the latent factor structure of the aud diagnostic criteria and examine item characteristics of the aud diagnostic criteria using item response theory we hypothesized that a single continuous latent factor representing aud severity would best fit the data in our sample irt analyses were exploratory and we did not have a priori hypotheses for the irt models methods measures addiction severity index demographic information was obtained using the asi a semistructured interview designed to assess several domains in individuals presenting for substance use concerns the asi has been shown to have good reliability and validity past year alcohol abuse and dependence were assessed using the scid alcohol use disorder module the scid alcohol use disorder module is a semistructured interview that assesses for alcohol abuse and alcohol dependence corresponding to the dsmivtr criteria this measure has demonstrated good reliability particularly when assessing alcohol abuse and dependence with kappa values ranging from 06510 structured clinical interview for diagnostic and statistical manual of mental disorders alcohol use module there was a change in the aud criteria from dsmivtr to dsm5 namely the removal of the legal consequences criterion and addition of the craving criterion although the scid for dsmivtr was used in this study a supplemental question addressing craving was also included a strong desire or urge to drink to assess the validity of the dsm5 criteria the legal consequences item was dropped from the analyses and the supplemental craving question was included for a total of 11 criteria in alignment with dsm5 alcohol abuse and dependence disorders were combined into a single disorder mild moderate and severe subclassifications also were used procedures the study was approved by the local university institutional review board and the tribal council research assistants explained the nature and condition of the study to all eligible participants and participants signed a statement of informed consent a federal certificate of confidentiality was also obtained from the national institute on alcohol abuse and alcoholism to protect participant information as part of a larger randomized trial participants completed baseline assessment measures before being randomized to a treatment condition all participants received compensation for the completion of the baseline assessment measures data analysis all analyses were performed with mplus data were treated as binary indicators such that each participant was coded as either having a criterion present or absent the scid is on a 3point likert scale with a score of one indicating absent two indicating subthreshold and three indicating threshold all absent and subthreshold indicators were coded as absent and all threshold scores were coded as present recommendations for sample size in cfa are varied but a critical sample size of at minimum five cases per parameter is needed the sample size in the current study size meets this minimum requirement with approximately 718 cases per parameter a single latent factor indicated by all 11 aud criteria items was tested with the latent factor mean set to 0 and variance set to 1 for model identification the robust weighted least squares estimation procedure was used to accommodate binary indicators and model fit was examined using the comparative fit index tuckerlewis index rootmeansquare error of approximation and weighted rootmean square residual there were missing data on three criteria failure to fulfill major role obligations hazardous use and interpersonal problems for 16 participants enrolled in the study wlsmv utilizes pairwise deletion to handle missing data we also estimated missing data using multiple imputation and there were no substantive changes in the pattern of results results item descriptive statistics percent endorsement of each aud criterion are presented in table 1 in this sample the repeated attempts to quitcontrol use and drinking morelonger than planned criteria were endorsed by almost all individuals in the sample much time spent using and activities given up to use were among the least frequently endorsed items of the 79 participants 9873 endorsed at least two criteria of participants meeting the dsm5 diagnostic threshold 641 qualified for a mild aud 1410 for a moderate aud and 7949 for a severe aud confirmatory factor analysis confirmatory factor analysis was conducted using the eleven aud criteria as indicators of a single latent construct the model provided an adequate fit of the data χ2 60219 p 00524 cfi 0954 tli 0940 rmsea 0068 p 0236 wrmr 0908 this provides evidence of the construct validity of the aud diagnosis in this population and further suggests that the dsm5 aud criteria reflect a unidimensional construct standardized factor loadings for each aud criterion are presented in table 1 results indicated that ten of the eleven criteria loaded strongly and significantly onto the latent factor ranging from 0522 tolerance to 0887 withdrawal the loading for repeated efforts to quitcontrol use was not significant item response theory item discrimination and difficulty given that the results from the cfa suggested that the aud criteria reflect measurement of a single latent trait in this sample of treatmentseeking native americans a twoparameter irt model was used to further examine the relationship between each criterion and the latent trait irt analyses provide information on two main parameters item discrimination and item difficulty discrimination scores are slope parameters steeper slopes indicate that a criterion is better able to distinguish between individuals scoring low and high on the aud latent trait continuum difficulty scores are xcoordinate parameters that correspond to a 50 probability of endorsing a criterion as the difficulty parameter increases it suggests that an individual needs a higher severity on the latent trait to endorse that criterion at least half of the time results from the irt analyses are presented in table 1 and item characteristic curves are presented in figure 1 the largest discrimination scores in the sample were found for withdrawal socialinterpersonal problems related to use and activities given up to use the criteria with the lowest discrimination scores were repeated attempts to quit control use tolerance and drinking morelonger than planned aud criteria associated with the highest severity scores were much time spent using and activities given up to use the lowest severity scores in the sample were repeated attempts to quitcontrol use and drinking morelonger than planned discussion this study is the first to have examined the validity of the dsm5 aud criteria in a sample of native american participants seeking treatment for substance use problems confirmatory factor analyses results suggested that an 11item onefactor solution was a good fit of these data in this native american treatment seeking sample these findings are in line with other research that has identified a onefactor model of the aud construct across studies and in a native american community sample albeit with 10 of the current 11 criteria furthermore these findings provide crosscultural support for the conceptualization of aud as a single continuous factor in a treatment seeking sample of native americans all criteria loaded significantly onto the latent construct except the repeated attempts to quitcontrol use criterion other research in treatment seeking samples has also found that this criterion did not load significantly onto a single latent factor furthermore this criterion was endorsed by almost all participants in the sample it could be that this criterion is appropriate for use in discriminating between those with and without aud but is less informative for treatment seeking individuals indeed kessler and colleagues found that endorsing this criterion was associated with increased odds of seeking treatment for an aud and preuss and colleagues suggested that the repeated attempts to quitcontrol use should be considered to reflect mild aud in their alternative classification system few studies have examined item difficulty and discrimination scores for dsm5 aud criteria in general and none have examined these parameters in a diverse treatmentseeking sample the current study suggested that the withdrawal socialinterpersonal problems related to use and activities give up to use criteria had the highest discrimination scores whereas the repeated attempts to quitcontrol use tolerance and drinking morelonger than planned criteria had the lowest discrimination scores these results are comparable to results from irt analyses in a nontreatment seeking native american sample using dsmivtr criteria and in an international sample of individuals who were consuming alcohol using dsm5 criteria in these samples social and interpersonal problems related to use and activities given up to use had the highest discrimination scores similarly the tolerance criterion had the lowest discrimination score in this native american sample less severe aud was represented by desire to quitcut down drinking morelonger than planned and tolerance these results directly reflect findings from other studies in which these items were also among the easiest to endorse more severe aud in this native american sample was represented by endorsement of the much time spent using and the activities given up to use criteria which coincide with results of preuss and colleagues in their native american community sample gilder et al found that withdrawal and activities given up to use were associated with greater severity all the difficulty parameters in the current native american sample had negative coefficients which may reflect the fact that all participants in this sample were treatment seeking and most had severe aud compared to other studies using nontreatment seeking samples or a survey of individuals who are currently consuming alcohol the results from the irt analyses suggest potentially useful treatment implications for aud in this native american sample specifically many of the items that were most informative with respect to discrimination and severity reflected a narrowing of activities and interpersonal problems related to use given these findings a treatment such as the community reinforcement approach may be a useful intervention cra targets relationship happiness and focuses on increasing pleasant reinforcing activities rather than just on stopping alcohol use results from an evaluation study and a pilot study suggest the efficacy of the cra approach in native american samples and the results from the current study suggest a cra framework for treatment may also be beneficial and address particularly salient consequences of problematic alcohol use in this sample limitations and future directions the current study had several limitations first the sample size used in this study was small and included a sample of native americans from one tribe in the southwestern united states future studies should replicate these findings using larger samples and examine whether these results generalize to other native american and indigenous groups second these data relied on selfreport recall of alcoholuse and alcoholrelated problems over the past year which may be subject to recall bias third this study used an adapted version of the scid for dsmivtr to assess for dsm5 criteria future studies should continue to assess the validity of the scid for dsm5 in diverse groups however in the current study the wording used in the different versions of the scid was quite similar the craving criterion was assessed using almost identical prompts and a comparable procedure was used in previous studies to help advise and test proposed changes made in the diagnostic criteria for aud from dsmivtr to dsm5 conclusions the current study provides preliminary support for the validity of the dsm5 aud diagnostic criteria as a single continuum in a sample of native americans seeking treatment for substance use concerns additionally this is the first study to examine the dsm5 aud criteria using irt analyses in a diverse sample of treatment seeking individuals these findings suggest that social and interpersonal problems related to use and activities give up to use may be more informative criteria for assessing aud severity in treatment seeking native american samples whereas repeated attempts to quitcontrol use and drinking morelonger than planned may be less informative future research with other native american and indigenous populations will shed light on the crosscultural applicability of the dsm5 aud diagnostic criteria and may highlight important cultural considerations in conceptualization measurement and treatment of aud

objective despite high rates of alcohol use disorder aud and alcoholinduced deaths among native americans there has been limited study of the construct validity of the aud diagnostic criteria the purpose of the current study was to examine the validity of the dsm5 aud criteria in a treatmentseeking group of native americansas part of a larger study 79 native americans concerned about their alcohol or drug use were recruited from a substance use disorder treatment agency located on a reservation in the southwestern united states participants were administered the structured clinical interview for the diagnostic and statistical manual for mental disorders dsmivtr scidivtr reworded to assess eleven dsm5 criteria for aud confirmatory factor analysis cfa was used to test the validity of the aud diagnostic criteria and item response theory irt was used to examine the item characteristics of the aud diagnosis in this native american samplecfa indicated that a onefactor model of the eleven items provided a good fit of the data irt parameter estimates suggested that withdrawal socialinterpersonal problems and activities given up to use had the highest discrimination parameters much time spent using and activities given up to use had the highest severity parametersthe current study provided support for the validity of aud dsm5 criteria and a unidimensional latent construct of aud in this sample of treatmentseeking native americans irt analyses replicate findings from previous studies to our knowledge this is the first study to examine the validity of the dsm5 aud criteria in a treatmentseeking sample of native americans continued research in other native american samples is needed

providers long ignored the suburban poor have recently attracted the attention of studies examining the intersection of poverty healthcare social services and drug use in the suburbs methamphetamine is a stimulant that provides energy produces a feeling of pleasure and decreases appetite which makes it an extremely desirable drug regardless of its illegal status yet there are tremendous problems associated with ma use including stroke cardiac arrhythmia stomach cramps and muscle tremor anxiety insomnia aggression paranoia and hallucinations ma use is associated with higher risks for infectious diseases ma withdrawal can produce depression and suicidal inclination and the mausing social context is highly associated with injury and violence for women in particular in this paper we examine mausing women living in suburban enclaves of poverty the aim of this study is to identify how this population accesses basic resources and needed services we use social capital to guide our analysis and direct our attention to the social determinants associated with drug use that impact social wellbeing and health theoretical framework social capital social capital refers to social resources that are available to individuals from their social networks social capital has emerged in the literature as a valuable concept to help understand the inequality of status achievement based on social ties and access to resources in addition the concept has been used to examine the unequal distribution of social resources within communities and across social networks that functions as a barrier to obtaining desired goals social networks are proposed to be the main source of social capital likely to profit individuals as adults for example as individuals become connected within their community social relations within this community provide resources such as access to employment opportunities or social and health services the relationship between the individual community resources and resources available from other social networks is part of what we call social capital social capital that results from relationships between individuals in the same community or network is called bonding social capital whereas bridging social capital results from relationships across social divisions such as race and class a robust association between social capital and health was found in an extensive literature review of international studies on the links between levels of increased social capital and better health which was particularly strong in the united states the literature suggests that the social capital concept also can be used to better understand drug use dynamics the concept of recovery capital based on correlation between social capital and recovery of addiction is used to predict cessation of drug use and sustained recovery social capital is sometimes referred to as the nature and extent of a persons involvement in informal and formal networks previous research suggests that these networks operate in conjunction to meet the persons needs informal networks are comprised of family friends and neighbors while formal networks include community organizations such as schools social service agencies and healthcare systems according to beggs haines and hurlbert the receipt of informal support affects the receipt of formal support a higher level of involvement in formal and informal social activities may lead to fewer negative health behaviors such as substance use networks have functional and instrumental components networks including relatives kin and friends can provide instrumental support such as transportation small loans or places to stay drugusing networks though can result in negative social capital physical and emotional risktaking stigmatization and selfdefeating behaviors are associated with resource allocation from drugusing networks in addition drug users and their social networks may utilize suboptimal medical services so although services may be utilized the quality and effectiveness of use is variable prior research suggests that financial resources are associated with healthrelated behaviors quality of life measures include individuals perception of health physical psychological and social functioning and wellbeing as well as position in life and expectations in the context of the culture in which they live the fact that people who are not well off have shorter life expectancies and more illnesses than the rich reveal that differences in health that are not only a social injustice but also highlight the social determinants of health as long as lack of education low job skills lack of sustainable employment and restrictions on geographic mobility stay in place their social mobility prospects will continue to be dim difficulty occurs when tearing away from the subculture community in pursuit of upward mobility for example facing the loss of subculture support was found to be a barrier for sex workers creating new lives for themselves leaving them more isolated from healthy forms of support women more than men drug users suffer from the impact of social capital loss and negative social capital women using drugs face double stigmatization by a society that accuses them of violating gender role expectations especially if they are mothers older female drug users also face narrowing social options and are more marginalized in society than their younger peers moreover poor substance abusing women are found to have scarce resources within their own networks marginalized female users can experience a loss of social access which is needed to pursue new social contexts ultimately when mausing women are not receiving access to needed resources these experiences also act as barriers to their social wellbeing and mobility while studies have examined the association between social capital and wellbeing among disadvantaged drugusing populations there is scant research on social capital dynamics among disenfranchised drug user populations living in the suburbs the aim of this paper is to examine how lowincome mausing females in the suburbs access needed resources we examine need areas including housing legal assistance education employment medical care dental care and drug treatment we investigate the processes involved and specifically how social capital resources are employed using the womens subjective accounts verified by our own ethnographic fieldwork this study advances our understanding of the social and contextual impact on social capital attainment and how this affects access to resources among this group of marginalized female drug users methods between 2009 to 2011 thirty active and former female methamphetamine users participated in this study drawn from the suburban counties around a large metropolitan area in southeastern usa participants were recruited using a combination of targeted snowball and theoretical sampling methods the majority of the 30 participants were recruited through targeted ethnographic fieldwork some referred their friends to call our study number resulting in 11 additional participants based on our developing theory of recovery trajectories we also recruited three former users with recovery experiences active users were defined as having used methamphetamine at least one time in the past month former users were defined as having used the drug for at least six consecutive months in the past but having been drugfree for the last month to be eligible participants had to be residing in the suburbs of the city at the time of use and be 18 years or older at the time of the interview for this study they also had to be female a consent form was read and agreed to before collecting data in order to protect the anonymity of the participants we collected a signed consent form that was not linked to the study data only the researchers on the study knew their identity and contact information participants were reimbursed for their time and given the choice of cash or gift certificate reimbursement for participants has been shown to be ethical and useful in collecting research on hidden and stigmatized behaviors the researchers universitys institutional review board approved the study methods and design a screening process was used to ensure that participants pass the eligibility criteria to participate in the study screening consisted of asking questions about age drug use in the past 30 days use of methamphetamine in the past six months and the county where the potential participant resides interviews were conducted in a safe location agreed upon by the interviewer and participant these included the interviewers car the participants home motel rooms private university rooms and library rooms participants were offered food during the interview such as pizza and soda or snacks the research team for this study included two female coinvestigators who conducted the first interviews and focus groups interviews and two female research assistants who helped with the focus groups a few of the followup interviews finding resources the women needed data management and analysis all research team members completed the nih webbased course on human participant protections education for research teams using ethnographic methods we conducted fieldwork that involved finding field sites distributing fliers and talking to anyone interested during the day we walked the streets of suburban towns or drove through subdivisions and trailer parks located in the suburbs in the evening and night we frequented bars clubs and 24hour diners we often employed a community consultant who was a person familiar with the drug using networks and could introduce us to insider settings the final sample consisted of 31 women but only 30 were used in this data analysis which was conducted before the last participant was interviewed among the 30 women in the sample 26 are white 2 latino and 1 african american one woman reported to be american indian the youngest woman was 19 and the oldest was 51 years old a little over half were active users of ma all active users were lowincome and the majority were unemployed underemployed or employed in illegal work the majority of former users were unemployed or being supported by relatives we collected data at three points in time from the same participants a first facetoface interview a followup indepth interview that was conducted facetoface or on the phone and a focus group interview participants chose to join a focus group or conduct the second or third followup interview alone among the 30 women in the study used for this analysis 5 were interviewed once 9 were interviewed two times with an average of 5 months between interviews and 16 were interviewed three times with an average of 7 months between the first and last interview this represents less a 17 attrition rate for the second interview point which is typical in longitudinal studies of hidden and hardtoreach populations we had a higher attrition rate by the third interview which was largely impacted by the number of women who became homeless and left the suburban communities in search of shelter sixteen women participated in one of the six focus groups we used a longitudinal design in this study in order to examine changes over time the first interview incorporated four data collection instruments a life history matrix a drug history matrix a short risk behavior inventory and a semistructured audiorecorded indepth interview the life history matrix completed with pencil by the interviewer is a research tool designed to focus the participants on retrospective life events during the indepth interview conducted at the start of the study this matrix data collection allowed the interviewers to develop rapport and established an additional validating strategy the interviewer then collected data on a drug history matrix with pencil the drug history included information on first use of each drug past six months use past 30day use and routes of administration the risk behavior inventory asked about the drug and sexual risk behaviors such as syringe and condom use in addition we provided healthcare and medical information of drug use health risks and a list of social service resources in the area the first interviews lasted about two hours participants were reimbursed 30 for their time for the followup interviews we updated the drug use matrix and risk behavior inventory and conducted a short qualitative interview specifically to see how they used the resource list we provided an updated healthcare social services and drug treatment resource list developed by the research assistants was given to each participant targeted for her specific needs followup interviews typically took about onehalf hour participants were given 40 cash or gift certificate for their time the increased amount was to encourage them to conduct the followup interview immediately after the focus group was completed the participants met individually with the researchers or research assistants to update the matrices and were asked privately about their access and utilization of service resources the women were free to discuss topics of interest to them as well since the data used for this paper are derived primarily from the focus group interviews we provide more details on this data collection the focus groups consisted of two three or four women who typically did not know each other we used participants study number or a pseudonym if they desired we started with introductions and then conducted an icebreaker exercise aimed to explore accessibility to risk awareness and utilization of social services and healthcare providers the exercise consisted of placing a number of cards on the table with the names of health and social services taken from the list we provided to the women in the first interview women were given colored cards to place on the resource each card coincided with a response as to whether the resources was needed used or not used immediately after the game we discussed why certain cards were put on each resource for example if a resource was needed but not used we asked why not if a resource was needed and used we asked about the experience of accessing the resource we found the card game to be very effective and provided more than merely an icebreaker in fact the women became so engrossed in identifying the right card that much discussion occurred during the game itself after the first focus group we included a different colored card stating i would like to talk more about this service to ensure more focused discussion during the focus group we employed a semistructured interview guide that served merely as a framework on which to maximize group discussion and interaction main questions included areas on recent health and hivrelated awareness prevention experiences needs assessment use of the resource list and experiences in gaining access to needed healthcare and desired treatment resources and approaches that were found to not be effective were discussed and suggestions for better strategies were explored accessibility to public healthcare services and employment opportunities emerged as the major problems refreshments were available either before or during the activity at a time when a break was needed the entire interview was recorded and the qualitative parts were transcribed participants were given 40 in cash or a gift certificate for their time all of the women stated that the focus group helped them and they hoped their discussion could help others who had problems similar to their own we conducted six focus groups with sixteen women a woman could only participate in one focus group and it could be on the same day as either the second or third interview the reasons why some women did not participate in a focus group included moved too far away from the research study area difficultly finding a twohour slot of freetime or preferred to conduct their followup interview alone in two cases the women were incarcerated in five cases our team lost contact with women who were homeless at the time of their first interview or lost their homes during the course of the study ethnography is a living and dynamic form of research an unexpected aspect of our ethnographic study was the changing involvement of the researchers similar to engaged ethnography while conducting our ethnographic fieldwork we recognized our privileged positions and did not ignore the cognitive dissonance we felt due to the knowledge that we had access to what our participants needed fortunately engaged action was fitting with of our study goal which was to better understand the availability and accessibility of healthcare and social services in the suburbs as well as barriers to these services instead of remaining distant observers of the social action we were investigating we became engaged ethnographers by applying what we found to be beneficial for the women our engaged ethnography led to applied ethnography meaning that not only did we think reflexively about what we were doing while conducting research but we also applied the tricks of the trade we learned while being engaged with our research participants applying our knowledge and better resources to help the women gain access to services they needed we discovered further barriers we would have missed if we had relied only on the womens limited resources one example illustrates this point poignantly when we learned that an initial barrier to services was lacking a phone and therefore not having a number to leave when the ubiquitous voice mail message asked for a number to return the call we called the service while we were with our participants and left our own study phone number due to this engagement in the research we subsequently learned that healthcare and social service staff typically failed to respond to our messages we continued to apply the resources we had available in another example when no one returned our phone call at a womens shelter we called a professional friend who we knew supported the shelter financially and within an hour received a phone call from the shelter director her intervention eventually led to a bed in a shelter however when our study participant arrived at the shelter with her children she learned that the house was located in a drugdealing neighborhood with crack dealers on every corner reluctant to expose her children to crack dealers she did not go to the shelter and instead accepted temporary shelter from a male friend but not without further consequences this obstacle of having to rely on friends in low places would never have been revealed nor reported had we not become engaged with overcoming initial obstacles to needed services and further applied our resources to ensure a bed in the shelter the socioeconomicgeographic barriers and the womens viewpoints on shelters located in dangerous areas were very important findings in this study although we did not achieve helping the women we did achieve our research goal of understanding the complexity of challenges the women faced when trying to access needed healthcare and social services interviewers wrote notes on their reflections of the interviews within 48 hours as the data were collected we compared the responses on the data to gain a clearer understanding of the phenomenon and to inform the continuing data collection and analysis the indepth interviews were transcribed word for word data analysis began with the first few interviews using the constant comparison analysis common in grounded theory the qualitative data analysis program qsr nvivo was used for data and coding management the research team conducted the initial coding and research assistants trained in qualitative methods helped with second and third coding for this paper the first coding was conducted by the first author and reaffirmed by the coinvestigators the codes focused on what the woman discussed regarding barriers to needed resources and for those who were successful how they accessed resources validity and reliability the interviewer notes life histories and drug histories indepth interviews and followup interviews were used to triangulate analysis of the data using the iterative model the iterative model of triangulating data throughout the study by comparing information collected from various sources and addressing issues of validity and reliability as the study progresses has been shown to provide greater confidence in understanding complex information although research show that drug users tend to report valid information in qualitative interviews the addition of quantitative data collected in the drug history matrix and risk behavior inventory was used as a reliability and validity check for the qualitative data any inconsistencies found were further explored through an iterative process in followup interviews field observations and focus groups data analysis based on the analysis of the interview transcripts field and interviewer notes and focus group transcripts 34 initial codes were created to identify needed resources the most problematic services and the barriers to accessing services codes were associated with restrictions initiated by the services and limitations on the part of the participants which were verified by the researchers during efforts to link participants with the services the services were categorized by resource type housing medical dental transportation education legal aid employment and treatment the most problematic services needed but not accessible were treatment medical dental and housing which is consistent with other research among the most marginalized suburban woman problematic needs also included education employment legal aid and transportation services barrier codes included lack of transportation service fees waiting lists lack of communication disqualifying criminal histories service use caps identification requirements and fear of agency intervention with children during the followup interviews and focus groups we examined how many women accessed the services they needed participants who did not receive the needed service in a specific category were coded unmet need if a participant accessed at least a resource in a specified need area she was classified as having a need met discussion of these coded areas revealed that social networks provided or facilitated the majority of links to needed resources this was a turning point in the analysis whereas previously we focused on formal or informal processes to provide resources we discovered that some of the women accessed resources indirectly through family friends extended social networks two network types formal and informal were first identified and coded based on whether resources came directly through a formal source the service or through an informal source such as their social network a third new category captured the process of accessing resources when mediated indirectly by a formal and informal network the three processes employed by the women attempting to obtain needed resources included formaldirectly from social services informaldirectly from family or close social networks mediatedindirectly mediated involving help from extended social networks or other contacts including researchers we then assessed if needs were met or not met through these processes and examined the results the findings are presented as positive or negative results for each of the three processes quotes are chosen that best represent the essence of what more than one woman expressed or experienced in her attempts to access needed resources findings whereas lowincome women access needed resources through formal or informal process our findings show that suburban female ma users often are not having their needs met through either formal service providers or informal networks instead many needs are met through a mediated process between their informal social networks and formal social service providers and staff the women mentioned barriers and risks for each type of process employed and we found both beneficial and negative results for each whether or not they obtained needed resources as is common of qualitatively defined categories the boundaries of our positive and negative codes are porous as we will point out although one result might appear positive since the goal of gaining a resource was achieved it may have been accompanied by immediate or potential risks to the women for example a woman might achieve making an appointment to a doctor at the cost of paying her neighbor gas money to drive her there which further depleted her precarious financial situation or worse indebted her to the neighbor who is typically a man we placed the womens reported experiences in the context of their social environments and social capital potential for example when a woman obtained her needed resource although there was a potential risk it was coded as positive unless a negative incident resulting from this process occurred during the period of the study due to the overlap in how women used their resources to obtain needed services and because it is not always possible to disentangle one type of method of obtaining resources from another we do not provide a quantitative assessment of the way women accessed services instead we provide an indepth qualitative assessment using the womens stories as data formal positiveexamples of positive formal processes of obtaining help while assumed to be the most realistic process since this is what social services were designed to do were actually the most difficult to document in this study in every instance where we heard a participant had obtained help directly through a health provider or social service on our resource list or elsewhere further inquiry revealed that either informal help or a mediator was used in the process in one case a woman had been trying to obtain medicaid to treat a health issue during her entire participation in the study we learned that she was finally successful three years later which was more than a year after the study ended so we were unable to document the details negativemany of the women found barriers when attempting to access services directly the most common barriers to accessing social services were waiting list service use caps criminal history fee id restrictions transportation lack of communication device and fear some women were referred to other services and given wrong numbers got only voice mail messages or were put on the service waiting lists as one participant stated theyre either not taking new patients closed theres so many criterias that you have to meet if you can even get on their list and if you get on the list the waiting time is like six months to a year by that time god knows where you are you wanna give up you wanna say to hell with it some of the service providers appeared not to acknowledge or care that needed services were not provided although a few seemed to have empathy for example when we attempted to access a shelter bed for one of our participants in a suburban county the social service worker told us the people in that county are screwed referring to the homeless fear of legal intervention and loss of child custody were real barriers for women with young children and some stories we confirmed showed that accessing services directly resulted in a negative experience for these women for example mothers are required to undergo drug tests before accessing some services and this resulted in unwanted intervention by public child protection services researchers observed no danger to child welfare but some women were frustrated with the public agency intrusion into their lives they viewed the required oversight as a loss of privacy rights and felt that family service agencies generally did more harm than good in their experiences emotional barriers such as shame guilt feelings of hopelessness and learned cultures of racism also deserved closer scrutiny a few women in predominantly white social networks feared using a shelter because there were too many blacks there for them the risks of violence at the hands of a male they knew were better than the risks of unknown people they had been taught as children to fear informal positive the women quite often turned to male assistance for their needs relying on male relationships tended to leave these marginalized women even more at risk yet sometimes their trust in a male in their network produced positive results we were a little apprehensive when one of our first participants who was homeless when we met her started a romantic relationship with a man she met at a support group meeting in a short time the unmet needs we had identified in our interviews were met through the help of her new male partner he gave her a car to drive to appointments a phone to call out and receive calls back from the services on our resource list and money for dental work including full dentures if it werent for him id be walking around with no teeth she told us as more of her immediate needs were met she was able to contact the legal resource contact we gave her to start the divorce paperwork that she had not been able to do for years with her boyfriends help this participant obtained more needed resources than any other woman in the study yet her complete reliance on one person leaves her at risk for exploitation abuse or abandonment another major inhibitor was transportation i didnt have a ride was a recurring reason not to make an appointment or keep an appointment at a social or healthcare service unless they lived on a bus line which most did not they lived too far from the service to walk and needed help from someone with a car the only hope for most of the women who were without cars was someone in their network who had a car as one woman who was in treatment said thats my main thing to get a job and get a car i need a car im just trying to get me a car because i feel so bad my sisters taking me to meetings my sisters taking me to doctors appointments likewise another participant described how a close knit femaleusing network obtains food from the store or a food pantry we help each other if one gets a ride they get food for the rest of us too negativehaving help from someone with a car was necessary for many woman to access needed resources but what was particularly problematic for these women was when it came from potentially harmful situations including exploitative friendships abusive male sex partners or broken family relations in these cases the woman was often in danger of being harmed or exploited which was a chance they usually took there were no direct harmful consequences during our study other than a few who said that someone they had relied on to go to an appointment never showed up or came hours late yet we heard many stories of past negative experiences when relying on close relations especially abusive partners of all the areas of need participants were most likely to obtain housing within their network this put them at risk for domestic violence instability and increased drug use for example one woman explained the power was turned off in our house so we moved in with our drug dealers boyfriend we lived over there and thats when all the shooting up injection drug use really began a young homeless female who occasionally stayed with her mom provided some more insight during her interview she mom tried suicide but it was a cry for attention and me and her are like thelma and louise we both are party animals you know it is better to stay away from my greatest demon interviewer do you have anyone who can help you no because youre a misfit youre no good when you got friends in low places you stay low referring to herself her mother and her friends this womans response was consistent with the emotional climate we found among other poor mausing suburban females they are often imbedded in social networks that have very little to offer and their communities are isolated in poor areas away from social services forcing them to further rely on the other mausing relationships we observed repeated exploitation of our participants for example one womans former landlord was helping her by allowing her to stay in a trailer with broken windows no working utilities and dog feces inside researchers visited the site and found it to be completely uninhabitable the same woman lost her only form of identification a drivers license which she was keeping at former employers home for safekeeping she did not report this person because she thought she might work again for her in the future which she did a few participants told us about a landlord who overworked and underpaid them to clean and manage the trailer park in exchange for free rent in dwellings that were not fit for human living one dwelling was a trailer in the hot sun with no shade and no air conditioning the temperature gauge inside was reported to read up in the 90s during the summer one of the females explained what happened if they slowed down in their work he was angry for us not going to be a slave some morecheap labor he gets everybody to do it you know gets that cheap labor does it to this housethat house everybody were going to have to stay there because we dont have no place right now many of the women in one extremely poor and disenfranchised social network remained in contact with us through the cell phone of one participant the females in this entire network made use of one single phone which provided some hope for return calls from potential job offers caseworkers and financial assistance organizations the women relying on this phone explained these people social service providers and employers want a telephone number to call you back and you get a recording you dont never get to talk to nobody i called i didnt have access to a phone number for them to call back but they acted like they would help me if i had a number the price however was the woman with control of the phone often took it upon herself to attempt to engage in conversations and provide questionable information about other participants when we called we wondered how she answered the phone when potential help from social services or employers was on the other end mediated positivealthough the women reported extreme difficulty attempting to obtain direct help from either formal services or informal social networks they seemed to have greater success when formal and informal social networks mediated services one of the most debilitating barriers was that of obtaining proper identification as voting requires citizens to present id we expected this to be a minor problem instead it was the main reason some of the women were living on the street without services for years for example we acted as mediators for one homeless woman to obtain an official id with no home address and all of her personal documents long gone she had to use the dental records of her recent trip to a dentist to first obtain a birth certificate in order to receive a copy of her drivers license that was stolen in this case we provided the mediation but it took over a week a photocopy machine a fax machine one of our personal credit cards and the use of our institutions address in order to acquire her birth certificate from another state another example of mediation came from an unlikely source one of our participants had tried unsuccessfully to enter an inpatient treatment center and finally was accepted at the emergency room when she said she was withdrawing from alcohol and barbiturate addiction and suicidal although she was an alcoholic she confided to us that only by saying she was suicidal was she sure they would take her for a short stay in the intensive detoxification unit while she was there she met another patient in the unit who was empathetic to her story in her words i didnt have anywhere to go i was headed for the woods i was headed for the tent city in front of the shelter because i cant go back to the shelter for six months because once you are there and you leave you cant go back for six months thats not an option so i called my friend that i was in the hospital with and she got into this program i said im just calling to tell you that im not in the motel i dont have anywhere to go ill be in the woods i dont know what else to do she said wait a minute let me call the director of our program let me see if i can get you in we played phone tag all afternoon and i got in without a facetoface interview on her wordbecause of my friend i got on the bus and she met me to take me downtown i was really amazed that i got in off the street on the word of one of their clients this service was located in the city and the network contact was made during a hospital stay and not a part of her close network but because her new contact gave her a referral to this residential treatment facility for women she was accepted the program included longterm case management by her last interview one year later she was drugfree working and planning to leave the facility and go to the next step of the program into a rental apartment she remained friends with the woman she had met in the hospital and who had acted as her mediator an informal social support group acted as a mediator for another woman in our study she lacked the fees needed for the general educational development registration she told us in dejectedly god its the most frustrating thing ive ever tried to do because its ged something thats so necessary if you want to do anything with your life and they make it so difficult to get it it makes me sick to my stomach there is no help if there is help i cant find it subsequently a contact she met through twelve step program offered the financial assistance she needed this was an example of help coming from outside of ones drugusing network negativealthough mediated help was usually successful problems could arise when social services were obtained from relationships outside the womens immediate social network especially when it was from positions of power participants reported unethical practices of service providers who used their connections although their intentions were often respectable in one example of a negative mediation a nonprofit director promised a set of dentures for one of the woman saying he would make her a poster girl for the reduced dental services program he ran when she arrived for her appointment all she obtained for free was a consultation with a dental plan showing she would need nearly a 1000 to complete needed dental work when asked why he did not do as promised he explained that he was out there trolling for money every day and donations were dwindling in another example a woman in the study overcame her fear of withdrawal and faced the threat of losing her children by attempting to enter a detoxification unit through the emergency room homeless she finally obtained transportation from a male friend to a detoxification facility only to be released 12 hours later she later tried to take barbiturates to qualify for detoxification but was also denied longterm admittance we intervened and called the emergency room only to be told that once stabilized uninsured patients are legally allowed to be discharged this failure of the social service system to connect an ma user who also used barbiturates and methadone directly with treatment resulted in this participant resorting to taking a dangerous combination of methadone and barbiturates to selfmedicate and ease her discomfort with withdrawal discussion participants in this study were lowincome women who used methamphetamine although their greatest difficulties stemmed from poverty and not drug use they tended to experience many psychological social and organizational barriers when trying to access needed healthcare and social services through formal processes additionally it seemed that many social workers treated participants in inappropriate ways by hanging up on callers failing to return their calls displaying negative attitudes and making disparaging remarks about them social research should investigate ways to resolve these negative attitudes and behaviors particularly toward vulnerable populations when women experienced continuous barriers to accessing resources they tended to rely on their social network for help informal network access to services increased their chances of successful attainment of these services but these networks often had little social capital and sometimes failed to be of assistance or kept them embedded in a life involving exchanging sex for services exploitation feelings of shame and selfdefeating behavior all of which potentially ties them in a cycle of drug use and poverty relying on these tight network bonds further binds the women to their mausing networks and for some poor female ma users utilizing ones social networks to gain formal resources was not an option they often place themselves at risk for injury exploitation and abuse at the whim of uncaring strangers which reduces their chances of recovery and social mobility there were no significant differences between women who were active or former users of methamphetamine in their experiences of barriers to services or access to resources the only significant difference in barriers to services found was among those who had been incarcerated and therefore lost most privileges to government services we also found differences in access to resources among those who participated in social programs such as 12step or church groups and therefore received help from people outside their immediate social networks however due to the lack of transportation most of the women were unable to continue attending any type of social program that was outside their immediate geographic location except for a few of the younger women all of the participants in the longitudinal study were in socially disenfranchised circles of family and friends who could offer little more than emotional support as the woman who told us the illustrative quote used in title of this paper described so expressively and to paraphrase here when your friends and your family are in the same poor and marginalized situation as you there are few resources available to help change your socialeconomic status our study revealed that both formal and informal processes for obtaining needed resources resulted in positive and negative outcomes although this was a small study and no definite conclusions can be made the mediated process of achieving resources appeared to be most successful whether the mediation involved close or extended informal networks with formal sources of help the women typically achieved their goals along with increased social capital we suggest further focus on mediated processes needs to be explored among poor drugusing populations models similar to mediated help for achieving needed resources already exist in case management that helps patients move smoothly through the healthcare system patient navigation which is a form of nursing care individualized to each patients needs was conceptualized by harold freeman specifically for poor cancer patients the patient navigation model was used successfully among pregnant women in drug courts we suggest a similar model is needed to mediate healthcare and social service navigation for women with few social resources that involve their informal social networks limitations the limitations of this study lie in its small sample size and exploratory nature further research is needed regarding the processes we examined to obtain needed resources also a larger study is needed to understand how some processes might be more harmful or successful than others for example reliance on family members or friends often include reciprocity that could put the women at further risk such as the women who relied on unlicensed rides from neighbors with cars who were usually men in addition mediation by informal groups also demands some commitment to the group and women who have children to care for or lack transportation cannot always fulfill these commitments we found that the failure to commit to these groups placed additional stress and guilt on the women which is another area that needs to be further studied the present study does not claim to fully capture the daily challenges associated with unmet resource needs for example although we knew that not having transportation was a reason why some of the women stopped going to a 12step support group or religious service as well as the reason for missing an appointment they often did not mention this unless we asked specifically moreover many of the participants did not want to discuss how many times a day they are negatively affected by other daily barriers such as not having someone they could trust to watch a child or not owning decent clothes to wear to church these were sources of shame and further stigmatization that some of the women discussed but others did not and needs to be further examined finally what we consider a barrier may be accepted as part of normal life for example as the women become accustomed to not having certain resources they learned to live without them and may no longer consider having to rely on a neighbor as a barrier to services they also felt that in comparison with some of the women in their social networks they were better off we often found that the women did not like to talk about their lack of resources and failures to access needed services because they did not want to seem as if they were complaining likewise we acknowledge that our participants were perhaps less likely to mention positive outcomes of directly accessing healthcare and social services finally our category of mediated processes is limited and involves primarily mediation conducted by members of the research team however we did not conduct the study with a mediated resource in mind instead this emerged as a result of the analysis the process of mediation applied by engaged researchers needs to be examined more thoroughly as a research topic in a future research study conclusion this exploratory study found that lowincome suburban female mausers are blocked by long lists of bureaucratic restrictions and other limitations from the formal social service network our data reveal that time after time many female ma users in these southern suburbs remained unable to obtain basic resources from the social service and healthcare systems designed to help them while bureaucratic inertia and apathy towards the needs of the poor is not a new finding this is one of the few studies that looked at how disenfranchised women living in the suburbs with few resources access needed services what we found is that many of the public resources available to women living in the cities were unavailable to women in the suburbs when they resorted to getting help from their social networks they remained anchored to marginalized members of disenfranchised communities with low or negative social capital leaving little hope for a better life we know that social exclusion plays a large role in health disparities across the life course and that social services and safety nets for the poor have not kept pace with the increasing dispersion of the poor from the cities to the suburbs in a seminal article written in 1976 syme and berkman wrote rather than attempting to identify specific risk factors for specific diseases …it may be more meaningful to identify those factors that affect general susceptibility to disease of particular interest would be research on the ways in which social and familial support networks mediate between impact of life events and stresses of diseases outcomes the medical field made long strides to incorporate the social determinants of health in research and practice since then we suggest that today rather than merely attempting to break down the barriers to access healthcare and social services we instead identify the process by which the poorest and most disenfranchised are obtaining needed resources mediated processes were generally successful in our small exploratory study however the consequences of mediation from different sources remains largely unexamined our findings suggest that mediated processes need to be incorporated into formal healthcare and social services such as shown in the patient navigation care model and mediated processes using informal social networks need to be further explored the findings highlight the success of employing a type of research design that is actively involved with the participants in the study similar to what has been known by various names including participatory research rapid ethnographic assessment or engaged ethnography the dynamic nature of our research produced an unintended applied ethnographic design we found that as compassionate women studying women we could not simply watch our participants struggle when some of the solutions to the challenges they faced were within our reach by becoming engaged in the process we applied our resources and found that structured mediation is needed our finding suggests that mediation should be incorporated more often as part of healthcare and social services moreover mediation must take into account the challenges presented in suburban environments and especially for the suburban poor

to examine access to needed resources among lowincome methamphetamineusing females we conducted interviews with 30 women living in poor suburban communities of a large southeastern metropolis as an invisible population in the suburbs underserved by social services the women remain geographically and socially anchored to their poor suburban enclaves as transit treatment and education remain out of reach the longitudinal study included three interviews over a twoyear period resources needed by the women were identified in the first interview and a list of available services was provided to them in subsequent interviews we asked how they accessed the services or barriers encountered and discussed these further in focus groups using a social capital framework in our qualitative analysis we identified three processes for accessing needed resources formal informal and mediated implications for policymakers and social service providers are suggested and models for future development proposed methamphetamine ma was proclaimed an epidemic as it crossed from the western coast of the united states settled in the heartland and continued eastward impacting primarily urban populations of young people and men who had sex with men msm and rural populations in an increasingly poorer countryside

introduction m ortality differentials among socioeconomic groups belong to the most consistent findings in public health but the magnitude of these inequalities differs substantially between countries a recent study of inequalities in health in 22 european countries in the 1990s showed that some southern european populations have relatively small educational inequalities in mortality 1 smaller inequalities in mortality in spain and italy were also found in a previous study 2 but have never been satisfactorily explained we therefore conducted an indepth study of potential explanations for smaller inequalities in mortality in spain spain is a young democracy with an underdeveloped welfare state important income inequalities and a universal national health service 3 evidence on socioeconomic differentials in mortality based on individual data is relatively scarce due to the poor quality of socioeconomic information included in death certificates and to restrictive legislation with regard to linkage of the death register with census information 45 international literature focused mainly on the city of barcelona or the region of madrid 5 6 7 8 9 one factor standing out from the more detailed analyses that have been performed is smoking inequalities in smoking are smaller in spain and italy than in other western european countries particularly among women and this is likely to contribute to smaller inequalities in ischemic heart disease 1011 and lung cancer 12 studies which tried to explain the comparatively small inequalities in mortality in spain are nonexistent and a comprehensive explanation is lacking so far the present study was based on evidence from three spanish populations which were compared with six other western european populations finland sweden norway denmark belgium and turin our analysis aimed at identifying the specific causes of death and some of the specific determinants which contributed to smaller inequalities in total mortality in the three spanish populations methods study population mortality data were obtained from longitudinal mortality studies based on linkage of death registries to population censuses and consisted of deaths and exposure counts by sex 5year age groups cause of death and level of education the data covered national regional and urban populations the linkage between census data and death registries was achieved for almost 100 in all populations except in barcelona madrid and the basque country where the linkage was obtained for only 945 70 and 941 of the population respectively to correct for the underestimation of deaths we weighted the number of deaths in the three spanish populations with a correction factor the correction factors were 10945 for barcelona 107 for madrid and 10941 for the basque country data on determinants of mortality by socioeconomic position came from nationally representative health or multipurpose surveys with a crosssectional design measures the causes of death were classified according to the ninth and 10th revision of the international classification of diseases we analysed a few large groups of causes cardiovascular diseases cancer infectious diseases respiratory diseases alcoholrelated causes external causes and all other causes as well as a data on determinants included smoking obesity sedentary lifestyle and health services utilization smoking status was measured as selfreported current tobacco smoking obesity was measured on the basis of selfreported height and weight and defined as a body mass index 29 and 70 sedentary lifestyle was measured either by asking the best described respondents leisure time activities or the frequency of respondents physical exercises or activities the measurement of health services utilization was based on visits to a general practitioner to specialists and to any physician all analyses of health services utilization were adjusted for selfassessed health educational level declared at the census and during the interview surveys was used as a measure of socioeconomic status and classified according to the international standard classification of education using three categories low middle and high persons with missing information on educational level were excluded from the analysis statistical analysis analyses were conducted separately for men and women aged 3074 years at baseline the followup time was 10 years for most countries except belgium denmark basque country and madrid to obtain comparable ages at death analyses were conducted on slightly older age groups at baseline for countries with shorter followup period in denmark no information on socioeconomic status was available for subject aged 75 years further information on this adjustment procedure can be found elsewhere 13 mortality rates by educational attainment were agestandardized with the direct method using the european standard population the contribution of a specific cause of death to inequalities in allcause mortality between lowand higheducated people was determined as the share of the rate difference for each cause of death out of the rate difference for total mortality the magnitude of mortality inequalities according to educational level was summarized by relative 14 as well as absolute measures of inequality 1 using poisson regression due to count data prevalence rates of determinants by educational level were also agestandardized and inequalities in determinant prevalence were summarized by riis as the prevalence of the determinants was relatively high we used logbinomial regression results mortality analyses all populations included in the analysis show a graded relationship between education and mortality but the absolute gap in mortality between the lowest and highest educated is smaller in the three spanish populations average mortality rates are also lower in spain than in other western european populations both among men and particularly among women where mortality in the lowest educated group is lower compared with the highest educated group in all other western european populations table 2 shows relative inequalities in total and causespecific mortality among men relative inequalities in total mortality in all spanish regions tend to be smaller than those in most other populations although the differences are neither entirely consistent nor substantial among women relative inequalities in total mortality in the three spanish regions are substantially smaller than those in all other populations with the exception of turin which has similarly small riis among men relative inequalities in cvd mortality in the three spanish regions are smaller than those in all other populations but inequalities in mortality from other causes of death are similar in magnitude or even larger than those elsewhere among women relative inequalities in mortality from cancer are smaller in the three spanish regions but inequalities in mortality from other causes are not consistently smaller than those in other populations moreover reverse pattern was observed for lung cancer among women in the three spanish populations and turin and for breast cancer among women in all populations except turin and the basque country the large inequalities in mortality from infectious diseases in spain are predominantly due to aids mortality more detailed data on causespecific mortality by educational level can be found in supplementary tables 24 figure 1 quantifies the contribution of specific causes of death to the difference in agestandardized mortality rates between low and high educated men and women it shows that the smaller absolute inequalities in mortality in the three spanish populations are partly due to smaller absolute inequalities in cvd mortality these are negligible in spain but substantial in most other populations among men these smaller contributions of cvd are due to both lower average rates of mortality and smaller relative inequalities in mortality among women these smaller contributions of cvd are mainly due to lower average rates of mortality and not to smaller relative inequalities in mortality among women smaller or negative absolute inequalities in cancer mortality also contribute importantly to smaller absolute inequalities in mortality in spain analyses of survey data among men inequalities in smoking are smaller in spain than in most other populations because of comparatively prevalent smoking among higher educated spanish men while among women they are small or absent in spain because higher educated spanish women smoke more than the lower educated similarly the smaller inequalities in sedentary lifestyle in the basque country are due to the fact that the higher educated are less physically active with regard to obesity the inequalities are substantial in all countries after adjustment for selfassessed health inequalities in health services utilization tended to favour the lower educated regarding visits to gp in most populations including spain the opposite was observed for the use of specialized services with the exception of the basque country discussion summary of findings the spanish populations have considerably smaller absolute inequalities in total mortality than other western european populations this is the result of both lower average levels of mortality and smaller relative inequalities in mortality however the analysis by cause of death reveals an important heterogeneity smaller relative inequalities in total mortality in spain are due mainly to comparatively small inequalities in mortality from cvd and cancer inequalities in mortality from most other causes are not smaller in spain than elsewhere and inequalities in infectious disease mortality are even substantially larger spain also has smaller inequalities in smoking and sedentary lifestyle but not in health services utilization and its inequalities in obesity among women are larger than in the other populations on the basis of these four determinants one cannot therefore conclude that the exposure of lower socioeconomic groups to health risks is generally more favourable in spain than elsewhere limitations although education as a measure of socioeconomic position remains constant during adult life and old age 1516 reverse causation is less likely 17 and educational level is comparable across european countries when broader categories classified according to the isced are used 18 the impact of education on individual overall socioeconomic position may differ between countries the comparability of the mortality rates may be compromised by differences between countries in calendar year at start and duration of followup while we adjusted our results for different followup periods we could not correct them for different starting years since there were mostly earlier for northern europe and since inequalities in mortality have been widening in these european countries 19 any bias due to differences in starting year would tend to lead any differences in the magnitude of mortality inequalities in spain to be underestimated regarding the differences in length of followup sensitivity analysis gives the same results the data available on the prevalence of determinants and the mortality followup applied to the same period data that would allow proper timelag to be incorporated between exposure and outcome in our analysis were not available however it is unlikely that the social patterning of these risk factors changes substantially within a 5or 10year period we cannot exclude that some of our causespecific results are affected by inaccuracies such as differences in certification or coding of causes of death between countries and socioeconomic groups 20 however we believe that those results using broad causeofdeath categories are likely to be robust differences in the magnitude of inequalities in mortality between northern and southern european populations may be biased by the fact that we compared national mortality data for northern european countries with urban or regional mortality data in southern european countries although turin barcelona madrid and the basque country are relatively more prosperous than other regions in italy and spain results show that inequalities in mortality in turin barcelona and madrid are not greater than in the basque country in addition on the basis of national mortality data during the 1980s kunst et al 21 have shown smaller inequalities in mortality in italy and spain as a whole recently regidor et al 22 reported small inequalities in mortality among older people in spain we therefore think that the comparatively small inequalities in mortality observed in barcelona madrid and the basque country can be generalized to spain as a whole interpretation the smaller educational inequalities in mortality observed in spain are likely to be an effect of a later socioeconomic modernization of spain than that of northern europe the socioeconomic modernization refers to the historical process of largescale socioeconomic changes in society such as rising prosperity industrialization urbanization and expansion of mass education this may have led to smaller educational inequalities in mortality in two ways the first is that due to later socioeconomic modernization educational attainment still may be less important as a social stratifier in spain than in northern europe during the 1990s the proportion of low educated people was still 70 in spain against only 3050 in northern europe spains very rapid economic development after the franco dictatorship 23 may have created a mismatch between education and other statusattainment variables such as income and occupational class this is confirmed by a review of comparative studies which found weaker relationship between educational attainment and occupational class in spain compared with northern european countries 2425 and the netherlands 26 the health survey data also suggested a weaker relationship between educational level and income in the basque country than in several northern european countries particularly among men the second possible pathway is that later socioeconomic development has delayed the epidemiologic transition 27 the transition from a mortality regime dominated by infectious diseases to one dominated by cvd and cancer occurred several decades later in spain than in northern europe 28 the small absolute inequalities in cvd mortality in spain are partly because average rates of mortality from cvd particularly ihd have remained low especially among men while the increase in ihd mortality started many years later than in northern europe the decline started only a few years later 29 the decline in ihd mortality in spain after 1975 has been ascribed to the decline in smoking and to improvements in medical care 29 in other words spain already started to benefit from advances in knowledge about risk factors for ihd and advances in medical care before the epidemic could reach a higher peak that ihd mortality has never reached great heights in spain is probably also due to the role of the mediterranean diet with comparatively high consumption of wine fish fruits vegetables and olive oil 30 in view of the fact that partial adherence to the mediterranean diet seems to explain the low average rates of mortality from ihd in spain it seems likely that adherence to this diet by lower socioeconomic groups also explains part of the smaller inequalities in ihd mortality and the low rates of ihd mortality among the high educated despite their high prevalence of smoking and physical inactivity this is confirmed by a review of inequalities in diet in different european countries which shows that the association between education and fruit and vegetables consumption is inconsistent in spain while the higher educated in spain consume more animal fat and fewer vegetable oils than the lower educated 31 not all studies however reach the same conclusions 3233 another reason for the smaller relative inequalities in ihd mortality in spain can probably also be found in the different timing of epidemiologic developments previous studies have concluded that southern european countries tend to be at an earlier stage of the smoking epidemic in which smoking is still more prevalent in upper socioeconomic groups especially among older people and women 19 regarding cancer mortality smaller absolute inequalities among women in the three spanish populations were due partly to the strong reverse gradients for breast and lung cancer breast cancer is related to reproductive behaviour and reverse gradients of breast cancer arise because higher educated women are the first to delay pregnancy to higher ages 34 the stronger reverse gradient in spain may be due to the fact that this aspect of modernization started later too 34 spain had very large inequalities in mortality from infectious diseases due mainly to aids during the 1990s large inequalities in aids mortality in spain were driven by a combination of lower access and adherence to treatment and to unfavourable material conditions among vulnerable groups 35 the introduction of highly active antiretroviral therapy has contributed importantly to narrowing absolute inequalities in aids mortality in spain 36 conclusion educational inequalities in causespecific mortality and its determinants are not consistently smaller in spain than in other western european populations smaller absolute inequalities in total mortality in spain reflect smaller absolute inequalities in mortality from cvd and cancer on the other hand spain does not have smaller inequalities in mortality from many other causes of death and as many of these relate to living conditions our findings suggest that smaller inequalities in total mortality in spain do not reflect a generally more favourable situation with regard to social inequality smaller inequalities in mortality from cvd and cancer are likely to be due to spains later socioeconomic modernization while the spanish example shows that inequalities in total mortality are not inevitable the favourable situation in terms of inequalities in mortality from cvd and cancer in this country seems to be a historical coincidence rather than the outcome of deliberate policies unfortunately in view of the ongoing changes in socialprotection policies in spain and the changing socioeconomic distribution of risk factors for mortality in the spanish population 37 this favourable situation is also likely to be transitory supplementary data supplementary data are available at eurpub online conflicts of interest none declared key points although the social inequalities in mortality and health are relatively small in southern european countries compared to the rest of europe the smaller size of inequality in total mortality in spain does not represent an unambiguously favourable situation smaller inequalities in mortality in spain were only found for cardiovascular disease and cancer inequalities in mortality from most other causes were not smaller in spain than elsewhere the smaller inequalities for cardiovascular diseases and cancer did not resulted from lower risk factor prevalence in lower socioeconomic groups but from relatively high risk factor prevalence in higher socioeconomic groups the ongoing changes in socialprotection policies in spain and the changing socioeconomic distribution of risk factors for mortality in the spanish population need to be taken into account to tackle health inequalities

epub ahead of print 34 borrell c espelt a rodriguezsanz m et al analyzing differences in the magnitude of socioeconomic inequalities in selfperceived health by countries of different political tradition in europe

introduction the escalating environmental challenges of our time demand urgent action placing a spotlight on critical issues such as plastic waste and consequential greenhouse gas emissions 12 recent studies underscore the alarming trajectory of plastic pollution which is expected to inflict severe damage on natural ecosystems and compromise air and soil quality 3 among the industries contributing significantly to these challenges the food service sector stands out for its notorious generation of singleuse plastic waste food and beverage packaging alone accounts for approximately 15 of total plastics produced since the 1950s 4 while commendable strides have been made in certain areas eg the transition to digital receipts paper straws and alternatives to plastic packaging as well as the emergence of environmentally related labeling on food products the pressing need for effective behavioral interventions remains 56 within the food service sector specifically restaurants play a pivotal role in bridging material innovations with consumer behaviors and can act as change agents in enacting strategies 7 however achieving transformative change requires a deeper integration of core environmental attitudes that influence consumer behaviors this monumental task mandates a profound introspection into what truly drives green lifestyles and a rigorous evaluation of the multitude of factors influencing ecodecisions these factors are not limited to but certainly encompass socioeconomic backgrounds and personal attributes each playing its pivotal role in shaping attitudes 67 publications in the literature spanning various disciplines consistently elucidate the interplay of personality demographics and foundational environmental attitudes offering pivotal insights into sustainable consumption patterns 8 9 10 11 an interesting nuance emerges when one delves into the role of age though not always a strong standalone predictor of ecoconsciousness younger digitalnative cohorts seem to exude a heightened sense of responsibility towards sustainable practices 12 further compounding this there is robust evidence pointing towards a correlation wherein individuals from elevated educational and economic echelons lean more towards environmentally friendly behaviors 1314 intimate familiarity with environmental issues can act as a potent catalyst triggering more aligned behaviors 15 when we navigate the domain of gender studies a pattern crystallizes there seems to be a female propensity towards ecoconscious behaviors a phenomenon shaped by an amalgamation of societal imprints gender roles and unique concerns spanning reproductive health and beyond 16 17 18 19 additionally the nexus between vegetarianism and proenvironmental behavior is intricate yielding mixed research outcomes although vegetarianism does not universally signify heightened awareness of environmental health 20 evidence indicates that adopting a vegetarian diet compared to a meatbased one can lead to reduced greenhouse gas emissions 21 additional studies have highlighted that a considerable proportion of the population exhibits hesitancy towards proenvironmental measures often stemming from either a propensity to prioritize shortterm gains or a potential lack of awareness regarding their environmental impact 22 this is further exacerbated by a prevailing sentiment wherein individuals often deflect personal accountability towards larger institutional entities a sentiment that becomes entangled with economic constraints that might hinder sustainable decisions 23 there is also a bias coming from selfidentification which needs to be considered in the understanding of these trends 6 as the world hurtles towards technological advancements emerging tools and methodologies like nudging present themselves as formidable allies in our journey towards sustainability 2425 nudging is a tactical concept from behavioral economics that refers to making small subtle changes to the environment or decisionmaking processes to encourage or nudge people towards making more sustainable choices 24 it can change behavior and attitudes without limiting choices or mandating actions 2627 nudging with messages about the impact of plastic waste has also been used in many contexts 28 it has been used specifically to reduce plastic use eg to reduce plastic bag usage in supermarkets 29 nudging has also been researched within the context of plastic pollution by referencing its detrimental effects on oceans and aquatic life 24 however different types of nudges may be more effective for different groups than others particularly concerning gender 25 technological advancements in virtual reality enable realistic simulations of foodshopping scenarios providing an accurate platform to evaluate influences on consumer choices 30 as research in this area grows vr is set to become a key tool in promoting sustainable food consumption presenting rich insights for both researchers and policymakers however integrating vr into studies requires careful attention to avoid introducing biases from the immersive environment 31 factors such as the language used and the visual cues presented in vr can sway participants perceptions potentially affecting the study outcomes furthermore personal attributes like individual past experiences educational background age and familiarity with the items under study can lead to varied interpretations this emphasizes the importance of designing vr experiences based on sound research to minimize unintended biases nonetheless a certain level of subjectivity remains unavoidable in crafting and deploying vr scenarios given the inherent personal touch involved in the design process by delving into the attitudes and behaviors of consumers in a virtual restaurant scenario this research aims to contribute valuable insights as the field of research utilizing vr technology expands it is poised to become a key tool in promoting sustainable food consumption offering rich insights for both researchers and industry decision makers the objective of this study is to explore potential disparities in proenvironmental behaviors among individuals based on their dietary preferences and packaging selections when they make takeaway purchases at restaurants this investigation formulated the following three hypotheses pertaining to environmental attitudes and behavior h1 primarily we posit that attitudes towards environmental action are intrinsically connected to demographic factors including age gender and education h2 secondly the study hypothesizes that environmental attitudes correlate with choices related to diet and packaging h3 lastly it is postulated that interventions geared towards heightening environmental awareness will yield a positive transformation inconsumer selections towards less plastic and more sustainable menu items to scrutinize these hypotheses a vr restaurant scenario was orchestrated wherein participants selections were evaluated through a choice half of the respondents were presented with a warning message of an animal hurting from plastic exposure while the control group did not see this cue all participants were asked to provide responses to established scales measuring environmental literacy responsibility and willingness to embrace ecofriendly consumption methods this study utilized a vr experiment simulating a takeaway restaurant environment to explore consumer behavior and attitudes related to environmental sustainability in this section we detail the experiments design wherein participants divided into intervention and control groups engaged in a choicebased tasks within our immersive vr setup followed by a survey incorporating key measures to assess the outcomes virtual reality experiment incorporating the immersive potential of vr this study unfolded within a simulated setting resembling a takeaway restaurant for order collection the vr experience initiated with participants virtually embarking on a journey from their own homes to a modest eatery alongside the participants demographic particulars encompassing age gender and educational background an intervention group of half of the participants received a cautionary infographic about the detrimental impact of plastic waste on ocean ecosystems following exposure to potential interventions and completion of selfassessment tasks participants immersed themselves in a vr scenario that replicated a restaurants ordering process the virtual environment faithfully recreated the ambiance participants would encounter in an actual restaurant in this context a virtual waiter engaged participants in two choicebased tasks the initial task required them to select from meal options vegetarian fish or meatbased subsequently the second choice involved their preference for packaging materials for the takeaway meal offering a selection between recyclable and nonrecyclable plastic following exposure to potential interventions and completion of selfassessment tasks participants immersed themselves in a vr scenario that replicated a restaurants ordering process the virtual environment faithfully recreated the ambiance participants would encounter in an actual restaurant in this context a virtual waiter engaged participants in two choicebased tasks the initial task required them to select from meal options vegetarian fish or meatbased subsequently the second choice involved their preference for packaging materials for the takeaway meal offering a selection between recyclable and nonrecyclable plastic measurement of attitudes after the vr simulation in other to evaluate participants stances on environmental concerns and sustainable practices this study employed three scales the perceived seriousness of environmental behavior perceived environmental responsibility and green purchase intention scales 32 respondents rated a series of statements on a 7point likert scale ranging from totally disagree to totally agree higher scores indicated stronger proenvironmental inclinations benefits and limitations this study harnessed the synergy between vr simulations and questionnaires to garner tailored data and attitudes for choicebased experiments this approach facilitated the exploration of how demographic variables and personality traits influence consumer decisions and proenvironmental attitudes vr simulations offered a costeffective means of creating quasirealistic scenarios with precise control over responses however it is following exposure to potential interventions and completion of selfassessment tasks participants immersed themselves in a vr scenario that replicated a restaurants ordering process the virtual environment faithfully recreated the ambiance participants would encounter in an actual restaurant in this context a virtual waiter engaged participants in two choicebased tasks the initial task required them to select from meal options vegetarian fish or meatbased subsequently the second choice involved their preference for packaging materials for the takeaway meal offering a selection between recyclable and nonrecyclable plastic measurement of attitudes after the vr simulation in other to evaluate participants stances on environmental concerns and sustainable practices this study employed three scales the perceived seriousness of environmental behavior perceived environmental responsibility and green purchase intention scales 32 respondents rated a series of statements on a 7point likert scale ranging from totally disagree to totally agree higher scores indicated stronger proenvironmental inclinations benefits and limitations this study harnessed the synergy between vr simulations and questionnaires to garner tailored data and attitudes for choicebased experiments this approach facilitated the exploration of how demographic variables and personality traits influence consumer decisions and proenvironmental attitudes vr simulations offered a costeffective means of creating quasirealistic scenarios with precise control over responses however it is measurement of attitudes after the vr simulation in other to evaluate participants stances on environmental concerns and sustainable practices this study employed three scales the perceived seriousness of environmental behavior perceived environmental responsibility and green purchase intention scales 32 respondents rated a series of statements on a 7point likert scale ranging from totally disagree to totally agree higher scores indicated stronger proenvironmental inclinations benefits and limitations this study harnessed the synergy between vr simulations and questionnaires to garner tailored data and attitudes for choicebased experiments this approach facilitated the exploration of how demographic variables and personality traits influence consumer decisions and proenvironmental attitudes vr simulations offered a costeffective means of creating quasirealistic scenarios with precise control over responses however it is important to acknowledge the inherent reliance on selfassessment the timeintensive nature of inperson procedures and the potential for divergent choices influenced by realworld factors like price and social pressures hypothesis tests to ascertain reliability cronbachs alpha measures were applied to the three green attitude scales a threshold of 06 was selected based on a general consensus of this being a sufficient condition 33 on the rationale of a small sample size and detected lack of normal distribution the means of attitude scales were compared with mannwhitney tests this was repeated for all three scales and the subgroups gender education message meal choice and package choice twosided hypotheses with a significance level of 005 were used for the connections between meal choicegender meal choiceintervention package choicegender and package choiceintervention fishers test of independence was used as the condition of at least five entries in every cell of a chisquare test was not fulfilled the descriptive and inferential analyses were carried out using r version 431 microsoft excel and google sheets results participant profile sampling in this exploratory study we recruited 22 students from the campus and randomly assigned them to two groups an intervention group of 11 students who received a warning message and a control group also comprising 11 students the decision to use a relatively small sample size was primarily driven by the studys exploratory nature aiming to test initial hypotheses and collect preliminary data within the context of virtual reality technology additionally the inherent constraints of vr environments particularly regarding participant management and data collection played a significant role in determining the sample size demographics the average participant age was 234 years comprising 73 females and 27 males among them 77 were pursuing bachelors degrees 18 were enrolled in masters programs and 5 were phd candidates attitude measurement all scales demonstrated satisfactory reliability levels as shown in table 1 shapirowilk tests showed that the per scale adhered to the assumption of normality and the ps and gpi scales deviated from a normal distribution consequently nonparametric tests were employed for all three scales influences on environmental attitudes table 2 presents confidence intervals and pvalues from mannwhitney tests comparing gender differences individuals with varying educational levels and the intervention and control groups across the three environmental attitude scales notably gender emerged as the sole factor significantly impacting personality traits associated with proenvironmental values consistently favoring females as being more conscious hypothesis 1 was confirmed in part interventioncontrol 05 02 03 03 00 08 note 95 confidence interval given in parentheses significant at 95 confidence level significant at 99 confidence level attitudes scales and consumption choices the relationship between proenvironmental dimensions as measured by the three scales and the consumption choices in the trial are displayed in table 3 note significant at 90 confidence level significant at 95 confidence level h2 was confirmed for the choice of meal where those picking the green meal also reported as more green in their values and purchase intentions there was no similar pattern between packaging choices and environmental attitudes intervention message packaging and choice of meal the packaging preference and meal choice considered in terms of intervention vs control are summarized in table 4 fishers test gave a p value of 004 thus indicating that the vr message had a significant influence on choice of meal fishers test gave a pvalue of 1 thus indicating that the message did not have a proven influence on packaging selection the combined findings from table 4 offer partial support for hypothesis 3 the data reveal a significant trend among consumers indicating that the vr message had a significant influence on choice of meal however these results did not indicate a statistically significant result in consumer choices towards items with reduced plastic usage further analysis revealed that neither gender nor education level significantly influenced meal choices or packaging preferences while females tended to choose vegetarian meals and recyclable packaging more than males and there were differences between undergraduates and graduates these variations were not statistically significant according to results from fishers test this suggests that gender and education may not be major factors in environmental choices regarding meals and packaging discussion this study delved into the intricate interplay between proenvironmental attitudes dietary preferences and packaging choices within the context of a vr restaurant scenario the results underscored the significant influence of gender on proenvironmental attitudes aligning with previous research highlighting womens heightened engagement in sustainable behaviors 1617 the potential causative links between gender roles psychological differences and perceptions of responsibility necessitate further exploration to comprehend the underlying dynamics all three hypotheses were fulfilled but only in part as the main effects were females being more conscious of environmental consumption those choosing plantbased meals having higher values on the green scales and the warning message leading to more vegetarian meals being chosen the investigation hence suggested a connection between environmental awareness interventions and positive transformations in attitudes although these findings did not reach statistical significance this echoes the principle of nudging as a valuable tool to encourage sustainable behaviors 2627 however the primary intended effect of reducing plastic usage by selecting reusable packaging was not observed the message was more efficient in shifting respondents towards the meal choice without animal proteins the link between dietary choices and environmental consciousness has been investigated extensively with a vegetarian diet frequently associated with lower environmental impact 22 this studys findings add to this narrative but the nuanced nature of dietary preferences influenced by factors beyond environmental concerns highlights the complexity of causation with regards to sociodemographics the gender dimension has been underlined through multiple surveys confirming that females in general are better aligned with environmental health in their attitudes and consumption 17 18 19 as far as higher degrees go research has confirmed two opposing effects on the one hand greater knowledge of climate issues spurs more sustainable actions while a higher income also leads to a higher footprint even more so for the most affluent and highest echelons of social status 34 in terms of packaging choices the research did not identify statistically significant relationships between gender proenvironmental attitudes and packaging preferences however the potential implications of these choices on plastic waste and environmental impact remain paramount the significance of efforts to reduce singleuse plastics and promote ecofriendly alternatives requires sustained attention 29 despite its contributions this study possesses certain limitations the relatively small sample size and the use of a convenience sample from a single demographic could undermine the generalizability of the results furthermore the potential influence of contextual factors like price and social pressure on participants choices in the vr scenario is not fully addressed additionally while the vr approach facilitates control and immersion the experiential aspect might introduce biases related to personal interpretation conclusions this study ventured into the dynamic relationship between proenvironmental attitudes dietary choices and packaging preferences within a vr restaurant scenario while the results suggested significant correlations between gender and proenvironmental attitudes and a potential connection between adopting vegetarian diets and proenvironmental attitudes the study also highlighted the nuanced yet complex nature of these relationships the potential impact of interventions such as environmental awareness messages on transforming attitudes towards sustainability was also hinted at although not statistically proven as behavioral interventions like nudging become increasingly common practice this studys application of vr serves as a steppingstone towards understanding how individuals interact with choice scenarios in the quest for a greener future it is important to reiterate that factors beyond dietary choices such as social norms access to resources and education level influence consumers proenvironmental behavior therefore while dietary choices can be essential in reducing environmental impact they are not the only factor and should not be viewed in isolation ones consumption patterns whether related to diet or materials may reflect personal values that result from individualistic and societal conditioning identifying solid correlations between these factors and dietary choices may be possible though implying causation may be misleading and merits continued avenues of exploration ultimately the pursuit of sustainable behaviors and a reduction in environmental impact found in this study underscores the monumental need for continued interdisciplinary research largerscale studies and strategic interventions for the food service sector this task mandates a profound introspection into what truly drives green lifestyles and a rigorous evaluation of multifaceted factors pivotal roles in shaping attitudes data availability statement data will be made available upon request by contacting the corresponding author author contributions conceptualization arf methodology arf formal analysis hl investigation arf and hl resources arf writingoriginal draft preparation hl writingreview and editing arf hl jmw sw and jk funding acquisition arf all authors have read and agreed to the published version of the manuscript

this research paper delves into the complex relationship between proenvironmental attitudes dietary preferences and packaging choices using a virtual reality vr restaurant scenario the imperative is to address environmental concerns particularly plastic waste and greenhouse gas emissions as they pertain to sectors of the food service sector this study seeks to understand the factors influencing environmental attitudes and behaviors with a focus on dietary preferences and packaging choices using a vr restaurant scenario this study explores connections between gender education interventions and proenvironmental attitudes as well as the correlation between vegetarian diets and sustainable behaviors while the results suggest significant correlations between gender and proenvironmental attitudes and a potential connection between adopting vegetarian diets and proenvironmental attitudes our study emphasizes the nuanced nature of these relationships the findings underline the importance of interdisciplinary research and strategic interventions for fostering sustainable behaviors and reducing environmental impact the use of vr simulation adds a novel dimension to understanding individuals choices in controlled environments shedding light on the intricate dynamics of proenvironmental decision making this paper contributes to the ongoing discourse on sustainable behavior by offering insights into the interplay between personal preferences environmental awareness and choices with significant environmental implications

introduction as highly social animals humans experience better mental and physical health and cope with stressors better when they have access to social support 1 one antecedent of animals 2022 12 3434 2 of 12 social support is the extent to which those in supporting roles empathise with us 2 the term empathy is often used ambiguously in the scientific literature but for the purposes of this work we take empathy to involve emotional cognitive and behaviourally expressive aspects and to entail an observer perceiving anothers affect and experiencing shared feeling 3 companion relationships with nonhuman animals have evolved over 15000 and perhaps as long as 40000 years 4 they are reported to be positive for our mental and physical health 56 this phenomenon is known as the pet effect 7 while there is debate as to the veracity of the positive effect of companion animals due to contrasting results 8 studies that consider attachment and social support theories suggest that nonhuman animals fulfil human needs for emotional support 9 even acting as substitutes for reduced human support networks 10 however the role of animal empathy towards humans in generating this social support has not been explicitly investigated attributing uniquely human capacities to nonhuman entities is considered anthropomorphic 11 despite a human tendency to anthropomorphize literally anything 12 the primary target remains animals 13 while examination of the phenomenon of anthropomorphism is accelerating 1415 being anthropomorphic is often considered unscientific and viewed negatively by the scientific community though anthropomorphism can have positive impacts on humananimal relationships as a counterpoint anthropocentrism has been defined as the interpretation of reality according to human values needs and experience due to a belief structure where humans are primary amongst all species 11 we can perceive our companion animals and their capacities through either lens either affording them humanlike capacities perhaps beyond their physiological and cognitive abilities or denying them such affordances based on a bias that views humans as exceptional while there is mounting evidence for canine empathic abilities 17 the study of feline empathy lags far behindfor example a major review of emotional contagion research in mammals included no references to studies in cats 18 regardless owners retain beliefs that both cats and dogs can empathise with us 19 as mutual caring reciprocal support and empathy moderate human relationships it is possible that these same attributes play a role in the bond humans have with their companions hence examining how we perceive and construct animal empathy experiences can generate valid and important information to aid our understanding of how animals provide social supportin particular by revealing the extent to which people use anthropomorphic explanations for experiences of empathy from canine and feline companions this study investigates the phenomenology of animal empathy by focussing on how humans construct sensemaking narratives of animal empathy experiences we hypothesized that anthropomorphic attributions would play a key role in these constructions to elucidate a deep understanding of each participants experience and draw interpretative meaning from them a qualitative approach concerned with subjective experience and in particular emotional responses is essential therefore the current study used the qualitative methodology of interpretative phenomenological analysis to gain insight into how participants identified and constructed a lived experience of animal empathy materials and methods theoretical framework as the research question centred on how participants identified and understood their experiences of animal empathy this study utilized the qualitative approach of interpretative phenomenological analysis which focusses on participants lived experiences and the meaning they make of them this method facilitates the deep examination of experiential phenomena and is particularly beneficial for understanding how participants interpret and react emotionally to the experiences of interest ipa is an inductive method and is the product of a joint elucidatory process in which not only does the participant interpret their lived experience but the analyst ultimately provides their account of what they think the participant is thinking resulting in a double hermeneutic 20 interviews semistructured interviews were conducted by a single interviewer following the established ipa methodology 20 this paper addresses themes arising from part b questions 4 5 and 6 of the interview schedule themes arising from parts a and c are interpreted in future work the italicised words are replaced by the actual name of animal during the interview the interview schedule and interview technique were piloted with two unanalysed participants after which suitable amendments were made each interview lasted approximately one hour and all were conducted online via a video conferencing platform suitable for nonsensitive data between march and may 2021 recordings were immediately downloaded to a secure university server and then deleted from the online platform interviews were recorded and transcribed automatically by the video conferencing platform with transcriptions later checked against audio recording and manually corrected by the interviewer to ensure verbatim accuracy data analysis interviews were analysed sequentially by the interviewer and recruitment terminated when themes reached saturation transcripts were first read and reread to ensure familiarity with content then exploratory comments were made line by line which were categorised as descriptive linguistic or conceptual 20 an interpretation was then conducted by the systematic coding of transcripts using proprietary software followed by clustering of evolving themes emerging themes were examined for divergence convergence repetition and nuance and this process was repeated for each transcript to uphold a commitment to each participants meaningmaking reflexivity was enhanced by cycling back over previously analysed materials in an inductive cycle to move the interpretation from the individual level to a gestalt understanding of relationships between themes generated themes and coded data were discussed in tandem with psychological knowledge from other authors throughout the analysis to test and develop the plausibility and coherence of the interpretative account results two superordinate themes were identified the first covered the context and identification of animal empathy experiences while the second encompassed multiple themes and subthemes concerned with how participants constructed their experiences subthemes with interpretive commentary and illustrative extracts are presented below with those concerning how animal empathy is constructed by guardians further interpreted through anthropomorphic mixed or anthropocentric lenses participants are anonymised and pseudonyms are used for animal names context and identification of animal empathy participants reported a variety of contexts where selfidentified experiences of animal empathy took place some described empathic interactions in terms of entirely emotional support such as in situations of grief loneliness and stress others in terms of physical support including protection and illness while several participants described both emotional and physical support in this extract participant e describes a period of grief after the death of a close friend and the emotional support role of barney during that time pe but sometimes therell be something and it takes my breath away and its almost like sometimes that he picks up on that and will just come and lean on me or will come and flop next to me or something and i do find it really comforting in all cases participants identified a change from their cat or dogs normal behaviour as the indicator of an empathic interaction in the following extract participant f describes the actions of henry during a period of convalescence pf me and henry would always lie we had a particular position that we always lay in and i was on my back and she sat right on my womb where id had this horrendous operation and just sat there so it was not a position shed normally sit in at all and if i tried to move shed hiss at me and she never hissed at me either in this extract the narrator uses alteration in behaviour to identify that henry is attempting to care for them bodily this extract also shows that in common with all interviews participant f used their animals increasing physical proximity as an identifier of an empathic interaction as does participant c when speaking about tukker pc hed seek you out and try to initiate contact if he could see youd had a crap day you know come and put his head on my lap hed come wriggle up to me in this extract participant c also attributes tukker with the ability to identify their emotional need this is illustrative of the following thematic framework which attempts to unpick the diversity of how animal empathy experiences are constructed and understood by participants constructions of animal empathy how participants understood what was going on inside their animal during their experience of animal empathy varied across a spectrum from highly anthropomorphic to highly anthropocentric with some explanations involving a mix of both multiple explanations were used by each participant with some participants expressing conflicting constructs within their reasoning in this extract participant c also attributes tukker with the ability to identify their emotional need this is illustrative of the following thematic framework which attempts to unpick the diversity of how animal empathy experiences are constructed and understood by participants constructions of animal empathy how participants understood what was going on inside their animal during their experience of animal empathy varied across a spectrum from highly anthropomorphic to highly anthropocentric with some explanations involving a mix of both multiple explanations were used by each participant with some participants expressing conflicting constructs within their reasoning anthropomorphic constructions many participants provided explanations that utilised humanlike capacities to construct understanding of their experiences of animal empathy cognitive attribution the most anthropomorphic explanations provided by participants were those attributing high levels of cogitation and intention by the animals involved such as shown in this extract from participant a pa bay was thinking mums in trouble or mums getting hurt and i need to do something about it like i have to protect mum here the participant ascribes bay not only with understanding of the context of what was happening but also of conscious thought and action intention by giving bay an internal voice this participant also assumes that bay categorizes their relationship in a familial way and sees participant a as mum participant f likewise affords henry with the ability to apply humanlike cognition as they recovered from painful abdominal surgery pf it was exactly where it was hurting me absolutely and its like she completely knew and she was just like just lie the fuck down keep still youre not well i want you to recover and she sort of looked after me all through the next week when i was in recovery from the operation here participant f apportions conscious knowing to henry including what was wrong and what needed to happen and as with the previous extract also ascribes henry an internal voice anthropomorphic constructions many participants provided explanations that utilised humanlike capacities to construct understanding of their experiences of animal empathy cognitive attribution the most anthropomorphic explanations provided by participants were those attributing high levels of cogitation and intention by the animals involved such as shown in this extract from participant a pa bay was thinking mums in trouble or mums getting hurt and i need to do something about it like i have to protect mum here the participant ascribes bay not only with understanding of the context of what was happening but also of conscious thought and action intention by giving bay an internal voice this participant also assumes that bay categorizes their relationship in a familial way and sees participant a as mum participant f likewise affords henry with the ability to apply humanlike cognition as they recovered from painful abdominal surgery pf it was exactly where it was hurting me absolutely and its like she completely knew and she was just like just lie the fuck down keep still youre not well i want you to recover and she sort of looked after me all through the next week when i was in recovery from the operation here participant f apportions conscious knowing to henry including what was wrong and what needed to happen and as with the previous extract also ascribes henry an internal voice exceptionalism several participants expressed beliefs that their animal companions exceptionality explained how they were able to empathize with humans participant b describes the exceptional abilities of their cat as even allowing them to transcend species pb shes very yeah very unique i think that just makes her just almost makes her human though shes not human obviously but it almost makes her slightly human in what she does so i think she is very special because she does these things like that humans would do and i think thats probably how i feel about her more than other cats weve had because they just acted like normal cats here the anthropomorphic classification is made explicit alongside the elevation of this cat from others of its species several participants spoke of their animals as unique as a descriptor of their identity and in terms of their capacities being an extension of what a normal animal could do similarly participant g singled out one cat in their household for the ability to preempt and warn them of oncoming seizures pg i think shes highly intelligent and has managed because shes highly intelligent to understand what her normal senses are telling her this participant understood this cats ability to predict seizures in terms of its exceptional intelligence particularly in comparison to other cats and indeed humans this speaks to a view that for animals to understand our internal states and to communicate this to us requires skills beyond the capability of their conspecifics sometimes conferring on them a humanlike status against a backdrop of social norms that views many empathic and cognitive capacities as exclusively human to explain how these animals have acted in these experiences guardians may feel they have to separate their animal from the norm mixed constructions some constructions mixed anthropocentric and anthropomorphic interpretations as in the following subthemes special senses most participants utilized some degree of folk rationale to explain their animals behaviour these explanations centred around beliefs of animal knowing and the attribution of special nonhuman senses pb whether animals have got another an extra sense we dont know i dont know what it is that they feel or can sense but theres obviously something because they seem to try and be more of a comfort to you for that little period of time you think why are they doing this but i think they must have some sort of sense that they that you need help explaining animal empathy this way suggests that the animals actions were so inexplicable by any other means that abilities unknown or unknowable to humans must be at play this suggests that participants were sometimes reticent to attribute human empathic capacities perhaps due to concerns over allegations of anthropomorphism however the attribution of special senses was sometimes considered superior to human empathy pf you can trust them to sort of know and maybe have some kind of superior knowledge in certain situations like okay thats what she thinks thats what should happen so i felt that cats did do that you know they were capable of sort of targeted comfort like knowing when you need something participant f emphasized their trust in henry and based this on a belief that henry had access to knowledge that that wasnt available to humans considering special senses from this perspective could also be construed as highly anthropomorphic in that henry is in possession of more than human capacities surpriseexpectation participants often expressed surprise at the empathic actions of their animal pf it was amazing because yeah she was a cat youre like wow yeah i was really surprised but yeah it was really i really was amazed i was really like wow henry you know youre doing here here participant fs surprise can be interpreted from as anthropocentric in that nonhuman capacities are generally expected to be inferior hence any display of capacity beyond an accepted animal norm is worthy of astonishment while the previous extract illustrates wonder at animal knowing other participants were more anthropomorphic and held expectations of their animal companions pa so no i knew in the moment what it was and i wasnt surprised like i wasnt surprised at all yeah no no not at all and i feel like hed do it again he if it happened again with someone else i can hundred percent guarantee he would do it again yeah pb because they seem to try and be more of a comfort to you for that little period of time which is quite you know you think why are they doing this and i just grew up thinking all cats could do that but then people tell me no no no this final extract illustrates the contradiction within this theme by simultaneous expressing surprise questioning why the animal is providing comfort followed by an expectation that this is just something cats can do it also illustrates a tension some participants expressed attributable to believing in their animals capacities while in an anthropocentric culture as discussed in the next theme anthropocentric constructions three subthemes are interpreted as displaying commonality in anthropocentricity these subthemes illustrate a belief structure that sees humans as primary amongst species and the participant explanations are generated through a humancentric lens proofs all participants repeatedly stated proofs to verify their attributions of empathy this usually took the form of detailed and persistent explanations of the identifier of animal empathybehaviour change pa i got up to just use the bathroom that night and usually bay couldnt care less hell just keep sleeping but this night he actually got up and came to the bathroom which is very unusual bay just slept there with his head on my chest he would usually start the night sleeping on my chest anyway but he gets really hot and then he goes to my feet that night he was just like on my chest the whole night the deliberate caregiving described can be interpreted against a humancentric cultural backdrop whereby to make assertions of animal empathic capacities requires extensive and robust proof to protect from accusation of naive anthropomorphism participants were thus motivated to provide multiple proofs to show that their animals behaviour was not merely chance or being misinterpreted physiological explanation some participants employed concepts of normal physiological functioning to construct their experiences these explanations used the sensitivity of animal senses to interpret human internal states these rationales were rooted in reality as opposed to more magical abilities discussed in the special senses theme pa even down to my heart rate or how my physiology is changing and bay is just sensing it better than a human would sense it like he can probably tell my heart rates gone up that ever so slight decibel of my voice has gone up he can probably like smell it from my like hormones coming off me because im stressed i feel like they know what were thinking like a physiological way and then they react accordingly pg scientists say that the smell is picking up some kind of smell i give out that i cant smell but because shes got far more receptors than a dog has that she can pick it up easier participant a had an educational background that informed their more detailed physiological explanation while participant g relied on folk knowledge but both remain based in the reality of existing senses and physical functioning using physiological constructs to understand animal empathy behaviours is a more parsimonious explanation than those used in anthropomorphic or mixed reasonings and shows how the participants were at times wary of overattributing empathic capacities to their nonhuman companions black box the most anthropocentric explanations are grouped into a theme labelled black box in reference to a historical view of nonhuman animals as simple stimulusresponse organisms with no or limited conscious intention to their actions this view has its roots in cartesian thought and became validated for a time through the work of skinner and the behaviourist tradition pe i think thats a higherlevel thinking than i imagine barney could have theres no thought behind it its just a spontaneous emotional reaction when a dog is happy and he wags his tail if hes nervous his tail goes down if hes cross he barks if hes frightened he growls so i think he can recognize your emotions in that very basic way but i dont think my emotions would have an impact on how he was feeling here participant e also rejects the possibility of emotional contagion the emotional state matching of one individual to another 18 from humans to animals as does participant a pa dogs and cats in general are not going to feel sad just because im feeling sad i think theyll react to it that is just my thinking but i dont think that just because their human is sad that theyre just going to get sad like i dont i dont think thats how they would work both participants when musing on the internal workings of their companion animals describe the empathic behaviours as spontaneous or reactionary in essence incognizant this interpretation follows the behaviourist tradition which afforded no internal awareness to nonhuman animals while these extracts demonstrate a most parsimonious and anthropocentric interpretation the very same participants also expressed highly anthropomorphic readings of the same experiences as consciously thinking that mums in trouble similarly despite participant e describing barney as being unable to have higher level thinking they did attribute some cognitive abilities pe i do feel that he thinks hes looking after me that hes in that moment keeping me i dont mean safe physically but just keeping me okay hes acknowledging that perhaps theres something wrong and his closeness is perhaps a comfort yeah interviewer do you think hes choosing to do that like hes making a choice to fulfil that function pe yeah without a doubt i think he recognizes it and he yeah chooses or decides to just come and sit with me at that at that point interviewer do you think he knows your sad pe yes i dont know why but yes i think he does while demographic data of participants were not expressly obtained in this study it was apparent during the interviews that participant a and e had educational backgrounds that included psychology which may have informed their reticence to express unfettered anthropomorphic explanations to their experiences resulting in their representation in opposing thematic constructs discussion participants were consistent in reporting changes to their animals normal behaviour as key to the identification of animal empathy experiences yet they were highly paradoxical in their constructions of the internal drivers within the animal dichotomous explanations ranged from highly anthropomorphic where animal companions knew what their humans were thinking feeling and needed to highly anthropocentric expressions of animals as little more than stimulusresponse organisms furthermore there was a combination of these extremes both within individual participant narratives and within some thematic constructs the narratives also conformed to the social support theory of humananimal relationships devoldre et al 2 describe two positive forms of social support emotional and instrumental emotional support is that which assists the management of emotions which all participants narratives contained whereas instrumental support is characterised by more problemorientated help participant a f and g all described specific physical instrumental support provided by both cats and dogs in contrast to the investigation of accuracy and functionality there has been relatively limited exploration of the psychological basis of anthropomorphism 21 and while debate continues as to the accuracy versus erroneousness of anthropomorphic attributions in companion animals that anthropomorphism is an intrinsic aspect of human nature is less controversial anthropomorphic thinking varies between people 22 and previous work has shown it to be a stable trait in individuals 23 however the findings of the current study suggest that variability can also exist within individuals with seemingly incompatible views being held simultaneously this finding may relate to evidence in developmental psychology where a body of work shows that learners hold misconceptions about phenomena based on naïve theories gained from observation of the environment during their lives and go on to use multiple and sometimes contradictory explanations based on superficial reasoning to explain an event furthermore acknowledging contradictions is avoided by modifying observations to defend previously held views 24 the range of how participants constructed and understood animal empathy experiences may represent an inherent confusion as to what is really happening within their animals during perceived empathic encounters epley waytz and cacioppo 14 put forward a model of anthropomorphism that combines both motivational and cognitive aspects and this provides a framework to account for and predict this variably this model proposes three psychological factors accessibility and applicability of knowledge about humans motivation to explain and understand the behaviour of nonhumans and the desire for social contact the elicited agent knowledge factor affords that the accessibility of knowledge about us as humans plays a central role in attributions to nonhumans as we have such immediate access to rich phenomenological information of what it is like to be ourselves this forms a rapid and automatic basis for applying that knowledge to nonhuman agents that anthropomorphic explanations featured in all our participant narratives conforms to this factor furthermore this factor suggests that when internal knowledge is less accessible it is less likely to be applied this aspect may be seen in our data where some participants extended beyond anthropomorphic descriptions and into a morethanhuman realm of magical thinking ascribing special senses to their animal companions perhaps if the internal psychological mechanisms of empathy are difficult or inaccessible knowledge for some it then becomes difficult to apply to animals this may be an explanation for the resulting attribution of magical capacities to explain the unintelligible motivational factors in the model provide modulation to the degree of anthropomorphism used by participants sociality motivation relates to the desire to establish social connections and predicts that attributions to animals are increased in the absence of connections to other humans 14 in the context of social support and empathy this may be particularly relevant as evidenced by several participants describing the context of their empathy experiences as times of loneliness and loss of close human companions a motivation to reduce discomfort associated with uncertainty over the actions of nonhumans and improve the prediction of future behaviour by providing anthropomorphic explanations for animal actions is termed effectance motivation as nagal 25 would have it we cannot know what it is like to be a bat or indeed our companion cats and dogs hence there is a motivation to interpret their behaviour rather than leave it unexplained in this study there is the added incentive to explain the animals behaviour anthropomorphically because to do so increases the emotional support provided by the encounters if the animals are believed to be empathic after rapid application of elicited agent knowledge to provide anthropomorphic explanations the model suggests there is post hoc correction to accommodate evidential knowledge of nonhuman capacities participants who reported expertise in psychology and science appeared to conform to this aspect of the model as they were more careful to provide highly parsimonious explanations for their experiences perhaps due to a greater understanding of the negative view of anthropomorphism as folk or naive reasoning however it was also these participants that displayed the most notable dichotomy in their narratives perhaps illustrating a greater cognitive dissonance between the internal motivation to anthropomorphise and cognitive desire to correct in light of their knowledge as anthropomorphism is driven by both motivational and cognitive determinants the mixing of interpretations both thematically and in individual participants may represent the various ways participants combined and rationalised these competing methods of constructing their experiences the threefactor model of anthropomorphism assists us in understanding some aspects of the participant narratives but how might we understand the more anthropocentric themes dementalisation is a strategy unconsciously used by people to alleviate cognitive dissonance experienced by what is known as the meat paradoxthe inconsistency of loving some and animals and eating others 26 for example humans tend to deny food animals the capacity to suffer more so than they do for companion species 27 perhaps providing anthropocentric explanations particularly those that deny the animals emotional repercussions or contagion from their owners distress is motivated by similarly extending deniability of their capacity to be negatively affected thus assuaging any guilt owners may feel for using their animals for social support an important theme uncovered in this study was that of exceptionalism that some participants viewed their animals as exceptional in comparison to others shares commonality with the concept of subtyping of stereotypes in human prejudice literature subtyping refers to the separation of members of a stereotyped group into a separate category because they violate rules of the stereotype 28 as the exceptionalism theme emerged in these data it suggests that stereotypes about dog and cat empathic abilities exist and as display of animal empathy was a violation the stereotype is likely to lean toward the anthropocentric side of the spectrum limitations in comparison to other research methodologies the sample size used in this work may appear both small and biased however the purpose of this work is not to provide statistical or populationlevel generalisability instead in approaching the research question via an ipa method our aim was to achieve theoretical generalisability and provide novel insights into the topic which may then be taken forward via other research methods 29 when using ipa it is appropriate to purposively recruit a sample that is relatively homogeneous regarding the topic of interest and due to level of detail required in analysis of phenomenology small sample sizes are advised 20 this resulted in participants that were not only homogeneous with regard to their experiences but also their gender language and western cultural background these aspects must be taken into account when considering the insights generated in this work in particular as the construction of humananimal relationships is a semiotic process whereby the meanings generated from signals and experiences are hugely influenced by the culture of the participants it would be interesting to investigate constructions of animal empathy experiences in participants of different cultural backgrounds researcher experience with qualitative interviewing techniques can impact the quality of such work and while the lead researcher was new to this method thorough piloting of the interview schedule strict adherence to substantiated ipa data analysis protocols and clear establishment of rapport with participants leaves the authors confident that the resulting richness of the interview data provides relevant and compelling findings a further recognised limitation is that some participants may have been reticent to express anthropomorphic views to a research scientist perhaps skewing those participants towards more anthropocentric or parsimonious explanations in future work it is suggested that greater demographic detail is gathered such as the timescale of animal relationship participant education level and background and perhaps to consider blinding participants to the interviewers scientific background conclusions themes identified in this study provide valuable and rich insight into how humans understand their companion animals this research demonstrates that experiences of companion animal empathy can be powerful and meaningful for humans but the inconsistent mixture of anthropomorphic and anthropocentric reasoning illustrates the confused nature of human understanding of animals internal states as increasing public knowledge of the burgeoning scientific evidence of animal capacities intersects with a long history of anthropodenial 30 and aspersion of anthropomorphism this confused state may not quickly dissipate however as the ascribing of internal statesparticularly emotionsto animals has important implications for their moral status 31 gaining understanding and insight into how humans construct animal empathy may hold an applied value for example this knowledge could lead to more targeted education in areas where humans use companion animals for social support such as in animalassisted therapy and emotional support animals data availability statement the data presented in this study are available on request from the corresponding author author contributions conceptualization kmh km and rb methodology primary analysis and writingoriginal draft preparation kmh validation writingreview and editing and supervision km and rb all authors have read and agreed to the published version of the manuscript funding this research was supported by a university of sussex school of psychology phd studentship the apc was funded by the sussex university pgr oa fund institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the ethics committee of the university of sussex informed consent statement informed consent was obtained from all subjects involved in the study

as highly social animals humans experience better mental and physical health when they have access to social support one aspect of social support is the extent to which those in supporting roles empathise with us many humans useand rely uponcompanion animals to provide social support and believe them to be empathic in times of need this study used in depth interviews with six participants who identified as having had experiences when their dog or cat empathised with them to examine how they made sense of these experiences the participants consistently reported that changes to their animals normal behaviour was key to identifying animal empathy but there was significant variation in their understanding of how and why their animals performed empathic actions inconsistencies in participant explanations may illustrate the difficulties in understanding animals emotions motivations and cognitive abilities in light of a history of denial of animal capacities on one hand coupled with burgeoning scientific evidence about animal communication on the other the findings in this study can be applied in areas where companion animals are used explicitly for social support such as animalassisted therapy and emotional support animals

nursing homes have experienced devastating impacts of the covid19 pandemic although less than 05 of the us population live in nhs nh residents accounted for as much as 40 of covid19 deaths at the height of the pandemic the most frail and vulnerable nh residents such as those with advanced dementia are at highest risk of acquiring and dying from covid19 there are more than 860000 americans living with dementia in nhs comprising 614 of the nh population moreover 366 of nh residents have advanced dementia characterized by severe cognitive impairment and functional disability these residents with advanced dementia are unable to advocate for themselves cannot reliably communicate symptoms and are completely dependent on staff for all their care needs thus they may be especially negatively affected by insufficient staffing isolation and deficiencies in care due to the covid19 pandemic particularly when their family advocates cannot visit throughout the pandemic nhs struggled with the urgent need to make compassionate and effective management decisions maintain communication with family and protect the safety of residents and staff prominent national media reported widespread chaos and burden in the nh setting highlighting overwhelming infection and death rates among nh staff and residents this crisis also highlighted racial disparities in nh care with more black residents suffering with the virus little is known about the intersecting challenges of covid19 advanced dementia and disparities in nh care the assessment of disparities and variation for alzheimers disease nursing home care at end of life national institute on agingfunded study was a large qualitative study that sought to better understand the drivers of welldocumented regional and racial disparities in intensity of care provided to black and white nh residents with advanced dementia advance used nationwide databases to purposefully select 14 nhs within four hospital referral regions across the united states with varied intensity of advanced dementia care quantified by feeding tube and hospital transfer rates in this population advancec was a supplement grant that leveraged the unique cohort of diverse nhs and research infrastructure from advance the aim of this study was to explore nh staff and proxies experiences caring for these residents with dementia during the pandemic across multiple domains method we used a qualitative descriptive study design this study was approved by advarra institutional review board facility recruitment the methodology of the main advance study is described elsewhere briefly we used the 20162017 minimum data set aggregated to the nh level to quantify intensity of care for this population based on feeding tube and hospital transfer rates among residents with advanced dementia highor lowintensity hrrs were defined as above or below the national median hospital transfer and tubefeeding rates for residents with advanced dementia respectively highand lowintensity facilities were defined as above or below hrr median hospital transfer and tubefeeding rates for residents with advanced dementia respectively from the hrrs included in advance we selected one highintensity hrr located in georgia and one lowintensity hrr located in new york and aimed to recruit two highintensity facilities and two lowintensity facilities within each hrr and the same staff and proxies who participated in advance data collection data collection occurred from october 2020 through march 2021 during staggered 2week periods at each facility the data collection team included two mastersprepared researchers trained in qualitative methods semistructured digitally recorded qualitative interviews were conducted via zoom or telephone verbal consent was obtained from participants and they were given a 25 gift card interview guides for staff and proxies comprised openended questions focused on a priori domains the five staff domains were as follows decision making organizational resources care processes vaccinations and personal impact the five proxy domains were as follows connecting with residents nh response to the crisis communicating with nh decision making and personal impact of the pandemic data analysis recorded interviews were transcribed and checked for accuracy data were analyzed by four investigators with formal training in qualitative analyses including two interviewers using framework analysis methodology transcripts were coded independently by two analysts and interrater reliability assessed using the coding comparison query in nvivo version 12 discrepancies were discussed until consensus was reached analysis consisted of open thematic and matrix coding in open coding raw data were grouped to create large discrete themes initially guided by our a priori domains in thematic coding themes were identified and refined in matrix coding themes were displayed on twodimensional matrices and compared across hrrs nhs and proxy racial groups evolving themes and results were discussed with the entire research team which included qualitative methods and nursing home experts results of the eight facilities in the two hrrs five facilities agreed to participate two highintensity facilities and three lowintensity facilities characteristics of staff and proxy participants are shown in tables 1 and2 staff interviews averaged 37 min of the participating staff 11 identified as black 22 were white and were from the following disciplines administrators directors of nursing social workers nurses cnas prescribing providers and other proxy interviews averaged 27 minutes of the participating proxies 428 identified as black 571 were white and included spouses adult children and other relationships although advancec aimed to explore differences in staff findings by hrr and facility intensity and proxy findings between black and white proxies matrix analyses did not show discernible patterns or differences along these parameters thus results are described for staff and proxies in all facilities without reference to hrr or nh intensity of care or proxy race ga1 n 8 ga2 n 8 ga3 n 8 ny1 n 8 ny2 n b 0 0 1 1 3 occupation n administrator 1 1 1 1 1 director of nursing 1 1 1 1 1 nurse 2 2 2 2 2 certified nursing assistant 1 2 2 1 1 social worker 0 1 1 1 1 prescribing provider 2 1 1 1 0 other c 1 0 0 1 0 mean staff experiences decision making the family has to be able to trust us because residents with advanced dementia cannot communicate for themselves staff frequently referred to the importance of having a connection with proxies when making decisions related to hospital transfers advance directives and care planning staff also recognized the importance of having the proxies trust this was especially relevant in discussions around advance directives and care planning all facilities readdressed care plans and advance directives during the pandemic some facilities had processes in place to readdress advance care plans regularly others implemented processes specifically for the pandemic visitors were not allowed into the facilities so proxies had to rely on and trust the staff reports of the residents with advanced dementia status and video calls with the resident to make decisions as an administrator said and so its a whole lot more communication between because if the family come in and able to see their loved one it is much easier to portray the picture um advanced dementia as well as the decline in the progression of the disease process versus now its basically through the little zoom visit … the family has to be able to have that trust in us that we speak on the uh what is best for the resident on behalf of the resident another nurse practitioner further described the challenges around zoom visits and the importance of the proxy trusting the staff reports of the residents status while having to make decisions about care for someone with advanced dementia like this … you know … you just uh give them what you see … you have that sense of trust because youve been dealing with them for a while and so they trust your observation they do trust the staff as well so it makes a huge difference … you know and they do have the zoom calls so they can see you know… but she was sleeping the whole time i could barely get her to wake up she was rattling during the call um and then theyd make the decisions based on that … and they make the decision on you know on whether to transfer the patient or not organizational resources we all came together the major organizational resource available to staff was their ability to pull together as a team all facilities reported experiencing grave staffing shortages throughout the pandemic due to staff quitting out of concerns for their safety or their familys safety unemployment offering higher reimbursement or staff needing to quarantine during facility outbreaks theres times where we had over 56 staff members out at one time despite these shortages all staff participants discussed how their team took an all hands on deck approach utilizing nonclinical staff to assist with care such as administrators and social workers assisting residents with advanced dementia with feedings and providing direct care when needed many described how this brought their team closer together for example one social worker mentioned ga1 n 2 ga2 n 1 ga3 n 2 ny1 n 2 ny2 n 0 proxy characteristic mean age years 770 790 650 665 sex n male 1 0 0 0 female 1 1 2 2 race n black 1 0 1 1 white 1 1 1 1 relationship to resident n partnerspouse 1 1 0 0 adult child 0 0 1 2 niececousin 1 0 1 0 notes ga georgia ny new york sd standard deviation … you had directors and management and administration that were you know going to the floors and … working weekends and helping with feeding when we had staff out with covid … i think it really brought everyone closer together another administrator described i really feel like that we have come together as a team … weve gotta do whatever weve gotta do to keep these residents safe care processes you have to become even more family staff reported difficulties with adaptations in care that did not benefit and were even detrimental for residents with advanced dementia for example all facilities reported using video calls phone calls window visits and scheduled socially distant outdoor visits to maintain connections between residents and families however staff noted that although these interactions were sometimes helpful for families they were largely ineffective for residents residents with advanced dementia were unable to hear their families due to social distancing recognize their faces due to masks or receive their physical touch a common way for families to communicate affection for these residents who cannot understand their surroundings one np described we had a number of family members that … stopped scheduling the calls just because there was no connection there … they basically were looking at a picture of their loved one … so we did have a number of family members that had just decided … that it was doing more … emotional harm to them personally than it was good for the resident staff also reported sarscov2 testing as especially challenging for residents with advanced dementia because these residents could not understand what was happening to them during nasopharyngeal swabs it was very difficult for staff to test for the virus many residents with advanced dementia had to be restrained and others were too combative to test them regularly the residents suffering and anguish was emotionally distressing for staff one social worker described … for this person to scream bloody murder youre sticking something in their nose and theyre confused you know that really hurt me to the point that i was emotional many staff talked about the significant impact of isolation on residents with advanced dementia staff reported that residents lacked the normal social cues to eat during meal times which contributed to significant weight loss they also perceived more rapid cognitive decline than usual one administrator mentioned that antipsychotic use increased trying to manage worsened behaviors among their residents with dementia … we were doing really doing great on the use of antipsychotics that definitely went up … people definitely got more medication and more depressed during the pandemic while caring for residents with dementia staff also reported difficulty connecting with residents while having to wear masks because residents could no longer see their facessmiles as this np described … wearing a mask and a shield going into a room i cant interact like i would or make someone feel comfortable with my smiles … you know you feel a barrier just because there is a barrier due to these particular challenges for residents with advanced dementia staff reported needing to become even more family or a type of surrogate family member many staff felt it was even more important throughout the pandemic to spend more time with residents with advanced dementia because families were unable to visit a nurse said at that time you got to be a family member not only a caregiver but you got to be a family member because their family members couldnt be there a director of nursing described weve had to step up more and be more of a family to these residents … but because literally their family cant come here we i think have all taken it personal to love em even more care for em even more show em the family love more staff also discussed how government guidelines negatively affected their care processes one lpn said keeping up with the changing guidelines was a fulltime job others felt the guidelines were important to keeping the virus from spreading some staff reported extreme frustration with the restrictiveness of government guidelines as one cna expressed theyve made us imprison them take away all their rights put them in their room not let them have any interaction with others except for the person that theyre in the room with for months for almost a whole year now vaccinations it was chaotic at the time of data collection vaccines were not available in two facilities in the others many staff reported discomfort at being among the first group to be vaccinated almost all administrative and leadership teams were vaccinated but many staff reported initial reluctance about getting a vaccine as one social worker stated people wanna see … the rest of us go through it first and see how it went … we are seeing more people want it now facilities partnered with pharmacies but administrators reported the first vaccine rounds were chaotic rushed and unorganized one administrator described disappointment with how delayed vaccines coincided with a facility outbreak of covid19 you know how many lives could have been saved … had the vaccine came to us sooner as promised or at least initially promised … the response plan from the federal and the state level was so uncoordinated personal impact i bear an enormous burden all staff discussed the difficulty of caring for residents through the pandemic they described the emotional toll of caring for dying residents with dementia the burden of shifts lasting 12 hr or longer and symptoms of burnout as one cna described … months and months of it and just watching the decline … and people die it just weighs on you … some days ill leave here and … just cry on the way home i feel terrible about it i bear an enormous burden and a sense of guilt over it … because you know i cant do anything about it staff in the georgia facilities reported faith as a source of comfort to help deal or cope with the stress in one nh a cna said i pray i ask god to give me strength to make it through the day while the social worker described having daily conversations with god about about the stress of caring for residents and how it is although many staff did not express concerns for their personal safety others expressed concerns about bringing covid19 home to their loved ones especially to vulnerable family members an lpn said i didnt feel safe going home after work and then i didnt feel safe coming back here because i have children and grandchildren proxy experiences connection with resident well be there as soon as theyll let us proxies reported nhs trying various ways to maintain connections with residents including video calls outdoor visits and very limited socially distant indoor visits although some proxies reported that these visits were helpful many said not being able to see residents in person was extremely difficult and that they were waiting for visitor restrictions to be lifted some proxies mentioned that time was limited with their loved ones because they were at the end of their lives making the lack of visiting especially difficult one proxy described i have to tell her that well be there as soon as theyll let us come in… its very hard you know she doesnt understand and its harder i guess because i know she doesnt have that much more time that shell know us and we wasted a year because of covid nh response they did the very best they could in general most proxies overwhelmingly felt nhs did the best they could under the circumstances and empathized with nh staff one proxy described concerns for not only their loved one but for the health and wellbeing of staff … theyve done an excellent job because theyve only had one outbreak of covid resident did not have covid … its hard for me not being able to go but i understand the situation theyre in and i know how contagious this is however proxies in one nh described how mistrust of the facility staff combined with the inability of the resident with advanced dementia to advocate for themselves contributed to worry about whether their loved one was receiving the best care possible … are they sincerely caring for her are they jerking her around and just because she cant communicate … some of the … people are in the wrong calling if that makes any sense i think you got to have that in your heart and you mind to be a good caregiver communication they always let us know the majority of proxies were very satisfied with availability and frequency of communications with frontline and administrative staff one proxy said i talk to them every day and they share with me you know everything … my communication with them could not be any better proxies reported receiving phone calls emails and video meetings that included updates on their residents condition as well as facility covid updates one proxy described how phone calls from nh staff made them feel like they knew what was happening during the time they were not allowed to visit the facility i think theyve done a good job of is just keeping me abreast of what is going on with her um you know all of the times she was tested for covid they would call and say you know she tested negative…i dont know they just seem to check in oftenso that while i cant see her i know whats going on decision making they know our wishes almost all proxies reported not having to make decisions around hospital transfers care planning or resuscitation because the residents and proxy preferences were already known and documented a proxy in the south described how having their residents preferences on file from admission made them feel more confident about having to make a decision around hospitalization should the decision arise residents hospitalization preferences is in their file theyve got all of it they know our wishes one proxy did hospitalize their loved one and described the decision as traumatic because the resident could not understand what was happening or advocate for herself they sent her to the hospital and because she cant read she cant write she doesnt understand and theyre asking her questions it was very very traumatic … and the doctor … was trying to ask her questions because he wanted to give her an mri and she cant answer them so it was very traumatic personal impact its been a rollercoaster all proxies described feeling stressed and very emotional emotionally … its been a rollercoaster throughout the pandemic without the ability to see their loved ones whenever they chose and the toll of being separated from their family support systems proxies described video calls with the residents as heartbreaking i do video calls and everything but … if i sit here and say it wasnt difficult even with me having the best experience its still … difficult and i appreciate you calling because i dont think ive expressed how i felt about this another proxy described the stress of worrying about their family member getting and discussion this unique qualitative study sheds light on the experience of caring for residents with advanced dementia during the covid19 pandemic our findings highlight the importance of developing dementiaspecific policies and procedures for future crises the critical nature of communication to both quality of care and the experiences of family of nh residents with advanced dementia and the detrimental effect of social isolation on both residents and proxies nh staff experienced ubiquitous challenges providing care for this vulnerable population regardless of region and facility intensity staff reported common adaptations made for residents during the pandemic such as window visits and video calls were not effective in maintaining connections for residents with advanced dementia however technology played a critical role in maintaining frequent communication via phone calls video calls and emails for the decision makers of nh residents with advanced dementia proxies of residents with advanced dementia indicated that although facilities were doing their best to try and to maintain personal connection they felt especially isolated from their loved ones throughout the pandemic staff and proxies stressed that the separation and isolation of nh residents with advanced dementia from their families due to infection control guidelines was detrimental to not only the health of residents but the wellbeing of the proxy both staff and proxies emphasized that mutual trust was critical for making decisions regarding residents care during the pandemic this report extends prior literature regarding nh staff experiences during the pandemic by providing a deeper understanding focused on the impact of caring for residents with advanced dementia similar to previous research staff reported concerns of bringing the virus home to their families and a deep sense of empathy and concern for residents in their care however staff encountered substantial challenges specific to advanced dementia such as testing these residents for the virus keeping their masks on and keeping them isolated in their rooms the ability of residents with advanced dementia to comprehend precautions precluded successful implementation of infection control protocols most staff reported that isolating residents with dementia was particularly challenging and had unforeseen outcomes consistent with national media reports nh staff perceived more rapid decline in cognitive status and weight loss among residents with dementia due to the lack of social interaction taken together the staff experience underscored the need for dementiaspecific considerations for future nh emergency preparedness plans the majority of proxies expressed satisfaction with nh communication and the critical role communication played instilling their trust in staff contrary to media reports of families kept in the dark about their loved ones status in nhs during the pandemic our findings indicate proxies felt that nhs continually updated them on residents status and any facility changes the unique needs of proxies of nh residents with advanced dementia should be noted understanding that these residents have limited life expectancy proxies consistently reported distress regarding missing out on their loved ones remaining days adding to the emotional burden they carried through the pandemic limitations of the study merit comment we used best methodological practices to mitigate biases found in qualitative analyses nevertheless these findings are limited to participating nhs and individuals who consented to be interviewed but do include the experiences of diverse nhs staff and proxies moreover we may not have captured prevalent racial differences in experiences between black and white proxies due to the small number of participants lastly due to restrictions we were unable to conduct any physical observations in participating facilities therefore our findings rely solely on staff reports of experiences in the nhs this study provided a unique opportunity to understand experiences of nh staff and proxies of residents with advanced dementia during the covid19 pandemic in facilities in different regions of the united states with differing intensity of care staff consistently described the heavy emotional burden of caring for residents with advanced dementia and underscored the importance of considering the psychological consequences of the trauma they experienced throughout the pandemic overall the findings suggest staff and proxies felt that facilities were doing the best they could with the resources available to them with an all handsondeck approach to providing care especially for residents with advanced dementia while hospital staff and other frontline healthcare workers were touted as heroes nh staff were often vilified in the media in the wake of the pandemic 2405 staff and 153445 nh residents have died from covid19 to date the pandemic shone a harsh light on critical flaws in the us nh system and further exacerbated longstanding inequities of its most vulnerable residents particularly those with advanced dementia the pandemic also renewed calls for widespread system transformation and heightened focus on emergency preparedness for future public health emergencies and natural disasters this report emphasizes the need for dementiaspecific strategies to improve nh preparedness for future crises it further underscores the need for increased support for nh staff from policymakers and clinicians a demand that will surely continue following the pandemic challenges nh staff and proxies faced throughout the covid19 pandemic exacerbated the burden and stress they experience and are likely to contribute to continued staff shortages and increased rates of caregiver burnout in the future it is critical that dementiaspecific strategies strive to balance best practices to mitigate future crises while maintaining family connections and personcentered care for this vulnerable population supplementary material supplementary data are available at the journals of gerontology series b psychological sciences and social sciences online conflict of interest none declared

objectives assessment of disparities and variation for alzheimers disease nursing home care at end of life advance is a multisite qualitative study of regionally diverse nursing homes nhs n 14 providing varied intensity of advanced dementia care advancec explored the experiences of nh staff and proxies during the covid19 pandemic methods data collection occurred in five of the advance facilities located in georgia n 3 and new york n 2 semistructured qualitative interviews with nh staff n 38 and proxies of advanced dementia residents n 7 were conducted framework analyses explored five staff domains care processes decision making organizational resources vaccinations and personal experience and five proxy domains connecting with residents nh response communicating with nh decision making and personal impact of the pandemic results staff mentioned difficulties implementing infection control policies specifically for advanced dementia residents staff reported trust between the facility and proxies as critical in making decisions during the pandemic all staff participants spoke about coming together to address persistent staffing shortages proxies described their role as an emotional rollercoaster emphasizing how hard it was being separate from their loved ones the accommodations made for nh residents were not beneficial for those with advanced dementia the majority of proxies felt nh staff were doing their best and expressed deep appreciation for their care discussion caring for advanced dementia residents during the covid19 pandemic had unique challenges for both staff and proxies strategies for similar future crises should strive to balance best practices to contain the virus while maintaining family connections and personcentered care

the practical side of transparency how can scientists increase the transparency of their work to begin with they could adopt open research practices such as study preregistration and data sharing 3 4 5 many journals institutions and funders now encourage or require researchers to adopt these practices some scientific subfields have seen broad initiatives to promote transparency standards for reporting and summarizing research findings such as start spirit prisma strobe and consort a few journals ask authors to answer checklist questions about statistical and methodological practices transparency checklist we provide a consensusbased comprehensive transparency checklist that behavioural and social science researchers can use to improve and document the transparency of their research especially for confirmatory work the checklist reinforces the norm of transparency by identifying concrete actions that researchers can take to enhance transparency at all the major stages of the research process responses to the checklist items can be submitted along with a manuscript providing reviewers editors and eventually readers with critical information about the research process necessary to evaluate the robustness of a finding journals could adopt this checklist as a standard part of the submission process thereby improving documentation of the transparency of the research that they publish we developed the checklist contents using a preregistered reactivedelphi expert consensus process 10 with the goal of ensuring that the contents cover most of the elements relevant to transparency and accountability in behavioural research the initial set of items was evaluated by 45 behavioural and social science journal editorsinchief and associate editors as well as 18 openscience advocates the transparency checklist was iteratively modified by deleting adding and rewording the items until a sufficiently high level of acceptability and consensus were reached and no strong counter arguments for single items were made as a result the checklist represents a consensus among these experts the final version of the transparency checklist 10 contains 36 items that cover four components of a study preregistration methods results and discussion and data code and materials availability for each item authors select the appropriate answer from prespecified options it is important to emphasize that none of the responses on the checklist is a priori good or bad and that the transparency report provides researchers the opportunity to explain their choices at the end of each section in addition to the full checklist we provide a shortened 12item version by reducing the demands on researchers time to a minimum the shortened list may facilitate broader adoption especially among journals that intend to promote transparency but are reluctant to ask authors to complete a 36item list we created online applications for the two checklists that allow users to complete the form and generate a report that they can submit with their manuscript andor post to a public repository the checklist is subject to continual improvement and users can always access the most current version on the checklist website access to previous versions will be provided on a subpage this checklist presents a consensusbased solution to a difficult task identifying the most important steps needed for achieving transparent research in the social and behavioural sciences although this checklist was developed for social and behavioural researchers who conduct and report confirmatory research on primary data other research approaches and disciplines might find value in it and adapt it to their fields needs we believe that consensusbased solutions and userfriendly tools are necessary to achieve meaningful change in scientific practice while there may certainly remain important topics the current version fails to cover nonetheless we trust that this version provides a useful to facilitate starting point for transparency reporting the checklist is subject to continual improvement and we encourage researchers funding agencies and journals to provide feedback and recommendations we also encourage metaresearchers to assess the use of the checklist and its impact in the transparency of research data availability all anonymized raw and processed data as well as the survey materials are publicly shared on the open science framework page of the project our methodology and dataanalysis plan were preregistered before the project the preregistration document can be accessed at v5p2rregistrations competing interests sk is chief editor of the journal nature human behaviour sk has recused herself from any aspect of decisionmaking on this manuscript and played no part in the assignment of this manuscript to inhouse editors or peer reviewers she was also separated and blinded from the editorial process from submission inception to decision the other authors declared no competing interests additional information supplementary information is available for this paper at 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 license and indicate if changes were made the images or other third party material in this article are included in the articles creative commons license unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons license 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 license visit

we present a consensusbased checklist to improve and document the transparency of research reports in social and behavioural research an accompanying online application allows users to complete the form and generate a report that they can submit with their manuscript or post to a public repository

introduction by 2050 the worlds population is projected to increase from its present level of 67 billion people to 92 billion people1 such a population rise will put a strain on the communitys infrastructure as well as its food supply medical services and general wellbeing governments have incorporated family planning as a component of their demographic control program in order to offset the impacts of such a massive surge in population according to the most recent united nations figures india had 1342463457 people as of 2017 it is the second most populous nation given that indias median age is 269 years a significant portion of women are also of reproductive age it is not unfair to state that women continue to pass away in our nation due to conditions that are almost unknown in industrialised nations2 1786 of all people on earth live on the indian subcontinent3 in 2019 there are 19 billion women globally in the reproductive age range and 11 billion of them need family planning4 contraception is recommended in order to meet the vital issue of rapid population expansion as well as the demands of both men and women in terms of reproductive health5 according to research 222 million spouses do not use any kind of contraception even in this day and age this is mostly due to a lack of awareness and resources as well as cultural taboos and attitudes around the usage of various forms of contraception6 this hypothesis is reinforced by the statistic that among women with unplanned pregnancies roughly sixty percent of them were not using any kind of contraception this concept uses the practice of spacing between each child through the use of contraceptive methods7 induced abortions are frequently the outcome of unplanned pregnancies which presents a serious problem for young peoples reproductive health in developing nations like india8 therefore the current study intended to evaluate married females who were 18 years of age and orders awareness acceptance and adoption for contraception methodology the current study was done over a sixmonth period using a cross sectional design participants was recruited based on predetermined criteria and attendeddelivered at the saidham hospital affiliated to dr mane medical foundation and research centre maharashtra india married women who are 18 years of age or older of reproductive age and those who were willing to participate were included and participants who chose a permanent method of contraception those who underwent hysterectomy were excluded from the study sample size calculated by using reference from bamniya j et al study9 finding and using following formula sample size z 2pqd2 where p 63 participants were not using any method of contraception 5 absolute precision considering alpha 5 and z value 196 putting these values in equation sample size 2 ×63×37 2 calculated sample size was 359 to examine the feasibility applicability and validity of the questionnaire a pilot study was carried out for this initial test a premade questionnaire was employed the questionnaire was improved based on the feedback we got and the difficulties we ran into during the pilot trial the pretested final version was then used to conduct data gathering questionnaire was of three parts viz part 1 contains sociodemographic information part 2 history of obstetrics and gynaecology part 3knowledge attitude and practise questions the accuracy of the data tools was verified and data input and coding were carried out in microsoft excel to highlight key aspects the raw data was organised categorised and presented in a tabular and graphical format after confirming that all of the gathered questionnaires were complete data coding and input were carried out in microsoft excel spss software 21 was used to examine the data the analysis employed descriptive and inferential methods such percentage mean standard deviation odds ratio and chisquare test p values under 005 were deemed significant for statistical analysis results table 1 shows the demographic variables of study participants our study revealed that out of a total of 359 study participants the majority 115 belonged to the 2125 age group while 197 were housewives 112 had higher secondary education 201 belonged to the lower socioeconomic class and were bpl cardholders 191 belonged to rural areas and hindu populations contributed 182 furthermore165 study participants had one child and 21 had a history of one abortion table 4 shows associations of demographic variables with contraception usage our study revealed that there was no statistically significant relationship between age and contraception usage while occupation level of education socioeconomic class area of residence and religion showed statistically significant relationships with contraception usage furthermore the number of children and history of abortion did not show any statistically significant associations with contraception usage discussion our our study found that occupation level of education socioeconomic class area of residence and religion showed statistically significant relationships with contraception usage furthermore the number of children and history of abortion did not show any statistically significant associations with contraception usageas per gothwal m et al study shows significant association of age marital status family size with usage of contraception10 as per bamniya j et al study education of women education of spouse occupation of women parity live birth show statistically significance with usage of contraception9 conclusion the present study concludes that the majority of women of reproductive age still do not use contraceptives and their opinion is not taken into account more similar studies are needed to ascertain the determinants of contraceptive use and such knowledge can be used to formulate specific health education needed for adoption of family planning methods compliance with ethical standards disclosure of conflict of interest no conflict of interest to be disclosed statement of ethical approval institutional ethical committee permission was obtained before commencing the study statement of informed consent the aim and objectives of the present study were explained to participants in vernacular language and informed consent was obtained from all individual participants included in the study

introduction according to the who family planning is an approach to thinking and living that people and couples freely adopt in order to enhance their health and welfare based on their knowledge attitude and responsible choices each year incorrect use of contraceptives or their failure to work as intended results in around onethird of unwanted births the obstacles that exist in poorer nations include a lack of awareness about contraceptive techniques the availability of supplies their cost or their inadequate accessibilitythis was a cross sectional study conducted to asses o contraception awareness acceptance and adoption among women of reproductive age women who attendeddelivered at the saidham hospital affiliated to dr mane medical foundation and research centre dmmfarc maharashtra india were included facetoface interviews were conducted while data were collected using a structured questionnaire result out of total 359 total women the majority 115 3202 belonged to the 2125 age group while 197 5487 were housewives 112 3119 had higher secondary education 201 5498 belonged to the lower socioeconomic class and were bpl cardholders 191 5220 belonged to rural areas and hindu populations contributed 182 5069 furthermore165 4596 study participants had one child and 21 584 had a history of one abortion occupation level of education socioeconomic class area of residence and religion showed statistically significant relationships with contraception usagethe present study concludes that the majority of women of reproductive age still do not use contraceptives and their opinion is not taken into account more similar studies are needed to ascertain the determinants of contraceptive use and such knowledge can be used to formulate specific health education needed for adoption of family planning methods

introduction children who grow up in families where the parents have alcohol problems are at increased risk of several negative consequences including poor school performance poor mental health and early onset alcohol use 1 2 3 4 5 6 parentification may also occur where children assume adult roles even though they are not developmentally or emotionally ready 7 the consequences are often longterm 8 and they augment the likelihood of other disorders for instance mental disorders such as major depression 9 furthermore studies have demonstrated that when parents have alcohol problems their offspring are at increased risk of alcoholrelated hospitalization and mortality including suicide 1011 currently international studies have estimated that the prevalence of children with parents who have alcohol problems is 429 12 13 14 15 16 17 the primary reason for this broad range is that parental alcohol problems are defined and assessed differently in different studies for instance some studies examined hazardous drinking among parents and others examined parental alcohol use disorder furthermore some studies were based on selfreports from either the children or parents and others were based on surveys psychiatric interviews or registry data drinking patterns vary across countries and there may also be differences in how alcohol problems are defined of 10 in nordic countries only a handful of scientifically determined estimates are available and the estimated prevalence varies a webbased survey distributed to swedish youth 1619 years old concluded that 201 of the sample had at least one parent with an alcohol problem 13 in that study perceived alcohol problems were assessed with the short version of the children of alcoholics screening test 18 another survey which was distributed to a nationally representative sample of swedish adults 1784 years old assessed alcohol problems with the mini international psychiatric interview derived from the diagnostic and statistical manual of mental disorders fourth edition they concluded that 37 of children had at least one parent with a current alcohol use disorder 12 another study based on danish registry data concluded that 45 of children had parents that had been hospitalized due to an alcoholrelated illness 17 a recent danish study based on 75853 highschool and vocational school students reported that 73 of the surveyed students perceived that they had at least one parent with alcohol problems 19 a norwegian study based on reports from parents of teenagers found that 156 of fathers and 47 of mothers were defined as individuals that misused alcohol 20 however these figures may not be generalizable to parents with younger children 21 the scarcity of data on the prevalence of children who have parents with alcohol problems in norway calls for further studies early adversity may have a negative impact on many aspects of life including socioeconomic indicators such as education employment and income 22 however to the best of our knowledge no studies have explicitly investigated whether there exists a social gradient connected to parental alcohol problems in nonclinical populations moreover although it is important to understand how widespread parental alcohol problems are it would be valuable to have estimates based on the perceptions of the children or adult children therefore this study aimed to estimate the prevalence of parental alcohol problems during childhood in a general population of norwegian adults and to investigate associations between parental alcohol problems during childhood and lower socioeconomic status in adulthood materials and methods this crosssectional study included a random sample of 75191 individuals aged 18 years or older that resided in the region of agder the sample was drawn from the norwegian population registry and emails or telephone numbers were obtained from the contact registry of the agency for public management and egovernment individuals who had declined to participate in surveys individuals registered as deceased those with unverified contact information and those with an address outside the region were removed thus in 2019 61611 inhabitants were invited to participate in the norwegian counties public health survey the respondents participated by completing a questionnaire online the questionnaire included questions related to health wellbeing childhood living conditions local environments accidents and injuries participants gave online consent to participate when they answered the survey questions and provided their age and sex to confirm their identity of the 61611 invited individuals 28047 completed the questionnaire the response rate was 455 ethics informed consent was obtained from all subjects involved in the study all personal identification variables were removed before the researchers obtained the dataset data were handled in compliance with applicable personal data protection regulations the norwegian institute of public health is responsible for the health survey the survey was approved by the norwegian data inspectorate and it adhered to the regulations of the personal health data filing system act in addition a data protection impact assessment was performed by the norwegian institute of public health ethical approval for the current study was obtained from the national committees for research ethics in norway and from the faculty ethics committee at the university of agder measures the questions response categories and definitions used in the survey are shown in table 1 vocational trainingmiddle school upper secondaryjunior college 3 universitycollege 4 years 4 universitycollege ≥4 years 1 low education 2 intermediate education 3 and 4 higher education financial capabilities for oneperson households consider your total income if you live with others consider the total income of everyone in the household how easy or difficult is it for you to make ends meet day to day with this income 1 very difficult 2 difficult 3 relatively difficult 4 relatively easy 5 easy 6 very easy 7 do not know 13 low economic capability vs 47 middlehigh economic capability employment status what is your current status concerning employment etc 1 fulltime 2 parttime 3 selfemployed 4 on sick leave 5 unemployed 6 receiving disability pensionwork assessment allowance 7 receiving social assistance benefits 8 in retirementearly retirement 9 pupilstudent 10 undertaking nationalalternative civilian service 11 homemaker 1 ≥ 32 hweek vs not2 32 hweek vs not3 selfemployed vs not4 on sickleave vs not6 and 7 receiving welfare benefits vs not the sixitem cast6 instrument was used to estimate perceived parental alcohol problems 18 respondents could answer yes 1 or no 0 to each question and the total score ranged from 0 to 6 the cast6 demonstrated high internal consistency and concurrent validity compared to the original 30item cast for adults 182324 moreover it showed good to excellent testretest reliability for both adults and adolescents 23 24 25 in the present study the scale showed excellent reliability two alternative cutoff scores are commonly used with the cast6 one cutoff score is more inclusive and the other is more conservative 18242627 the more conservative cutoff score was used in the current study data on socioeconomic factors were collected with questions related to education economic capability employment status and whether respondents received welfare benefits participants age and sex were provided through the national population registry in addition participants were asked about their marital status statistical analysis data were analysed with spss version 25 descriptive statistics for the overall sample were estimated for key demographic and socioeconomic variables pearsons χ 2 analyses were performed to evaluate associations between the overall distribution of parental alcohol problems and the demographic and socioeconomic variables multivariable logistic regression was performed to investigate the association between parental alcohol problems and measures of low socioeconomic status adjusted for age and sex results are expressed as odds ratios with 95 confidence intervals a pvalue 005 was considered statistically significant results descriptive characteristics of the sample are provided in table 2 multiple responses could be selected education level and employment status are defined in table 1 table 3 shows that overall 156 of the respondents had experienced problematic alcohol use among their parents during childhood this experience was significantly more prevalent among females than among males the proportion of individuals who reported experiences of problematic parental alcohol use varied among different age groups the lowest prevalence was observed for respondents aged 67 years or older moreover this experience was less common among respondents that were married or had a registered partner compared to those with another relationship status we also observed a consistent social gradient in associations between parental alcohol problems and various socioeconomic variables parental alcohol problems were more prevalent among those with a lower education level compared to those with intermediate or high education levels among those with low economic capability compared to those with middlehigh economic capability among those on sick leave compared to those not on sick leave and among those who received welfare benefits compared to those who did not receive welfare benefits 1 results from the multivariable logistic regression are displayed in figure 1 findings revealed consistent associations between parental alcohol problems and all measures of low socioeconomic status the strongest association was found between parental alcohol problems and the need for welfare benefits other forms of marginalization within the work force such as being on sick leave or being unemployed were also associated with parental alcohol problems the experience of parental alcohol problems was also significantly associated with no collegeuniversity education forms of marginalization within the work force such as being on sick leave or being unemployed were also associated with parental alcohol problems the experience of parental alcohol problems was also significantly associated with no collegeuniversity education discussion we found that among an adult norwegian sample randomly drawn from the general population 156 had experienced problematic parental alcohol use during childhood to the best of our knowledge no previous studies have estimated the prevalence of parental alcohol problems in the nordic context based on a broad age range of adult offspring from the general population a previous norwegian study analysed selfreported problems with alcohol use among parents of teenagers they found that 156 of the fathers had alcohol problems but the proportion of mothers in this category was significantly lower in our study we did not group individuals based on parental sex thus our finding that 156 of parents had problematic drinking behaviours included fathers mothers or both other international estimates of the prevalence of parental alcohol problems have varied greatly 12 13 14 15 16 17 this variation might partly be explained by differences in the samples and measures used in different studies a swedish study included adolescents aged 1619 years and also used the cast6 they found that the prevalence of respondents that reported perceived parental alcohol problems was 201 13 which was somewhat higher than our estimate this difference might be explained by the difference in respondents age between studies our results indicated that the oldest age group was least likely to report parental alcohol problems this result could be explained by several factors first the questions were retrospective in nature and recall bias could be a prominent issue 28 second it has been shown that adverse childhood experiences such as parental alcohol problems were associated with impaired health 29 and elevated mortality 10 therefore the oldest respondents who experienced problematic parental alcohol problems could have been underrepresented third alcohol consumption among norwegian adults increased after the second world war 30 thus it is plausible that the prevalence of parental alcohol problems was in fact relatively low during the era that the oldest participants grew up discussion we found that among an adult norwegian sample randomly drawn from the general population 156 had experienced problematic parental alcohol use during childhood to the best of our knowledge no previous studies have estimated the prevalence of parental alcohol problems in the nordic context based on a broad age range of adult offspring from the general population a previous norwegian study analysed selfreported problems with alcohol use among parents of teenagers they found that 156 of the fathers had alcohol problems but the proportion of mothers in this category was significantly lower in our study we did not group individuals based on parental sex thus our finding that 156 of parents had problematic drinking behaviours included fathers mothers or both other international estimates of the prevalence of parental alcohol problems have varied greatly 12 13 14 15 16 17 this variation might partly be explained by differences in the samples and measures used in different studies a swedish study included adolescents aged 1619 years and also used the cast6 they found that the prevalence of respondents that reported perceived parental alcohol problems was 201 13 which was somewhat higher than our estimate this difference might be explained by the difference in respondents age between studies our results indicated that the oldest age group was least likely to report parental alcohol problems this result could be explained by several factors first the questions were retrospective in nature and recall bias could be a prominent issue 28 second it has been shown that adverse childhood experiences such as parental alcohol problems were associated with impaired health 29 and elevated mortality 10 therefore the oldest respondents who experienced problematic parental alcohol problems could have been underrepresented third alcohol consumption among norwegian adults increased after the second world war 30 thus it is plausible that the prevalence of parental alcohol problems was in fact relatively low during the era that the oldest participants grew up we also found that parental alcohol problems were reported slightly more frequently by females than by males although this result was puzzling other studies have shown similar findings 2425 havey and dodd 25 have suggested that females compared to males may be more sensitised toward substance use and related issues within the family and that they also may be more prone to express concern about a family situation in a selfreported questionnaire overall our findings showed that perceived parental alcohol problems were most prevalent among socioeconomically disadvantaged groups the largest proportion of respondents that experienced parental alcohol problems comprised those who received a disability pension work assessment allowance or social assistance benefits in this group of respondents 25 experienced parental alcohol problems during childhood this finding remained significant after adjusting for age and sex in the multivariable analyses although alcohol consumption in norway was found to be highest among adults with a high education level 31 we found that the respondents childhood experiences of problematic parental alcohol use were inversely associated with the respondents education level other studies have also found socioeconomic inequalities in the distribution of individuals that experienced alcoholrelated harm 32 although we lack studies that have specifically addressed socioeconomic differences in the distribution of individuals with parental alcohol problems other studies have shown that adverse life experiences are socially patterned in childhood 33 therefore the social gradient that we observed among our adult respondents could be related to the socioeconomic disadvantage present in childhood however adverse childhood experiences can also reduce educational attainment indeed houtepen et al 34 found that this relationship remained significant after controlling for family socioeconomic variables possible explanations of these relationships are likely complex exposure to chronic stress may induce changes in the developing brain and impact a range of important functions that interfere with learning and other skills needed to succeed in education or the workplace 35 childhood adversities such as parental alcohol problems could also increase health risk behaviours physical and mental health problems and developmental disruptions 36 which may also contribute to economic marginalisation study strengths and limitations this study has expanded existing knowledge by contributing estimates of perceived parental alcohol problems based on reports from a large adult sample of 28047 individuals drawn randomly from the general population our outcome was based on the cast6 which is a validated instrument 24 item four of the cast6 presumes the presence of two parents which could influence the score for respondents who grew up in singleparent families sensitivity analyses excluding this item did not alter the findings significantly our findings shed light on the socioeconomic patterns associated with the prevalence of parental alcohol problems which were rarely studied in previous research this study was limited by its retrospective design moreover responses could be prone to recall bias and the risk of measurement error 28 the validity of retrospective assessments of childhood experiences has been debated however a comparison between retrospective reports and prospective results did not reveal a bias in the retrospective assessment of difficult childhood experiences 37 additionally cautiousness regarding the generalizability of the findings is necessary due to possible nonresponse bias finally this study was based on crosssectional data therefore the results should be interpreted with caution when considering causality implication for practice the cast6 was not designed to identify diagnostic criteria instead it identifies individual perceptions of problematic parental alcohol use previous studies that investigated adverse outcomes related to parental nondependent alcohol use had mainly focused on offspring substance use 38 however several studies have identified other negative outcomes related to parental nondependent drinking patterns 39 40 41 these dysfunctional patterns often continue into the next generation to break the patterns early support interventions should be available however support might be available to varying degrees for instance in sweden the vast majority of municipal social services provide support to children growing up with parental substance use problems most often in the form of individual counselling or support groups but at the same time support only reaches a small proportion of the targeted children 42 several organizations identify children in need and offer support including the adult substanceuse treatment services psychiatric care and social services however studies have shown that in most cases those organizations did not determine whether the clients had children 43 the situation in norway appears to be similar only about one fifth of the professionals working in substance use treatment facilities offered support to their clients children and about half of the professionals never assessed whether the clients had children 44 one obvious arena to identify children in need of support is the school setting since these children often are neglected schools could work with policy documents and action plans and inform and train their staff about this vulnerable group previous research has shown that policy documents increase the likelihood of school staff to receive training in this issue which in turn increases the likelihood of identifying these vulnerable children in the school setting 45 digital interventions represent a promising approach for increasing the availability of support however currently only a small number of digital interventions are currently being tested that target this group of individuals 46 47 48 49 for instance in sweden an online chat group program has been developed 47 based on a dutch program 48 the program consists of eight weekly sessions each 6090 min long focusing on themes such as your role in the family social networks and substance use tolerance and heredity each session is moderated by a trained counsellor the program is currently being evaluated but has the potential to reach a large number of adolescents and young adults conclusions this study showed that one in six adults reported problematic parental alcohol use and among disadvantaged subgroups this prevalence increased to one in four it is imperative to make both universal and selective prevention interventions available at an earlier age if we expect to break family patterns of problematic alcohol consumption in addition we need better methods for early detection for instance by identifying burdened children when parents are in contact with general or more specialized health care 4350 furthermore we should ensure proper support and followup for these children and their families data availability statement restrictions apply to the availability of these data data was obtained from norwegian institute of public health and are available at with the permission of niph informed consent statement informed consent was obtained from all subjects involved in the study

the aim of the study presented here was to estimate the prevalence of parental alcohol problems during childhood in a general population of norwegian adults and to investigate associations between parental alcohol problems during childhood and lower socioeconomic status in adulthood this crosssectional study recruited 28047 adults ≥18 years to an online health survey norwegian counties public health surveys we evaluated demographic and socioeconomic measures and responses to a shortened version of the children of alcoholics screening test cast6 scale to assess whether respondents perceived parental alcohol consumption during childhood as problematic respondents reported parental alcohol problems at a rate of 156 but the experience was more prevalent among adults with a low education 200 compared to those with intermediate 164 or high educations 138 χ 2 2 87486 p 0001 and it was more common among respondents with low economic capabilities 211 compared to those with middlehigh capabilities 142 χ 2 1 162089 p 0001 parental alcohol problems were most prevalent among respondents that received welfare benefits 245 multivariable logistic regression analyses revealed associations between parental alcohol problems and low socioeconomic status in adulthood odds ratios 95 confidence intervals ranged from 133 125142 to 189 172206 from a public health perspective children who grow up with parental alcohol problems should be reached through both universal and selective interventions

background breast cancer is a prevalent chronic disease affecting millions of women with recent statistics indicating that approximately 1 in 8 women in the united states will be diagnosed in their lifetime 1 for women with hormone receptorpositive breast cancer adjuvant endocrine therapies are often needed for several years as prophylaxis against cancer recurrence following primary treatment 2 previous studies have mostly focused on addressing the social support needs of these women during initial diagnosis and primary treatment phases 3 the adjuvant phase is much longer than the diagnosistreatment phase and still understudied completion of primary treatment coincides with a sudden decrease in healthcare encounters from several times per month during active treatment to once every three to six months during the adjuvant phase 4 this decrease results in patients having fewer occasions to obtain support from their healthcare teams 5 moreover patients tend to underutilize their support networks and report receiving less social support from their friends and family a year following primary treatment 6 thus for many women the start of aet marks the beginning of a decline in social support which may create new unmet social support needs several studies show a positive association between social support and clinical health outcomes such as medication adherence and mortality 7 8 9 10 11 12 13 for women on aet unmet social support needs are also associated with increased symptom burden 14 higher leukocyte proinflammatory and prometastatic gene expression 15 increased depressive symptoms 16 and lower overall quality of life 17 specifically social support from other survivors referred to as experiential support has been shown to improve a patients ability to appraise her breast cancer experiences while also reducing feelings of isolation and promoting optimism for the future 18 while this type of support can be facilitated via formal support groups less than 12 of women with breast cancer regularly attend formal meetings 19 accordingly scholars and clinicians have called for examining new ways to improve access to social support particularly experiential support for women with breast cancer 20 understanding racial differences in social support is especially important for regions with significant disparities such as memphis tennessee the memphis metropolitan region has high breast cancer mortality relative to other cities of its size 21 and significant blackwhite disparities 22 black women in memphis are more than twice as likely to die from breast cancer as white women 23 still little is known about racial differences in social support and how they may contribute to these welldocumented racial disparities we conducted four focus groups with women diagnosed with early stage hr breast cancer taking aets to explore social support needs among black and white women with breast cancer following primary treatment methods procedures following approval by the institutional review board at the university of tennessee health science center a wcc research nurse reviewed electronic health records to identify women who met our eligibility criteria using purposive sampling tj confirmed participant eligibility and provided an overview of the study and topics to be discussed during onetime fgs four 90minute fg interviews were conducted between december 2017 and january 2018 before starting each group informed consent was obtained from each participant who also completed a survey assessing demographic and medical characteristics 24 these groups were stratified by race and length of aet treatment each fg participant was compensated with a 40 gift card raceand genderconcordant moderators a clinical psychologist and a health communication scholar led the fgs both moderators completed formalized fg training and have extensive backgrounds in facilitating fgs a semistructured moderator guide containing questions and prompts was drafted by jna which was reviewed and edited by the study team until a consensus was reached regarding content and phrasing for consistency across fgs moderators asked questions in the guide wordforword and followup probes were asked and clarifications were provided as needed for instance some interview questions included what do you think the team should know about womens physical mental emotional spiritual and social support needs when taking your hormone therapy and what recommendations would you make to the team in order to ensure the accuracy of perspectives and to increase validity moderators employed the strategy of member checking 25 by periodically summarizing participants comments throughout the fgs to reduce bias toward perspectives of more loquacious participants moderators identified participants who were contributing less frequently and encouraged them to offer their perspectives analysiswe audiorecorded fg interviews and transcribed verbatim to obtain accurate data using a modified version of silvermans transcription conventions 26 first fg interview transcripts were analyzed separately by group two authors conducted linebyline coding for each transcript these authors used the qualitative strategy of constant comparison 2728 to identify emergent themes from the raw data after these initial themes were identified two authors performed additional coding and analysis to assess racebased differences in social support interrater reliability between ap and ig via percent agreement was calculated to be 896 with cohens κ 087 discrepant coding was resolved by a third party another author conducted an independent review of the final codebook and qualitative analyses results table 1 in appendix a describes fg participants demographic and medical characteristics average age was 64 years 48 were not married and 19 had a 4year college degree or higher the majority of participants were prescribed the aet medication anastrazole and 48 reported not being fully adherent across the fgs participants identified family and friends as key sources of informational and emotional support from their initial breast cancer diagnosis through the adjuvant treatment phase importantly the fg modality itself served as a source of support from which fg participants drew upon to address unanswered questions and receive emotional validation white women often reported having support from other survivors however black women did not make any references to providing or receiving social support from other breast cancer survivors outside of the fgs informational and emotional support from family friendsparticipants from all fgs noted the importance of family and friends to accomplish varied instrumental support and informationseeking tasks and serve as additional listening ears during physician visits one participant noted the importance of family inclusion during provider visits which can help facilitate the acquisition of necessary informational support she said and i had several questions and had my daughter mother my husband and my sonso it was like a familylike presentation to us because these are the people that are going to have to help you outside of the medical facility another participant expressed how her daughter a pharmacist who had also been diagnosed with breast cancer helped her navigate her own cancer she said i was blessed to have my daughter who… had been through breast cancer… to answer a lot of my questions one participant reported that she maximized the knowledge and skills of her network to help her find the best plastic surgeon in her area saying i really literally called everyone that cares about me and i care about them and i gave them assignments i really truly did you tell me you find me your job is to find who the best plastic surgeon in … is additionally participants underscored the value of emotional support provided by networks of family members and friends participants in our study readily admitted to relying on spouses children and inlaws to provide comfort during medical visits especially when serious or negative news from providers was anticipated one participant stated my soninlaw was exceptional he went with me every time i went to the doctor when my daughter couldnt go so i feel so fortunate another participant added …its my husband hes has been my strength through everything racebased differences in support white women more likely to report having other breast cancer survivors in their social support networksdespite having many similarities in needs we observed some racebased differences in sources of support white participants frequently noted the importance of relationships they had with other breast cancer survivors who provided informational support during participants active and adjuvant treatment phases based on firsthand knowledge and insights from their own cancer experiences for example one white participant expressed gratitude for the small network of longterm breast cancer survivors with whom she was able to talk and receive reassurance during her treatment she said ive got a lot of support in my work group and my sister has had breast cancer but she is 15 years older and she lives in missouri…its nice to be able to sit down and talk to people who have been through it recently conversely there were no explicit references made by black women in our sample to receiving or providing support from other breast cancer survivors outside of the fg white women more likely to report addressing other breast cancer survivors emotional needsunlike black women white women in our sample also reported finding mutual benefit in providing emotional support to other breast cancer survivors in their lives our participants noted the importance of having someoneeven a complete strangerminister to their emotional needs during temporal moments of fear uncertainty or hopelessness this was particularly the case among older white women in our study who often expressed the need for survivors to be sensitive to others emotional needs for instance one participant recounted an experience in which she was able to provide some comfort to another patient during a short elevator ride she said oh we all you know didnt know how to do and what to do and she looked so floored that i said would a hug help and she said i think it would and so i hugged her and she said she had been going through another type of cancer for 12 years and the breast cancer stuff was new interestingly all of the fgs created environments where participants were able to give and receive support in fact in every fg a spirit of sisterhood was fostered among some participants experiential support occurred more frequently as seeking and providing informational support to each other in fgs of black participants and more frequently as seeking and providing emotional support to each other in fgs of white participants black women more likely to provide informational support to each other during fg interviewssome black participants used fg discussions to query others about tumor growth and genetic testing and to share tips and overthecounter products for combating aet medication side effects one black participant who worked in a pharmacy made a point of providing medical information she knew by virtue of her occupation to other women in the fg sometimes as was the case for one exchange in fg4 participants provided informational and emotional support concurrently for example black participants acknowledged the harsh effects of active treatment while providing affirming statements to one woman who felt selfconscious about her radiation burns white women more likely to provide emotional support to each other during fg interviewsstudy participants regardless of race noted that sharing their personal experiences with breast cancer and subsequent treatments in safe supportive environments with other women who are going through the same thing was meaningful and spiritually helpful several women even suggested meeting monthly for lunch yet white women were more likely than black women to explicitly provide emotional support to other fg members during the interviews for instance one participant said to another i just met you what an hour ago id hug you because sometimes you just feel like you need that you just need somebody to say oh i know what you mean ive been through that too the following conversation sparked by one participant about hair loss in the adjuvant phase is a telling example participant a is anyone else losing their hair participant b my hair is coming out and its so thin now participant c mine was thin before participant b but this is just from breast cancer not the anastrozole mine is coming in thicker than i had before participant a i just got a clip on the top is mine participant c yeah it looks good similarly white women in our study did not pass judgment when one participant admitted to being nonadherent to their aet participant d how often i forget to take the medicine you know maybe once a week i forget it moderator and that would be a little uncomfortable participant d well yeah because its to save my life you know whats my problem participant e i think everyone forgets every once in a while white women more likely to report a desire for stagespecific support groups white women in our study who had been newly prescribed an aet medication discussed the importance of sharing their experiences with other breast cancer survivors in similar stages of treatment these women noted that their cancer experiences often differ from other family members who were diagnosed years prior because of new medical advancements thus they reported wanting opportunities to connect with women who have been through it recently for one participant the absence of social support because of limited familial or friendship networks made experiential support provision from fg participants even more important this was reinforced by another participant who expressed concern about other women with breast cancer who might not have an extensive social network from which to derive support saying and you know you dont know who doesnt have anybody here in town you dont know what we all are going through and how much we rely on other people or dont participants suggested the wcc should facilitate monthly social support groups for newly diagnosed women with breast cancer in addition to general or topicspecific support groups conclusions our study found that women with earlystage breast cancer have a variety of informational and emotional social support needs during aet the presence of relatives and other allies to accompany patients during medical visits was a key factor in meeting participants emotional and informational needs instances of this were recounted as crucial to processing information during encounters with healthcare providers especially when family and friends functioned as emotional buttresses that made information more easily absorbed despite some similarities in experiences among all participants white women frequently reported receiving and providing support from other breast cancer survivors while explicit references to this type of support were absent for the black participants experiential support provision among study participants was noted in all fgs however black women were more likely to provide informational support and white women more frequently provided emotional support to each other in each group participants developed camaraderie and sisterhood with each other they provided informational support by asking questions about treatment and giving advice about symptom management and expectations they provided emotional support by validating commonalities in symptom experiences and by extending gestures of affection and care to each other consistent with our findings previous research of black survivors found that they often utilized support from friends and family and never referenced support from other survivors they also note that black women are more likely to rely on god for support 2930 still it is possible that having a more limited support network drives black women to rely on god another study among primarily white participants found that support from formal groups with other survivors and informal support from family and friends are essential to postprimary treatment wellbeing 31 our study expands upon the previous research by juxtaposing needs and illuminating differences in the manifestation of social support among both white and black patients the importance of experiential social support in the form of reassurance and validation from others with breast cancer was a central theme in other qualitative studies examining the lived experiences of breast cancer survivors 3132 though all participants in our study acknowledged that they relied on a network of family friends and even relative strangers to meet their informational and emotional supports needs black women did not bring up other survivors as part of the support they received in several instances among white participants family members and friends were also breast cancer survivors and the support they provided was essential to fg participants during the challenges of cancer diagnosis and treatment in fgs of black women participants readily exchanged experiential support with each other but they did not explicitly mention other cancer survivors as being part of their existing networks the seeking and provision of informational support by black women is also consistent with past research that suggests that individuals from racialethnic minority groups are less likely than white patients to report having their informational needs met 33 34 this suggests that convening breast cancer support groups for black women comprised of other black survivors could be particularly beneficial in meeting their social support needs perhaps connections with other survivors are not being accessed as easily for black women compared to their white peers because of sociocultural factors unexplored in the current study past research suggests that formal breast cancer support groups that include participants with a significant range of treatment phases and experiences may be less helpful in meeting patients needs 35 our participants expressed similar sentiments stating that meeting with women going through the same phase of treatment was more helpful than having discussions with women who had gone through it years ago while there are some support groups that target specific raceethnicities 36 few target specific treatment phases given that social support is important for cancer outcomes and social networks and social support groups are underutilized our findings suggest that providing smaller raceand treatment phasespecific groups might be a more effective and impactful way of reducing deficits in support by leveraging experiential support prior literature suggests that adopting and encouraging peer mentorship programs leads to greater satisfaction and fulfillment of needs 37 thus women might also benefit from oneonone peer mentors 38 to fully capitalise on empowering experiential support women with limited social networks and fewer personal resources may especially benefit from experiential peer support 39 digitally connected technologies and online support groups 40 might be a novel way to connect patients in similar phases of treatment and life experiences who may not be able to connect locally limitations and strengths this paper is the first to qualitatively analyze the social support needs of women in the adjuvant phase of their breast cancer treatment with a specific focus on racebased differences in experiential support moreover this study incorporated the perspective of a group not usually well represented in research and employed racestratified fgs using raceconcordant moderators to facilitate and enrich discussions therefore this study offers valuable insights into the shared and different needs that arise from diverse viewpoints among survivors in the adjuvant phase of treatment future research should approach this research question quantitatively and experimentally to assess the degree to which experiential support from women of similar backgrounds might be associated with improvements in outcomes still this study also had some limitations despite endeavors to mitigate this some of the more assertive personalities of the group might have dominated over others and influenced the results and themes that emerged from conversations some women might have agreed with some of the discussion but might not have spontaneously shared the same perspective if the methodology were different finally generalizability is limited due to the nature of qualitative research clinical implications our findings highlight the importance of assessing social support needs in the adjuvant phase and offering resources to meet deficiencies in support prioritizing ways to foster and encourage experiential support could be a way to fill the gap left by decreased healthcare encounters following primary treatment our findings suggest that support groups that are more homogeneous and targeted to specific treatment phases may be better suited to meet the varying needs of patients this can be accomplished through healthcare and communitybased organizations and online communities creating formal and informal support groups or oneonone peer groups targeted to treatment phase social support from friends and family as well as experiential support from other breast cancer survivors are needed to help women navigate their adjuvant care knowing and understanding the nuances of support needs are crucial first steps to developing novel interventions that capitalise on the saliency of experiential support to fill unmet needs for these populations ultimately such interventions should address needs by facilitating connections among survivors offering more avenues to receive support from the healthcare team and encouraging women to utilize their existing networks by inviting family and friends to be active contributors in their care supplementary material refer to web version on pubmed central for supplementary material

social support is a critical component of breast cancer care and is associated with clinical and quality of life outcomes significant health disparities exist between black and white women with breast cancer our study used qualitative methods to explore the social support needs of black and white women with hormone receptorpositive breast cancer on adjuvant endocrine therapy aet we conducted four focus group fg interviews n28 stratified by race ie black and white and time on aet fgs were audiotaped transcribed and analyzed according to conventions of thematic analysisparticipants noted the importance of having their informational and emotional social support needs met by friends and family members white participants reported support provided by others with breast cancer was crucial black women did not discuss other survivors as part of their networks notably both white and black participants used the fg environment to provide experiential social support to each otherwhite participants noted that having other breast cancer survivors in their support network was essential for meeting their social support needs however black participants did not reference other breast cancer survivors as part of their networks cancer centers should consider reviewing patients access to experiential support and facilitate opportunities to connect women in the adjuvant phase

introduction sustainable smart cities are complex living ecosystems that involve diverse stakeholders participation both public and private sectors have led urban development that mobilizes information communication technologies as it requires substantial funds and infrastructure the technologies are geared toward developing several smart city capabilities to satisfy users demands so it becomes essential to consider the citizens participation and to satisfy local needs in the context of sociotechnical transitions 1 these trends make cities powerful places to observe and pilot urban transformation 2 3 4 the united nations emphasizes the digital development agenda in cooperation with diverse stakeholder partnerships particularly engaging citizens and private sectors in a wholeofgovernment and wholeofsociety approach globally 4 according to the unhabitat world cities report 2020 smart cities are rapidly deploying technology to address various challenges and to meet the digital development agenda 5 by collaboration across multiple fields including urban planning transport planning administration healthcare economics infrastructure environment weather safety security public services community engagement and research and innovation 4 smart cities have evolved from technological platforms for managing urban resources to innovation generators with the participation of public private citizen and nongovernmental sectors to satisfy local demands and deal with local challenges 6 in other words smart cities are not only innovative engines or smart cities as complex systems the concept of cities as complex systems has been developed by various fields including social science ecology business management and smart city studies after it was introduced in the biological sciences fields in the early 20th century 12 it was later adapted and expanded by ludwig von bertalanffy through his revised general systems theory 69 when the concept initially appeared in contemporary science it ignored the interactions of various fields and emphasized isomorphic laws to unify individual sciences vertically as an organized wholeness bertalanffy argued that the existing theory would ignore local events and dynamic interaction manifest in mathematical approaches and suggested that in open systems approaches the entropy of the system through dynamic interconnection becomes a fixed arrangement in the models of equivalent feedback and adaptive behavior the modified general systems theory transformed the concept of cities into distinct collections of interacting entities in equilibrium which firstly influences the planning and management process in topdown approaches such as in ideal cities for example ville radieuse or those of other modern architects 70 michael batty explained that the spatial structure is in an equilibrium stage even though technologies and fashions have triggered many social economic and environmental changes and that cities are in states far from equilibrium in consideration of urban dynamics in historically evolved economic cycles which coincide with scientific and technological advances cultural movement and migrations of the population in relation to climate changes or physical conditions 71 in addition the physical equilibrium is described as outofsync with disequilibrium events even if they are subsystems in cities 72 the perspectives of scales in the urban environment create diverse stances toward the phenomenon of development of cities cities have unique systems when it comes to micro perspectives as michael batty mentioned while from macro perspectives they have universal and spatiotemporal systems the urban system dynamics which jay forrester demonstrates dealt with the lifecycle of city development based on three internal structures of the model consisting of three subsystems namely industry housing and people which are controlled by an external environment 73 the model proposed that adjustment between the attraction of internal systems and the total attractiveness of the city needs to develop the accommodation capacity of the city 73 bettencourt and west found that the scale of cities is a significant determinant of the characteristics of cities and that the development route follows the city size which positively correlates to crime rates gdp and income so the scale of cities is called a scaling law 74 they also showed that urbanization makes cities greener more efficient more prosperous and safer as the cities adapt 74 on top of the scaling law bettencourt et al discovered successive cycles of super linear innovation which are led initially by the biological organization by sociotechnical organization in the middle and later by an individual organization and these processes are tied up with the degree of urbanization economic development and knowledge creation 75 in other words the time scales of emerging innovation become shorter as the population increases and is more connected than before smart cities comprise multiple intelligently connected systems and integrate material construction agencies cultures living creatures and services in systems of subsystems smart cities are intricate systems comprised of subsystems that integrate interactive systems between ictbased urban services and a diverse range of stakeholders within the smart city service model terms such as factors services domains components systems layers and sensors are often used to refer to various segments while groups of segments are commonly referred to as architecture models systems frameworks and dimensions to address the interoperability issues between technologies and services and to facilitate knowledge expression methods or maximize synergies between ict infrastructures various telecommunications and electronic field researchers have introduced serviceoriented reference architectures from technological perspectives 63 76 77 78 the other perspectives prioritize multistakeholder partnerships and cocreation networks by exchanging knowledge 63 79 80 81 82 83 numerous researchers have also organized service models from complex sociological environmental and economic perspectives to establish indicators that analyze city data and rank the cities 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 some studies have suggested service models to identify the evolutionary paths of service development in the history of smart cities and intelligent communities 1565 the ictbased services and multistakeholder partnerships facilitate the transformation of egovernment to smart governance 84 city governance which the government develops is an extendedterm with multifaceted and multilevel systems of stakeholders sectors and agencies 3384 the development of smart cities has led to the transformation of traditional egovernment into smart governance the concept of smart city governance has been extensively discussed in the context of sociotechnical transitions the theory from multilevel perspectives was first framed by geel 58 who was influenced by nelsonwinters evolutionary economics 85 dosis technological trajectories 86 malerbas sectoral systems 87 carlssons technological systems 88 and bijkers technological systems in relation with sociology institutions and rules 89 smart city governance has been developed from egovernment and digital government unlike the government which refers to a form of authority governance refers to a process of action processes traditions and institutions by which collective decisions are made and implemented 84 in the context of digital transformation egovernment focuses on implementing digitizing technologies to formulate data based on existing analog government while digital government emphasizes satisfying local needs and users demands by reengineering and redesigning services and processes 90 in the streams of transformations smart cities are researched from sociotechnical perspectives to contribute to a theoretical smart city governance model mora et al analyze the landscape of smart cities from sociotechnical dynamics perspectives the city is a complex and evolutionary adaptive system for urban innovation and urban sustainability in cooperation mainly with public and private sectors and a few with civil society 48 kim and yang analyze the empirical characteristics of conceptually related smart cities services evolution from perspectives of sociotechnical transitions based on multistakeholders and found different services advancement depending on phases of partnership and common characteristics of developing services regardless of stakeholders partnership 34 some researchers applied it to the governance model nam and pardo connect urban governance to egovernment and innovation to make cities smarter from a technopolitical perspective 68 calzada researched the transition of four smart european cities regarding the technopolitics of data from the perspectives of multilevel governance devolution schemes 59 waart et al emphasize the networking of topdown and bottomup elements in transitions of smart city dynamics 91 the existing literature reveals that the sociotechnical transition consists of rich perspectives explaining smart cities dynamics based on technical and social analysis that develop a theoretical understanding of technogovernance 892 there is a dearth of appropriate models for governing smart cities which can be attributed to several factors including diverse visions inconsistent implementation and oversimplified technological solutions 123393 current models tend to focus more on the interplay between technologies services data and buildings while neglecting the crucially connected role of stakeholders partnerships and urban contexts as an attempt to deal with the issue robert et al proposed a conceptual model for smart city governance based on 13 indicators encompassing components such as services technologies stakeholders legislation and structures as well as contextual factors and outcomes 33 in this regard the key players in driving sustainable innovation are connected and agglomerated communities individuals and organizations on the basis of frontier technologies calzada demonstrates the importance of devolution in smart city development to increase the ownership and the selfresponsibility of investment in infrastructure and data 59 additionally ownership of data and cities has blown up the debate on multistakeholder participation since citizens and all stakeholders can be seen as tiny chips along with artificial intelligences inside a giant system to collect and analyze data as harari argued 5994 however smart city implementations in real projects still suffer from fragmentation due to variations in definitions as well as the lack of a model that reflects the multidimensional operational nature of cities and the importance of multistakeholder partnerships 101193 these challenges are aggravated by the lack of a model reflecting urbanization contexts and multistakeholder partnerships considering the multidimensional operational nature of cities 12 this study addresses the gaps in the existing literature by identifying the characteristics of stakeholder partnership systems and their relationship to the implementation of sustainable smart city services by doing so this study seeks to contribute to developing a more comprehensive smart city governance model that considers the role of multistakeholder partnerships in realizing sustainable urban development materials and methods social network analysis is primarily utilized to identify the study aim based on the published data in kim and yangs research 34 as demonstrated in figure 1 the study commences with a research question motivated by smart city governance challenges as explained in the preceding section the primary research question is then broken down into three objective research questions directly corresponding to the study objectives under the study aim in essence this research aims to identify characteristics of services implementations depending on the stakeholders partnerships from the perspectives of governance and sociotechnical systems that are established by the major research question ie how the stakeholders partnership systems are networked with the conceptually related smart cities services implementation from perspectives of governance and sociotechnical systems the aim is achieved through three research questions each directly linked to three objectives the first research question aims to clarify the characteristics of services in the evolution of smart cities while the second focuses on demonstrating the different services phases developed depending on stakeholder partnerships the third research question identifies connected services and stakeholders assuming that smart cities are connected both virtually and physically the research question is closely linked with the study aim and the concept which comprise measurable indicators that establish the study framework 3495 as illustrated in figure 1 the concept encompasses six aspects namely social technological governmental economic environmental and managerial factors and a single keyword namely the research question is closely linked with the study aim and the concept which comprise measurable indicators that establish the study framework 3495 as illustrated in figure 1 the concept encompasses six aspects namely social technological governmental economic environmental and managerial factors and a single keyword namely the sustainability of urban services these aspects and keywords are utilized to provide a background for analysis and select target cities european cities were selected as the target cities using cluster sampling from a population of 221 smart cities which were investigated by smart city tracker 1q18 96 the study population was derived by combining three ranking lists of sustainable smart cities that represent the six aspects of the concept these ranking lists are the united nationshabitat global urban competitiveness report 97 the mckinsey companys smart cities digital solutions for a more livable future 98 and the united nations egovernment survey 2020 84 as shown in table 1 the studys first selection resulted in 36 cities after removal of cities mentioned more than twice in the three ranking lists the top 20 smart cities from the rank of smart cities performance published by juniper research were integrated with the first screening results to select highperforming sustainable smart cities in the second sampling which resulted in 12 cities finally european cities were chosen because they have been leaders in egovernment development within the united nations egovernment development index which is an index of online services telecommunications and human capital since 2010 499 as this study aims to identify characteristics of conceptually related smart cities services implementations from perspectives of governance and sociotechnical transitions the selected cities embody the critical elements of the concept of sustainable smart cities and stand out as pilot cities for building smart city governance within the paradigm of sociotechnical transitions for this study the target cities are barcelona london and berlin on the basis of research questions linked with study aims this research selects the data regarding conceptually related smart cities for three target cities the data are from kim and yangs article 34 which coded and weighted datasets on three relevant cities projects and plans from 1969 to 2021 in a sophisticated analysis aligning with the study aim and the concept of sustainable smart cities the researchers formulate a citylevel dataset which is configured with categories including year data sources stakeholders services converted number of stakeholders the sum of the converted number of stakeholders and converted weights of services 34 the data categorized with events services year and stakeholder data were weighted and coded using the preferred reporting items for systematic review and metaanalysis protocol the weights are assigned to each year as 1 equally and the weight was then divided by the number of participating stakeholders in that year to distribute the divided weights to each stakeholder 34 this means that individual services are given different weights based on the number of implemented services and participating stakeholders in that year thereby giving equal weight to services and stakeholders that are correspondingly aligned in the same year 34 a social network analysis is utilized for this research this is a specific application of graph theory that originated from eulers mathematical investigation to represent social actors networks using points and social relations using lines this approach is based on german sociology where georg simmel and others emphasized the formal properties of social relations 100 alfred vierkandt and ledpold von wiese adopted terminologies of node edges and connections that make up social network analysis while moreno provided the idea of a sociometric a type dataset depicting a metric of sociogram 101 social network analysis has been utilized to identify corporate power and interlocking directorships 102 the successive research has explored the power and influence of banks 103 it is also utilized to analyze community structures with business networks 104 it has also been utilized to identify and map knowledge flow between organizations since it was introduced to regional and innovation economics fields 105 ma breaks up the collaborative innovation network into spatial and topological networks using social network analysis 105 radulescu et al deploy it to define critical competencies and human resources in the innovation network from the collaborative model of a smart city 106 mora et al utilize the analysis to show the twodimensional network of actors collaborating to enable smart city development in new york city in a quadruplehelix collaborative model of stakeholder engagement 48 sconavacca et al explore the active areas in the evolution of smart city research using the method 107 kim and yi analyze the coherence between national and local smart cities plans regarding the keywords and service elements 108 the existing literature on the method has been developed to reveal the relations between social activities and organizations in the urban environment at the same time it highlights the interdisciplinary traits of smart cities research in regards to diverse aggregation and disaggregation of services technologies infrastructures and stakeholders social network analysis is utilized to confirm the data relations among systems of services stakeholders and cities in regard to the research aim it mainly utilizes gephi 092 software opensource software and interactive tools used for visualization and examination or assessment of various simple and complex networks and dynamic and hierarchical graphs 109 gephi 092 needs two datasets for social network analysis a node dataset comprising a network of actors and an edge dataset consisting of a list of relations between actors the node list consists of three columns id label and attribute the label column includes the names of all actors including services and stakeholders the id is set up with constant numbers which take the role of links between the node dataset and edge dataset the edge list utilizes the stakeholders services and their weights the dataset is transformed into an edge list containing four columns source target type and weight then a column of source and target which were initially filled with words needs to substitute with the corresponding id referring to an identical label in the node dataset after completing the dataset gephi 092 is used to analyze the relationship between service and stakeholders by importing the node table first and the edge table appended to the previously opened node table among analysis functions such as average degree average weighted degree network diameter graph density hits modularity pagerank connected components and others average weighted degree betweenness centrality and eigenvector centrality are utilized in this study the average weighted degree reflects the cumulative number of keyword connections between surrounding keywords to obtain the node and connection frequency the eigenvector centrality indicates neighbors weighted centrality which considers not only the number of connected nodes but also other nodes centrality as the concept of eigenvector centrality basically states that if each actor is connected to a neighbor with a high connection centrality index the influence on the network is greater than if it is connected to a neighbor that does not the betweenness centrality introduced by freeman is the shortest path based on the enumeration of identifying critical actors in the network 110 a node with higher betweenness centrality can penetrate the blocked or siloed information from fields to fields through the node so that it has the potential to rise in power 111112 the three network analyses are visualized in a preview tab and the detailed data are identified in a data laboratory tab lastly the interpretation process demonstrates the research questions concerning the network between cities and services at first then second the stakeholders and services and last the cities organic network systems in consideration of three factors results characteristics of the conceptually related smart cities services the early smart city development features are reflected in accumulated characteristics of the conceptually related smart city services depending on stakeholder partnerships these results support and expand the existing literature this paper provides results for the identical phases of three cities partnerships which were qualitatively measured in the existing literature kim and yangs study 34 as shown in table 2 it is revealed that for the three cities the public and private sectors are mostly leading stakeholders when one is selected as the leading stakeholder and others in the other stakeholders the analysis reveals barcelona in a publicpeople partnership london in a publicacademicngo partnership and berlin in a privatepeople partnership as indicated by yellow shades in table 1 moreover this study expands the existing studies by identifying the early development of smart city services in the current development of smart cities and the accumulated local contexts of developing smart city services the services in the top 10 weighted degrees highlighted with green in table 1 are related to the early development of smart city services illustrated in figure 2 for instance barcelona developed social economic architectural governance transportation data and infrastructure services in the beginning during the launch of the first stage of the bcn plan the city was developed to regenerate cities based on citizens creative ideas and infrastructure advancement for building a global smart city model in a holistic and comprehensive city renewal approach 56113 the services developed at the beginning in barcelona in the knowledgebased urban development project which was an initiated smart city project have higher weights in the accumulated network results of the weighted degree the london services in the high rank were also mainly developed at the beginning of smart cities evolutions until the launch of the government plan inclusion through innovation except for some temporal services regarding health history and standardization the highranked berlin services in the weighted degree analysis are infrastructure social economy data governance and transportation services developed from the beginning of smart cities before the implementation of silicon allee the results demonstrate that understanding the context of smart city development is crucial in developing smart cities in the context of smart city development the early services carry significant weight while high levels of network mediation by various stakeholders characterize the later services that evolve in sociotechnical transitions social network analysis provides quantitative information and correlations to understand network variables 12 according to table 3 the services with higher degrees of centrality including eigenvector centrality and betweenness centrality receive improved ranks in weighted degrees among the three cities barcelona and berlin whose partnerships commonly involve citizens exhibit strikingly similar results when the two centralities are compared in each city independently the citizen partnerships promote the highly connected services that are sustained and strengthened such as education environment and health for barcelona and safety services for berlin in other words citizens become human resources or agencies to connect services through their data and active participation specifically the architecture service in barcelona which has modest weight by itself is linked with various services through the public people academia and private sectors thereby becoming prominent in the eigenvector centrality conversely the energy service in the same city which has low weight and few links with stakeholders was downgraded in the eigenvector centrality furthermore data and knowledge play a role in transmitting information throughout sociotechnical transitions the services two centralities commonly receive higher weights than weighted degrees when analyzed as a whole indicating that explicit and tacit knowledge is transferred from one generation to the next by being embedded in the in the context of smart city development the early services carry significant weight while high levels of network mediation by various stakeholders characterize the later services that evolve in sociotechnical transitions social network analysis provides quantitative information and correlations to understand network variables 12 according to table 3 the services with higher degrees of centrality including eigenvector centrality and betweenness centrality receive improved ranks in weighted degrees among the three cities barcelona and berlin whose partnerships commonly involve citizens exhibit strikingly similar results when the two centralities are compared in each city independently the citizen partnerships promote the highly connected services that are sustained and strengthened such as education environment and health for barcelona and safety services for berlin in other words citizens become human resources or agencies to connect services through their data and active participation specifically the architecture service in barcelona which has modest weight by itself is linked with various services through the public people academia and private sectors thereby becoming prominent in the eigenvector centrality conversely the energy service in the same city which has low weight and few links with stakeholders was downgraded in the eigenvector centrality furthermore data and knowledge play a role in transmitting information throughout sociotechnical transitions the services two centralities commonly receive higher weights than weighted degrees when analyzed as a whole indicating that explicit and tacit knowledge is transferred from one generation to the next by being embedded in the development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have eigenvector centrality development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have betweenness centrality development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have development of infrastructure social economic environmental and other fundamental services while basic services intrinsically develop data services barcelona london berlin weighted degree eigenvector centrality betweenness centrality the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have the characteristics of conceptually related smart city services reflect the features of services evolution in sociotechnical transitions the phases of partnership in each city support the existing literature the smart city implemented context influences current development in that the highweighted services reflect earlydeveloped services the early developed services have high weighted services which refers high frequency of implementation and later developed services have high degrees of network mediated by stakeholders amid an evolution some intermediated services are highlighted recently this result is identified through weighted degree eigenvector centrality and betweenness centrality in social network analysis services developments depending on stakeholders partnerships the development of different smart city services depends on partnerships with various stakeholders social network analysis can provide information on decision framing and key actors and it is a relatively quick and easy way to conduct research that encourages participation from diverse viewpoints and actors 12 sustainable smart cities have been planned and developed in cooperation with the public and private sectors as shown in table 2 while diverse services are connected and networked through multiple agents as illustrated in table 3 although the weighted degree results of all partnerships primarily emphasize the implementation of infrastructure and economic services this is not the only reason for smart city development which should not be overlooked as simply a project developing the economy through giant investments in infrastructure and technology the connected services through cities and services are diverse and dependent on partnerships as analyzed in table 4 public sectors sustain and enlarge the services connection based on the fundamental services while private sectors connect with emerging services that are different from public sectors the fundamental services are infrastructure economic social and data services the services led by the public and other stakeholders are accumulated and affixed to service development phases of less influential partnerships compared with publicpeople partnerships publicacademicngo partnerships and publicpeople partnerships for instance the standardization service in publicacademicngo is added to the highranked publicpeople partnership services health tourism and media services in publicprivate partnerships are affixed to those in privateacademicngo in other words the publicpeople partnership is becoming a means to develop smart cities from a humanistic perspective compared with the prevailing publicprivate partnerships even though there are gaps between partnerships with public sectors some services are mainly led by their partnerships including governance education safety environment transportation and architecture services meanwhile partnerships with the private sector and other players disclose different services connection than the ones with the public sector even though their implementation seems to occur in an ad hoc way representative instances include tourism services in privatepeople partnerships and health tourism services in privateacademicngo partnerships compared with identical partnerships with public sectors indeed multistakeholder partnerships are crucial in addressing complex issues such as energy and waste management in urban areas table 4 in the last column demonstrates that multistakeholder partnerships are one of the alternative solutions to deal with recently emerged urbanization challenges regarding energy and waste issues these two issues are related to co2 emissions which are reduced by changed behaviors in cities resulting from compact or walkable cities emobility in combination with lowemission energy sources and enhanced carbon uptake and storage using nature 114 the two services production is mismatched with consumption regarding geographical aspects the energy is produced outside cities and consumed inside them while the waste issue follows the reverse pattern 115 technological advancements such as smart meters and smart bins can assist in identifying the average demands for households and reducing waste in addition urban planning can play a crucial role in developing services close to demand centers leading to simpler networks and lower costs the integration of energy and waste services through district heating systems can also bring benefits in terms of energy savings barcelonas solar ordinance is an excellent example of a multistakeholder partnership promoting renewable energy use 115 by encouraging the installation of thermal solar panels in buildings the city has achieved significant energy savings such initiatives not only promote sustainability but also have positive economic impacts including reduced energy costs and increased job opportunities in the renewable energy sector note abbreviations wd weighted degree ec eigenvector centrality and bc betweenness centrality green and blue highlights refer to services within the top five rankings networks of conceptually related smart cities the networks of conceptually related smart cities provide ways to improve stakeholder partnerships and service implementation systems social network analysis can facilitate understanding of socioinstitutional structures actors linkages and approaches to enhance knowledge transfer including tacit and explicit knowledge 12 when the three cities are highly connected services related to data education environment health media and tourism receive higher emphasis in eigenvector centrality compared with a weighted degree as presented in table 5 the shades in table 5 illustrate the rising elements in eigenvector centrality compared with weighted degrees these elements include private people academic and ngo sectors and the services concerning data education environment health media and art and tourism the intermediated elements are shown to increase their connectivity and importance in connected sustainable smart cities the connected sustainable smart cities emphasize the human resources or agencies to connect services through their data and active participation private sectors play a crucial role in attracting innovations by collaborating with other stakeholders to provide various services they cooperate with academia to research new technologies and services based on data provided by citizens and other organizations 63 smart cities have been developed in cooperation with the public and private sectors from the perspectives of governance systems local government partnerships and supportive national governments are necessary to build on private creative ideas from private sectors and people who own successive localities from generation to generation the local government subsidies contribute to the advancement of local communities and private sectors devolution strengthens and amplifies the networks among infrastructure data social governance education and environment and health which are the result of this research social services interconnect private sectors with other sectors the other four services including data government environment and health services provide fundamental linkages between the public and private sectors in this sense city networks which are built up on a foundation of developing local entities transform the service ecosystems to bring out intermediated services even though the cities are not geographically adjacent discussion the first result reflects the urban geographic economy and demonstrates the distinct features of conceptually related smart cities as they undergo sociotechnical transitions through measures such as weighted degree eigenvector centrality and betweenness centrality the context of smart city implementation plays a significant role in current developments with highweighted services reflecting the earliest implemented services while the latter services are essential for connecting with existing or emerging services mediated by stakeholders data and knowledge are among the intermediated services that have recently gained importance amid sociotechnical transitions the concept of eigenvector centrality betweenness centrality and weighted degrees emerged in urban geography the eigenvector centrality is correlated with selfreinforcement in the urbanization economy while betweenness centrality is the intermediate element as the urbanization economy shares some intermediate elements such as business services transportation services public infrastructure and labor pooling organizations that require facetoface contact including corporate headquarters or knowledgebased businesses tend to cluster as selfreinforcing factors 116 this means that the intermediate elements are crucial to the modern economy 116 in this paper the services with weighted degrees include fundamental services such as infrastructure economy social data and government while the service with high betweenness centrality is data which connects the highweighted services so that it has high eigenvector centrality in this light services with high betweenness centrality have the potential to drive emerging industries or services similar to how it occurs in the urban geographic economy the use of connected intelligent data including artificial intelligence can serve as a unifying force to link urban services living organisms organizations and environments within a governance model in order to create a safer and more prosperous world in densely populated and centralized areas 59117 accordingly the ecosystems of evolving service systems are identified through the geographic economy when it extends to the relationship among geography organization and specific fields ma clarifies multiproximity factors driving dynamics including geographical proximity research contextualized cognitive proximity and organizational proximity 105 the first result extends the existing literature by clarifying the initial implemented services frame influence on the later network of services it highlights the necessity of understanding the context of smart city services evolution in the context of sociotechnical transitions for making sustainable smart cities moreover the study indicates that the smart cities service development ecosystems are analogous to the urban geographic economy regarding the relationships among stakeholders or organizations intermediated services and selfreinforced services in the urbanization economy the second finding underscores the importance of multistakeholder partnerships from perspectives of service development it presents various stages of developing conceptually related smart city services depending on stakeholder partnerships publicprivate partnerships have been increasingly utilized in the implementation of smart city services and urban planning in recent years the concept of publicprivate partnerships in urban governance which is influenced by neoliberalization intends to achieve a common goal often in the form of infrastructure development or service provision while the public private partnerships have the potential to bring innovation and efficiency to urban planning there are also concerns that they may prioritize profit over public interest and may not adequately address issues of social equity and environmental sustainability 118 in this context the concept of communicative planning has emerged as an alternative approach that seeks to involve diverse stakeholders in decisionmaking processes this approach prioritizes inclusivity and seeks to ensure that all voices are heard and taken into consideration in the planning process by doing so communicative planning can help to avoid the isolation of vulnerable ecosystems and species and promote more sustainable and equitable outcomes moreover multistakeholder partnerships have the potential to offer an alternative solution to emerging challenges of urbanization particularly regarding the issues of energy and waste the telecommunication fields endeavors to establish dual systems of smart city service systems between topdown and bottomup that are ontologybased systems mediated by data to provide improved services to all stakeholders with limited resources 63 urban planning balanced between topdown and bottomup approaches has the potential to provide solutions to the future smart city challenges by encouraging citizens to interconnect with urban systems and organizations through mobilizing sustainable smart cities based on vision and measurable and controllable elements in master plans 119 the diverse stakeholder partnerships include cooperation among public private academic and ngos sectors and embrace the concept of devolution or decentralization devolution referring to the definite ownership and selfresponsibility of investment from a city or a regions ownership contributes to increasing data awareness among stakeholders 59 the connectivity and growing power of regions or cities lead to devolution as occurred in the 20th century in response to colonization 120 the sustainable development goals indicate two innovation approaches which are gaining prominence including the vital role of local leaders to drive global change in the transformative power of urbanization and in leaving no one behind 4 the interactions with local government foster connectivity with more local players leading to prompt and suitable actions toward local challenges with voluntarily participation from diverse stakeholders that results in improvements in the services and connectivity with decision making processes 121 the new urban agenda points out the appropriately balanced governance systems among the national government subnational and local governments and relevant stakeholders to revitalize strengthen and create partnerships 122 in this sense this study provides a managerial contribution regarding what types of partnerships are appropriated for european sustainable smart cities to promote specific services furthermore it empirically demonstrates the necessity of multistakeholder partnerships for making sustainable smart cities the last finding concerns the city network the concept of a city network has been discussed in line with glocalization a concept that appeared in the harvard business review 123 conurbation as mentioned by patrick geddes 124 and city knowledge exchanges in city expositions or exhibitions city networks have been traditionally considered among geographically adjacent cities such as in the concepts of conurbation and decentralization underlying the concept of cityregional development however with emerging smart city development the direction has changed into networking for improving governance systems and technologies taking into account existing assets budgets challenges and the background of sociotechnical urban transitions a typical instance is a city memorandum of understanding between public organizations or public and private organizations calzada argues that cities have the power to compete or cooperate as an investment destination so that the national government is not necessarily distributing subsidies for them 59 notably the private sector has been at the forefront of digital transformation especially during the covid19 era 4 this is based on local governmental supportive investment and legislation the united nations highlights that the next generation of digitalization requires an ecosystemcentric approach in which the public sector plays an entrepreneurial role in spurring innovation with private sectors based on fruitful research in highgrowth and highrisk areas and bringing diverse stakeholders for longrun growth strategies 4 serrano et al raise the issue that smart city networks can become a regional gateway to expand the business of multinational firms rather than empowering mediumsized cities or small national firms in this regard the local government should take an entrepreneurial role to empower local communities and corporations to germinate local innovation and expand their influences globally with other smart cities as a form of multinational organization this paper empirically identifies the emerging stances of private sectors under the assumption of connected cities services and stakeholders as a whole in sociotechnical transitions conclusions sustainable smart cities are multifaceted living ecosystems developed through diverse stakeholder participation in sociotechnical transitions however the lack of a suitable governance model that incorporates the various components of these systems such as connected technologies data services stakeholders organizations and legislation has led to indiscriminate development with a variety of names and oversimplification of technologies without consideration of the local context and traits of smart urbanization in sociotechnical transitions this study aims from the governance and sociotechnical systems perspectives to identify the characteristics of conceptually related smart city services implementations depending on stakeholder partnerships to achieve this goal this study has narrowed down three objectives to clarify the characteristics of services in the evolution of conceptually related smart cities by expanding on the existing literature to demonstrate the different phases of developing conceptually related smart cities services depending on different stakeholder partnerships and to identify connected services and stakeholders assuming that conceptually related smart cities are connected virtually and physically the application of social network analysis illustrates the relationships among stakeholders services and cities in establishing a smart governance model the data for the method is based on the findings of kim and yangs study 34 as their objectives and ideas pertaining to sustainable smart cities align with this study the target cities selected for analysis are european sustainable smart cities given europes continued leadership in egovernment development as evidenced by its consistent top ranking in the united nations egovernment development index since 2010 specifically barcelona berlin and london were chosen as they exemplify the european cases for the operational definition of sustainable smart cities used in this study the dataset on stakeholders services and cities reveals several key findings firstly the initial services associated with the conceptually related smart cities are reflected in the accumulated and current characteristics of the smart city services depending on stakeholder partnerships however the network features are different between the initial and later services secondly the development of different services depends on stakeholder partnerships indicating that multiple stakeholders including local entities must establish partnerships to tackle the current challenges of massive urbanization finally the analysis highlights the growing presence of private sectors and intermediate services in the global network of cities this study is subject to certain limitations despite the sophisticated structures utilized to demonstrate the empirical crscs service evolutionary characteristics firstly there is little explanation provided for how services are adapted to different geographical contexts based on stakeholder partnerships by maximizing societal benefits without incurring negative externalities this could be addressed by consulting the existing literature particularly kim and yangs study 34 secondly the study lacks a temporal or geographical dimension which could be remedied by researching geographically networked services among organizations with yearly or monthly data utilizing geographic information systems thirdly the results may not be readily generalizable as they are based on data from only three cities to address this issue it is recommended to analyze an identical number of sample cities in each continent using identical methodologies for data collection sorting coding classifying and analysis with periodic matrix taxonomy and social network analysis lastly this study does not serve to meet the urgent requirement in respect of implementation of the governance model or the provision of pragmatic specifications for the most effective ict investments to be made nor does it contribute to the decisionmaking process addressing the grand challenges for europe and global cities in meeting political commitments regarding climate change mitigation and adaptation further studies need to address these issues by conducting qualitative indepth research to investigate the significant challenges confronting in european and global megacities nonetheless the results of this study have significant managerial implications as they enable the identification of elements with high eigenvector intermediate elements and highly implemented fundamental services depending on different stakeholder partnerships these findings can inform decisionmaking regarding services development and contribute to the development of new smart cities by creating a smart city governance model with multifaceted multidisciplinary and multilevel systems of stakeholder sectors and services all connected by multiple partnerships additionally this study has theoretical implications as it empirically demonstrates the necessity of multistakeholder partnerships and devolution to build sustainable smart cities overall this research can help to advance the understanding of smart city development contributing to the practical and theoretical discourse on the subject data availability statement the data presented in this study are available in dataset kim n yang s sociotechnical characteristics of conceptually related smart cities services from an international perspective smart cities 6 196242 acknowledgments not applicable funding this research received no external funding

the absence of a comprehensive smart city governance model has prompted research into the characteristics of the relationships among cities services and stakeholders this study aims to identify from the perspectives of governance and sociotechnical systems the characteristics of conceptually related smart city service implementations based on stakeholder partnerships social network analysis was utilized based on existing research datasets stakeholders services and representative european sustainable smart cities were included in the dataset in relation to this studys operational definition the first finding is that the initial conceptually related smart city services are reflected in the accumulated and current characteristics of the smart city services these depend on stakeholder partnerships while the network foundation differs between the initial and latter services the second finding clarifies how different development services depend on stakeholder partnerships and how multiple stakeholders including local entities are vital to deal with current challenges in massive urbanizations the third finding demonstrates the emerging roles of private sectors and some intermediate services in the global network of cities this study contributes to the management of smart cities by identifying how service development occurs based on stakeholder partnerships and contributes to their theoretical basis by empirically demonstrating the importance of multistakeholder partnerships to address current urbanization challenges

introduction this research maps the evolution of two local food systems over time in order to understand broader trends in the evolution of local food marketing the trajectory and pace of change within local food networks offers clues about how rapidly the parts of the sum evolve local food systems are thought to strengthen social ties between growers and eaters giving a sense of community and shared social values that translate into shared political agendas the resulting alternative food network connects and mobilizes people toward civic agriculture forming what some scholars consider to be a social movement that at times and in certain communities advocates for farmland preservation andor food justice local food activists tout broad promises of transformation from improving diets that promote individual health to landscapelevel changes that reduce urban sprawl boost local economies and enhance ecological sustainability investment in these promises occurs through purchasing food labeled as local and supporting markets that carry and advertise such food in sum local food systems engage people in more than just social connectednessthey also prompt collective action against the status quo by reorienting markets the notion of local food is not a monolith nor is there a neat dichotomy between global and local the boundaries of what constitutes local are blurred the benefits of local food networks vary by community and priorities and allegiances shift over time in interviewing community supported agriculture subscribers schnell finds that the notion of local is not an objective spatial denotation but a social contract between food producers and consumers who share similar values local food may be considered food grown and consumed within 100 miles or 100 yards food that is advertised as local is not always produced with the same values while some farming operations may emphasize fair labor not all do further many farmers change their positions over time on a variety of issues from organic agriculture to animal welfare certifications as such this research explores the heterogeneity and changes in social ties across a variety of local food distribution practices without imposing limitations on distance analytical framework understanding network architecture social network analysis can help food scholars understand the future trajectory of local food systems and can help reveal locations where marketing networks are realigning with concurrent social movements sna is used to examine tiesrelationships between network actors such as individuals or in our research individual markets and farms sna statistics help elucidate which actors are central and presumably more influential to a network playing a coordinating or broker role in transmitting knowledge values and political agendas in addition sna can quantify the architecture of groups within a network and highlight where there are rifts or mutually reinforcing relationships sna has been used to understand social movements where the constellation of actors and organizations involved influences the outcomes changing how rapidly a movement can build alliances share ideas and practices coordinate activities legitimize political organization and prompt change sna can help scholars predict if local food systems are stable growing or shrinking there is a common narrative among scholars and policymakers that local food systems have been steadily growing acknowledging the rise of local food systems the united states department of agriculture began collecting direct marketing data for the agricultural census in 2002 finding a 32 increase in the percentage of directmarket sales from 2002 to 2007 and a 55 increase in the number of farms with dtc sales between 2007 and 2012 in 2012 nearly 8 of farms in the united states marketed foods locally which the usda defines as either directtoconsumer sales such as farm stands youpick operations farmers markets or community supported agriculture or sales through intermediaries such as restaurants grocery stores schools hospitals or other businesses intermediated markets account for twothirds of local food sales and are slowly gaining more research attention in addition short supply chains can connect farmers to consumers through food donations or urban gardening where food is shared but not sold these relationships are not tracked by the agricultural census but may be just as important to civic agriculture on the other hand some argue that local food networks are transient small scale farms make up the majority of those participating in local food systems with 85 of farms that sell in local markets earning less than 75000 in gross cash income in 2012 these smallerscale operations spend considerable time and effort in marketing while also being under constant threat as they compete for marketing contracts against larger growers additionally some researchers have emphasized the perils of farming on the edge of urban development landowners located on the periphery of growing urban areas are often tempted to sell farmland for more lucrative housing development as urban areas grow outward land values rise creating a perimetropolitan bow wave of higher prices that also increases the cost of doing business by raising land values and taxes for farmers indeed increased suburbanization has resulted in loss of prime agricultural land for this reason local food proponents often tie local food systems to attempts to rescue farmland from the avalanche of urban development for example nonprofit farmland 1 3 preservation groups spend up to 124000 per acre to buy development rights and preserve land in agriculture although many customers are willing to pay nearly double the price for locallygrown food products these trends do not necessarily translate into stable local food networks as shown by an autopsy on 32 farmers market closures in oregon even as new local food outlets arise many fail within a few years of opening in part due to individualized complex issues that are internal andor external to the market although the agricultural census measures the total number of participating farms and the composition of marketing methods little is known about how individual farms and markets connect to one another and how those marketing connections change over time some scholars posit that the increased trust and personal relationships characteristic of local food systems creates enduring social ties based on bonding social capital that would lead to longterm relationships and stable growth in support relationships that form through supply chain networks of local food systems exhibit transparency a hallmark of trust for instance restaurants often promote their local suppliers as part of their routine advertising efforts and diners build loyalty with the farms that grew the products they consume this interpretation of local food systems would lead researchers to assume that local food system growth reported in the agricultural census is a result of the addition of new members to a stable and growing cohort on the other hand cumulative pressures on local food systems would indicate that while there may be overall local food system growth actors and market channels may shift or die off at high rates particularly at the urban edge in such cases the local food system would be made up of what granovetter refers to as weak ties defined as loose affiliations that can nimbly innovate arguably communities with bridging social capital as well as bonding social capital may be the most effective in organizing for collective action sna can be used to visualize and quantify the spatiality and social clustering of relationships in the local food system as it changes over time helping to make sense of underlying drivers and limits to local food system change and its affiliated social impacts broadly speaking alternative food movements have been shifting priorities and increasingly incorporating concerns for food justice but little is known about how these shifts prompt changes in the architecture of their constituent market networks as activists conceptualize scaling up the political ambitions of alternative food movements sna of network architecture and change over time can illustrate how to move toward a globally interlinked network of local food systems such changes may be complex as social values differ across marketing pathways and from communitytocommunity and they also shift over time the longitudinal comparative research that we present here offers a starting point for understanding where a network of local food systems builds into larger scale social movements for example hinrichs theorized that csa members have more ruralfocused values than consumers who shop at urban farmers markets thus shaping the social relationships formed within these market pathways one might expect communities with more prominent csa presences to have a greater focus on farmland protection and growing practices in addition local food systems have internal feedback loops for example ohara and shideler found that increasing dtc food sales prompted increased sales at restaurants in metropolitan counties thus a better understanding of the heterogeneity in market channels offers insights into which locallyoriented markets may grow in the future and how their growth may shift their political attention to build toward the above this research uses sna to understand how local food system networks evolve scholars have only recently started to apply sna to the study of food systems lucy jarosz called for the combined use of network theory and supply chain analysis for regional food systems two decades later trivette utilized sna on 687 farms and 702 retailers across a threestate region in new england to reveal the central role of grocery stores and restaurants in local food systems in addition brinkley applied geosocial network analysis to understand the extent to which local food systems are socially and geographically embedded in the two study counties used in this research finding evidence of the local food systems impact on landuse policies our research contributes to these pioneering methodological efforts and is the largest sna of local food systems in scale and the first to utilize longitudinal data to examine change over time methods case selection this study focuses on the local food systems of chester county pennsylvania and baltimore county maryland both of which are located in periurban areas of the northeastern united states in close proximity to the large urban markets of philadelphia baltimore new york city and washington dc these counties have a long history of direct marketing and local food distribution channels the 2012 food network data was previously collected in both counties thus allowing for a novel longitudinal approach to food systems network analysis this research compares data collected in 2012 and again in 2018 both counties show flux within their agricultural sectors which make them interesting cases for comparison baltimore county saw an 8 increase in acreage of farmland within the county from 2012 to 2017 data collection social networks are comprised of nodes which are the actors or members of the network and edges which are the ties or relations linking the nodes data collection was limited to raw agricultural products rather than processed food or inedible valueadded products nodes include the farm as well as the location of its first point of sale or donations the basis of ties between actors is the distribution of food both via sales and donations based on the usda definition of local food sales could be made directly to consumers via csas farmers markets and youpick operations or to intermediaries such as restaurants distributors grocery stores food banks and institutions we focused on nodes and edges that are transparent meaning that connections are publicly documented data were collected through the review of publicly available online information including localharvestcom county documents and the official websites and social media pages of farms restaurants farmers markets food banks food pantries and schools snowball sampling was then used to identify other actors and their relationships in the network for example the first node added to the 2018 baltimore county dataset was a farmers market the farmers market website listed all the vendors that sell at the market thus enabling us to capture the second node in the dataset a farm also located within the county from node twos website we were able to capture their extensive list of direct sales relationships which included actors both inside and outside of the county we also logged attribute information for each node including the name of the business business address identification number an agricultural production typology code website address contact information and notes on how the node was found edges were coded based on the types of relationship they represented for instance a relationship between a farm and a farmers market was coded as farmers market in the edge table table 6 in the appendix shows the coding guide and relationship typologies captured the boundary that we set for this study was spatially defined by the political delimitation of each county we only captured relationships that involved at least one actor located within the county as a result we also included farms outside of chester and baltimore counties that distribute their product into the county similarly we also captured relationships between farms located within one of the study counties and sales outlets located outside of their respective county however we only captured instances in which the products would be distributed via ground transportation data preparation for both counties the data from 2012 to 2018 were merged into a single dataset using an r script edges and nodes were then individually coded based on whether they were unique to the 2012 data set unique to the 2018 data set or present in both data sets in 2018 we cross checked the nodes in each dataset to find establishments that appeared to have closed since 2012 closures were denoted in our datasets social network analysis and visualization the sna software package gephi was used to visualize the network graph and run descriptive statistics on the network data the network was visualized using the forcedirected fruchterman reingold projection which places nodes connected by an edge in relatively close proximity with one another the forcedirected multilevel yufan hu projection was also used this projection uses coarsening and clustering to simplify the output graph finally we also used gephis geolayout plugin which allows for the integration of geospatial analytics in order to visualize the spatiality of the network visualization in the exploratory stage of the analysis allowed us to identify apparent hubs in the network which are nodes that have high indegree or outdegree connections across the network we identified intermediaries and hubs by running statistics on degrees of centrality and clustering coefficients we performed descriptive statistics for changes in the numbers of nodes and edges between 2012 and 2018 as well as changes in the distribution of types of sales outlets using online business profiles on yelpcom google business websites and social media we manually calculated the percentage of establishments that appear to have closed since 2012 and we used gephi to calculate the proportion of connections that have been lost due to these business closures limitations because data was manually scraped from the web the network data is limited by how uptodate and extensive the various actors publicly available information is this is also a challenge faced by previous studies that have applied sna to local food systems although there is an economic incentive to keep distribution channels uptodate for all of the actors involved we know that not all of this data is an accurate reflection of the network for example many producers still listed restaurants that had recently closed on their list of distribution partners second data on closures in the network are likely incomplete business profiles on yelpcom and google report which restaurants and grocery stores have closed likely because those types of locations are often visited by the general public however because not all farms farmers markets and small vendors maintain a robust publicfacing web presence it is often difficult to tell if they are still in operation third in addition to utilizing manual web scraping the 2012 datasets were supplemented with online surveys which accounted for 195 nodes and 210 edges with 90 of these in the other category for node type 3 surveys were not used to augment the 2018 data set arguably therefore the 2012 dataset includes more comprehensive information on the local food network as a result comparisons of the 2012 and 2018 datasets become less accurate particularly in terms of magnitude at the same time however smartphone ownership has skyrocketed from 35 in 2011 to 81 in 2019 and the prevalence of online marketing has likely increased in tandem thus arguably making online marketing a more robust data source in 2018 when compared to 2012 last the data provided in this research omits numerous actors in the local food system most notably consumers consumers play a large role in driving and orienting the food system local and otherwise results sna is a powerful tool in quantitative analysis social networks are comprised of nodeswhich are the actors or members of the networkand edgeswhich are the ties or relations linking the nodes in the network nodes may have one or more relation and types of relations with each other for example a farm might sell produce to consumers at a farmers market however the same farm might also utilize their booth at the same farmers market as a csa pickup site as such there would be two edge connections between the farmers market and the farm one denoting dtc sales via farmers market sales unrelated to the csa and another denoting dtc sales through a csabased relationship this distinction is important because as hinrichs notes csas and farmers markets offer differently embedded social relationships although farmers markets enable facetoface interactions between farmers and consumers they are not necessarily developing longerterm continuous relationships on the other hand the csa model can foster greater trust and valuedriven relationships between customers who buy shares for the growing season and csa farmers who are commonly motivated by noneconomic factors and set share prices that are not exclusively profitdriven such relationships may have different staying power over time or allow for different evolutions across the network as farms transition from one form of marketing to another we are able to explore both relationships over time using sna growth and death to start we provide a descriptive comparison of both counties and the proportion of network actors and ties then we explore change over time and network architecture although chester county has a larger local food system network both in terms of nodes and edges the overall local food network of chester county is shrinking while the local food network of baltimore county is growing during the 6year study period baltimore county saw the addition of 284 new nodes and 495 new edges in the network during the same time period chester county saw the addition of 360 new nodes and 684 new edges but lost 393 nodes and 738 edges one possible explanation is that local food systems may reach a point beyond which added growth is very difficult due to plateauing consumer interest or market saturation however when delineated by category all sectors within the chester county local food system are growing the one exception is the other category which is primarily comprised of sales and donations to institutions and civic organizations this category relied more heavily on 2012 survey data to uncover the many farmtofood bank donations across chester county such donations are not as readily advertised on farm websites and may therefore lead to undercounting in the 2018 dataset this finding points to nuances in how local food system growth is tabulated both in research such as this and by the agricultural census where categories are broad and may overlook central connections like that of the chester county food bank both networks show substantial change from 2012 to 2018 with a relatively high rate of turnover of actors within the network when examined by node or edge category both counties show nearly equal rates of growth and death in network actors and their marketing relationships despite growth in many categories more than half of the participants in the local food system changed over the 6year period with only 40 of baltimore countys 2012 nodes found in the 2018 data and only 35 of chester countys 2012 nodes found in the 2018 data more telling the connections across the network changed even more than the actors themselves with only 18 of edges staying the same across both 2012 and 2018 in both counties the fluctuation in edges indicates that while actors may be stable their relationships with one another evolve the rates of endurance by category varied in the chester county dataset the following nodes endured 91 farms 23 schools involved in farmtoschool and food bank connections 18 farmers markets 18 grocery stores 15 restaurants 11 churches involved in food bank gardening and distribution and 3 food banks these locations accounted for 85 of the actors that endured from 2012 to 2018 the rest of the actors were csa dropoff locations community gardens and food hubs by comparison the baltimore county dataset showed 37 farms 30 restaurants 20 grocery stores and 14 farmers markets active in the network in both 2012 and 2018 these actors made up 87 of the actors that endured within the dataset the remaining enduring actors include csa dropoff locations two schools two catering companies and two churches generalizations across categories are shown in table 2 in 2012 the chester county other node category included 80 civic organizations many with gardens that donated food to other civic organizations these gardens largely catered to schools or the chester county food bank the chester 2012 data in the other category also included 88 csa dropoff locations while the number of restaurants farmers markets farms and grocers increased over the 6year period the miscellaneous category decreased with a decrease in both civic organizations and csa dropoff locations this change is likely because the number of gardens associated with the food bank and other civic organizations were not as readily found online in 2018 similarly the 2018 baltimore county other category included 15 churches and 3 food banks importantly the other category is larger than any other category across both counties this indicates the variety of actors beyond farms farmers markets restaurants and grocers which are currently the main focus of much of local food systems research the other category also captures new marketing typologies that may tap into other sociopolitical movements for example the 2018 baltimore county dataset included a recently legalized cannabis shop which purchases infused honey from a local beekeeper although the cannabis shop typology was collapsed into the other category for our analysis this represents a new aspect to local food systems that warrants further investigation particularly as hempderivatives become more common in other local food spaces such as farmers markets and as local food systems spread into new spaces with their own divergent or intersectional political objectives separating network actors into categories allows us to explore further properties of local food system stability for example farmers markets were the most stable nodes within the network across both counties this may be because farmers markets generally have an explicit goal of providing business opportunities for local food producers thus making them a relatively stable outlet for local food system sales more than half of the farmers markets stayed open in chester county through the 6year study period and nearly half of them stayed open in baltimore county this finding supports usda agricultural census information noting that in 7 years the number of farmers markets increased by 270 in chester county and by 40 in baltimore county however our data also show high rates of turnover with over 40 of the 2012 farmers markets no longer in operation by 2018 this flux over the course of a 6year period indicates a certain degree of market instability as well as rapid evolution in how consumers interact within an everchanging local food system across both counties grocers also appeared to be relatively stable actors in the local food system with a little less than half of the 2012 grocers remaining in the 2018 local food network because grocers are important intermediaries that are often central to local food networks their relative stability in the network offers promise for longterm stability and growth in local food systems the two counties in this study differ in terms of the growth of this food system actor with grocers making up the largest growth in the actor category for chester county but not baltimore county baltimore countys local food system is comparatively more reliant on restaurants this might explain the greater growth in the restaurant category with the addition of 84 new restaurants between 2012 and 2018 although 30restaurants remained in the baltimore county local food network throughout the course of the study a nearly equal number of restaurants also dropped out of the network between 2012 and 2018 the restaurant category had higher turnover in both counties when compared to grocers our data indicate that unlike restaurants farms have greater staying power they are also increasingly joining the local food system in both study counties although the usda agricultural census noted a 30 decrease in the number of farms that sell through directmarket channels from 2007 to 2012 in baltimore county our data shows an 11 increase in the number of farms in the local food system similarly the usda agricultural census notes a modest 4 increase in farms that sell through directmarket channels in chester county throughout 20072012 our research indicates that this county saw a 25 increase in the number of farms involved in the local food system the differences in figures could be because our data also capture farms that sell through intermediate markets intermediate markets account for twothirds of local sales further the offset in years between the usda agricultural census data collection and this study may also explain the difference in figures also of note the baltimore dataset appears to capture a more representative sample of directmarket farms compared to the census while the chester county dataset captures about 30 of directmarket farms compared to the usda agricultural census this may partly be because chester county has a large portion of amish farms that may take part in the agricultural census but may not have an online presence as a result of religious restrictions on technology use due to the nature of online data collection methodology employed in this study we were not able to verify these amish farms and as a result we could not access their marketing connections confirmed business closures between 2012 and 2018 provide supporting evidence for the broad categorical trends above importantly closure is distinct from actors simply dropping out of the network as closure implies a complete and indefinite severing of network ties uniquely sna allows us to assess the disproportionate impact that the loss of specific actors can have on a network restaurants made up 60 of the 36 confirmed closures in baltimore county the second highest category of closures were farms which represented an additional 16 of total closures similarly half of the chester networks nineteen confirmed closures were restaurants additionally four grocery stores three farms two farmers markets and one csa distribution location closed thus removing them from the 2018 network if a local food system is more dependent on restaurants the flux within the network could be greater as is the case in baltimore county the baltimore county dataset shows a greater loss of nodes in terms of confirmed closures with 12 of the nodes from 2012 having closed by 2018 this resulted in a 20 loss of edge connections as compared to a 3 loss rate for nodes and edge connections in the chester county dataset restaurants have a median lifespan of 45 years and other network actors may have a longer business lifespan thus translating to increased stability within the network many restaurants that close see the owners or chefs establish new eateries shortly thereafter future research could track such transitions to see if relationships are reestablished with the same farmers and distributors as new spaces open up or if restaurants that source locally have different survival rates than their nonlocally sourcing counterparts another possible explanation is that local food systems may need to achieve critical mass in order to compete with largerscale food supply chains it is possible that chester countys large local food system has less flux compared to the still growing local food system of baltimore county another way to view the confirmed closures is that each actor is a unique contributor to the local food system the confirmed closure of 36 actors in the baltimore county network had a disproportionate impact on edge connections resulting in 125 lost relationships conversely while chester county also saw the closure of a few actors those closures only resulted in the loss of 30 edge connections in baltimore county the closure of five actors in particular resulted in a substantial loss of edges these actors included the following restaurants and farms simmer rock farm atwaters ploughboy kitchen big city farm woodhall wine cellars and clementine restaurant simmer rock farm opened in 2010 and closed by 2013 resulting in the loss of 25 connections including three farmers market sales locations 15 restaurants that carried their food one grocery store and a csa the restaurant atwaters ploughboy kitchen also closed resulting in the loss of 37connections big city farm was a collection of urban farmers its closure resulted in the loss of 14 connections and the closure of woodhall wine cellars and clementine restaurant both resulted in the loss of seven connections collectively these account for the 72 of lost connections due to closures within the network pointing to the significant impact that a few actors can have on local food system dynamics visualization of network architecture to understand if markets are growing outward socially or if new members are incorporated at the heart of the network we use sna visualization to show how the web of market ties have changed over time when visualized socially with the most connected actors at the center of the network chester countys local food system shows growth and decay concentrated along the networks outer margins though growth and death within the network is widespread in contrast baltimore county shows significant network decay amongst actors that were central to the network in 2012 with growth occurring on the networks periphery broadly such patterns may be the hallmarks of a larger more established local food system in chester county evolving at the margins with stable central network actors maintaining the core relationships and network architecture conversely baltimore county appears to be reinventing itself with high turnover in actors that were once central to the network basic network statistics help reinforce the findings from visualizations while telling a more nuanced story about the evolution of the local food systems in both counties to quantify how connected the local food system is we use the average degree statistic which indicates the average number of actors to which each node is tied chester county had a stable average degree measure between 2012 and 2018 while the average degree of baltimore county declined substantially from 2023 to 137 meaning that actors within the local food system have fewer average connections in 2018 than they did in 2012 the clustering coefficient indicates the degree to which the neighbors of a node are connected a coefficient of 1 would indicate that all neighbors are connected to each other while a coefficient of 0 would indicate that none of a nodes connections have mutual ties while the average clustering coefficient for chester county remained stable at 00023 between 2012 and 2018 the clustering coefficient for baltimore county dropped from 0032 to 0023 in sum baltimores network became sparser and more porous due to the many confirmed closures mentioned above that were central to the network architecture as central actors dropped out of baltimore countys local food system newer actors grew at the networks fringe however this growth was not fast enough to reestablish the same level of connectivity across the network to understand how information might travel across the network we use network diameter which indicates the maximum distance between any two nodes within the network the network diameter shrank for both networks indicating that the overall local food system became more closeknit potentially enabling information to travel across market ties more quickly similarly the average path length for both networks also declined the average path length indicates the average steps needed to get from one actor in the network to another and is often used to gauge how quickly information can travel across a network declines in network diameter and average path length indicate the development of a more tightly integrated and consolidated local food system had the network split the path across would have become disconnected or very long such splits can occur when social or market networks fraction but this was not the case in either county finally graph density shows the total number of edges within the network relative to the possible number of edges within a network in other words if every node within a network were connected to every other node in the network the density value would be 1 while if no nodes were connected to each other the density value would be 0 both networks saw graph density decline between 2012 and 2018 as both local food systems are maturing they are consolidating and reducing the redundancy in connections centrality of actors the perseverance of actors and ties across both years could be interpreted as strong ties among actors while new connections and nodes may represent innovation and weak ties between 2012 and 2018 the actors most central to both networks cultivated new sales and market channel relationships both with actors that were new to the network and with enduring actors with whom they were not previously connected this finding indicates innovation among both enduring and new network actors collectively the above statistics demonstrate that the total makeup of the network is in considerable flux additionally the data indicate that the centrality of actors is changing betweenness centrality indicates the extent to which a node acts as a bridge between two other nodes as such high betweenness centrality can suggest a nodes substantial power within a network as it may serve as a broker between other actors in baltimore county only one node was ranked in the top ten highest betweenness centrality in both 2012 and 2018 similarly within the chester county dataset only one node was ranked in the top ten highest betweenness centrality across both years previous research has demonstrated the role that these specific actors have played in brokering new partnerships across the food system and influencing landuse policy the turnover of other actors central to the network was an unexpected finding showing deep changes within the local food system as the constellation of people and organizations changed these changes likely translate to shifts in the sphere of influence of these actors as well scholarly literature has portrayed growing local food systems as creating enduring embedded ties while also having a high turnover while these claims appear paradoxical this research helps show why such assertions may be simultaneously true the persistence of highcentrality nodes like the chester county food bank and springfield farm and strength of their ties across the local food system may be especially important in an everchanging network that is dominated by weak ties such weak ties foster innovation as new forms of market channels and associated sociopolitical alliances are formed across the local food system network spatiality last spatial trends related to network change over time help build on earlier research that considers the growth of local food systems as a response to the bow wave of urban development the chester county dataset shows growth of the local food network in the northern parts of the county and a simultaneous loss of food system actors in the southern portions of the county actor loss was clustered close to the city of philadelphia in baltimore county network actors that were present across both years of the dataset were engaged in forming new edges and maintaining old connections similar to chester county actor loss is clustered in the southern portion of baltimore county which is closest to the city of baltimore growth within the network is clustered to the north which corresponds with baltimore countys more rural areas in both counties the local food system experienced actor loss closer to urban areas and new growth further from cities in periurban and rural areas it is important to note that actors are not only farms but also other nodes such as farmers markets this finding suggests that there may be spatial boundaries to the ideological objectives of the local food movement as farms are forced further away from urban areas the distances to get to urban markets may become too far to traverse at the same time suburban growth may also stretch the social distance between urbanites and rural dwellers placing the many shared objectives of the local food movement further from peoples reach both physically and mentally while the counties have many differences the similarities across both datasets may point to larger trends regionally or nationally in local food marketing we show that farms are joining the local food movement this change is not captured in the usda agricultural census for either county though it is noted nationally the number of farms with dtc sales increased by 55 from 2007 to 2012 but with no increase in dtc sales and then the number of farms with dtc sales declined in 2017 like the usda agricultural census we found that the most common way of selling local food was through intermediate markets and that online marketing appeared to be on the rise marketing pathways are rapidly changing in addition both networks are consolidating and becoming more tight knit such change would indicate that these local food systems are made up of weak ties enabling rapid innovation with ever decreasing distances from one side of the network to the other as a result news travels faster the network architecture of these two cases reveals that despite these weak ties both counties have a stable central actor that maintains the core identity of the county through political engagement with landuse policy and planning these network findings help make sense of seemingly conflicting accounts that local food systems struggle and are growing innovate and are historic and last that they are dominated in numbers by weak ties and in central actors with strong bonds discussion and conclusion this research challenges common narratives about local food systems the substantial flux captured across both food systems has not been anticipated in past literature which often frame local food systems in terms of stable growth but overlook their simultaneous decay we found that the local food systems in both northeastern counties reinvented themselves by half and rewired nearly 80 of their connections within 6 years identifying drivers of growth stability and decay are important for generalizing findings further while past literature acknowledged that local food systems are multifaceted complex and adaptive the extent and timescale of their evolution generates new questions about how rapidly the social movements they represent shift sociopolitical focus and their constituents along with them there is evidence of these shifts at the national scale for example the rise of food justice movements highlights the lack of access to land ownership and markets for farmers of color as these movements continue to gain momentum task forces made up of growers and market managers of color are producing policy platforms soul fire farm in new york and the northeast farmers of color alliance put forth a food sovereignty proposal in soul fire farm and northeast farmers of color alliance 2018 which was acknowledged in elizabeth warrens national presidential campaign sna in combination with qualitative research could highlight where and how buy black campaigns or boycotting certain stores changes marketing networks and their embedded power structures similarly sna in combination with spatial regression analysis can trace if local food is increasingly moving to whiter more affluent block groups and where it interfaces with lower income communities and majorityminority block groups our research suggests that forming a network of networks to scale up the political ambitions of broader food movements may prove especially challenging given the high flux and heterogeneity at the local level but such an effort could happen rapidly given how local food networks are already reorganizing to this end social movement scholars note that the impact of a social movement on political change is understudied and that the outcomes over time must be measured against shifts in network composition political focus and tactics as this research reveals the very social architecture of local food systems is shifting one would expect the political objectives to also change the decay of the network particularly at the heart of the local food system in baltimore county prompts further considerations how much can a social network change and still endure the answer depends partly on how rapidly the network replenishes its ties and actors and how adept it is at recruiting our research suggests that a complete disruption in recruitment into the local food system could see the food system itself cease to exist in a 12year time frame if it followed a linear pattern there may be cascading events where closures create ripple effects and network disruption occurs more quickly than expected based on the architecture we suspect a longtailed distribution of network ties which would indicate that growth and death is exponential not linear such considerations are important to understanding how local laws restrict the ability of new local food systems to grow endure and thrive for example cities limit permits for new farmers markets and nations direct agricultural subsidies in a manner often counter to local food systems framed another way with more supportive policies our research gives clues to how quickly a local food system might blossom there are ample examples from the organizational literature with regard to how agricultural policies create new marketing networks allowing for example the rapid agricultural transformation in cuba if network growth socially builds outwards from a stable core as it has in chester county nonlinear exponential growth can be expected shifts in network alliances are of particular concern in understanding how communities regulate landuse spatial findings help reinforce research that considers the rise of local food as a response to a wave of urbanization further the eat local political focus of local food systems particularly around countylevel landuse policies suggests that as the system rewires it may reactively form new alliances in anticipation of major planning efforts both chester and baltimore counties showed network growth in more rural areas and network decay closer to the urban centers these findings lend support to john harts concept of a perimetropolitan bow wave in which metropolitan areas steadily encroach upon and eventually engulf adjacent periurban farmland even prior to engulfment encroachment has implications for farming operationsas the bow wave approaches and land values rise farmers often shift their production and market channels our findings demonstrate where constituents are turning to local food systems as an antidote during this study period the housing market was steadily recovering from the 2008 recession the shift of local food systems further from urban areas may differ under different housing markets or economic recessions a topic for future research on just how reactive or protective the local food movement may be for slowing suburbanization the spatial aspects of network decay also indicate that landuse patterns that keep rural and urban landuses in close proximity may help foster greater network ties and stability across the network in turn such market connections should reinforce ruralurban social relationships that produce mutual understandings and a shared political agenda the use of sna uniquely highlights the disproportionate impacts that a few organizations or individuals can exert on total network stability the chester county food banks role in promoting new farms and markets while connecting them to civic society undoubtedly contributes to their own stability and centrality to the network but also to the broader objectives of the local food movement in chester county to preserve farmland and provide food security this study was conducted during a time period with relatively low unemployment rates but economic recession will add pressure for food banks to mobilize food and volunteers and serve more people chester countys food bank is wellpositioned in mobilizing the local food system to such a daunting task other food banks nationally are also interfacing with local food movements such findings highlight the ties between local food and food security and open new avenues of research into how food banks both sustain the local food movements transactional markets and interface with its political objectives broader trends within marketing categories offer further timely generalizations for how to sustain local food systems during times of crises many states have banned restaurant dining during the covid19 pandemic and quarantine protocols have placed considerable economic pressure on small businesses half of small businesses have enough cash to survive for 27 days without new revenue restaurants have 16 buffer days on average local food systems with larger percentages of restaurants and which are more dependent on restaurants for network growth like that of baltimore county will likely have larger blows dealt to the local food system than counties that are not as reliant on restaurants widespread restaurant closures may have ripple effects across the local food movement impacting collective action and mobility for a variety of topics ranging from food justice policies to landuse planning while turnover in the restaurant business is well documented with the median restaurant lifespan of 45 years this research raises questions about the median lifespan of other businesses such as csa farms and farmers markets and the impact of market outlet closure on smallscale farms sna also demonstrates that the closure of just a few nodes can substantially alter network connectivity be those restaurants or other node typologies such findings help reinforce the notion that collective action in the food movement is dependent on many forms of food sales and donations using a longitudinal sna approach to compare the evolution of two local food systems opens the doors for a number of future studies this data raises questions about what methods of direct marketing are most vulnerable to disappearance and change chester county pennsylvania saw a significant reduction in the number of csa connections in the network are csas used as stepping stones towards other forms of direct and indirect sales relationships online and platformbased marketing introduce new questions about embeddedness characteristics as the local food system moves from a facetoface interaction to a virtual know your farmer experience will these new forms of embeddedness flavor the endurance or loyalty of network actors and differently influence civic engagement the collection of qualitative data through interviews and surveys could add additional detail to these findings indeed this research does not cover changes in consumer ties to markets which would presumably influence staying power consumer ties likely have important impacts on overall network architecture as well as associated local policy objectives and outcomes future studies may replicate findings and move the literature toward a typology of local food systems some like chester county may be relatively stable with the addition of new network members and connections on the periphery of the network others like baltimore could be reinventing themselves at their very core understanding how such changes in network architecture broadly correlate to shifts in policy objectives will yield new insights into how a network of local food networks could be scaled up globally currently a theoretical concept for broad social change farms with a you pick option where customers can come directly to the farm to pick their own produce mobile farmers market farmers market truck that brings fresh produce to communities cidery selfidentified cidery hobby gardener someone who grows in their backyard but sells some products community garden in chester a lot of the community gardens are donating to the food bank butcher butcher shop company that offers onor offsite catering farm to farm one farm or producer selling directly to another farm or producer school pk12 or collegeuniversity also includes dining service operators that work within schools hospital medical hospitals csa pickup customer goes to the farm to pick up their csa share csa pickup a location other than the farm at which a customer can pick up their csa share farm visits farm offers farm visits for schoolseducation farm stand farm sells their products at an onsite farm stand or store value added producer a company that buys produceproduct directly from the farm to produce a value added product restaurant includes brick and mortar locations coffee shops bakeries food trucks and farmers market vendors who turn farm goods into value added products that they sell at a farmers market donation donation sites such as food banks or churches box scheme produce delivery services online sales online sales direct from the farm youpick farms with a you pick option where customers can come directly to the farm to pick their own produce mobile farmers market farmers market truck that brings fresh produce to communities butcher to farm a butcher shop that sells their meat at farm stands donation donations from raised bed gardens to the chester county food bank fresh2you a specific program of the chester county food bank for distributing fresh food in the county farm to winery farms that sell fresh product to wineries appendix see tables 4 5 and6

local food systems are growing and little is known about how the constellation of farms and markets change over time we trace the evolution of two local food systems baltimore county maryland and chester county pennsylvania over six years including a dataset of over 2690 market connections edges between 1520 locations nodes longitudinal social network analysis reveals how the architecture actor network centrality magnitude and spatiality of these supply chains shifted during the 20122018 time period our findings demonstrate that despite growth in the number of farmers markets grocery stores farms and restaurants in both counties each local food system also experienced high turnover rates over 80 of the market connections changed during the study period farms farmers markets and grocery stores showed a 4050 survival rate indicating their role in sustaining local food systems over longer time periods other actors such as restaurants had a much higher turnover rate within the network both food systems became more closeknit and consolidated as the center of gravity for both local food systems pulled away from urban areas toward rural farmland evidence of both growth and decay within local food systems provides a new understanding of the social networks behind local food markets

introduction promoting sustainability while ensuring the world is safe and secure for its people and other species is an urgent concern for decisionmakers governments consumer industries and ordinary citizens worldwide this objective has been a central aspiration in the united nations conceptualization of sustainable development since the early formulations in the brundtland report from 1987 where it is stated that certain aspects of peace and security bear directly upon the concept of sustainable development indeed they are central to it these aspects are later specified as poverty inequality and uneven distribution of resources thus appealing to a holistic and convoluted approach to sustainability efforts that associates social sustainability with security the conceptualization of security as intertwined with social values has remained a fundamental pillar in the united nations peace and development resolutions communicated as an aim to build a world free from fear and free from want and to foster peaceful just and inclusive societies which are free from fear and violence these ideas have also impacted how the defense sector in a western liberal context has justified its monopoly on violence where maintaining democratic values and strengthening societys overall ability to deal with stress have remained pivotal factors for building a secure society handled by julia maria wittmayer drift erasmus university netherlands while the association between security and sustainability has been an ongoing discussion in the un over the last 40 years it has recently gained new momentum exemplified by the 2022 special report released by the united nations development programme which addresses new threats to human security in the era of the anthropocene particular areas of concern include the increasingly visible effects of climate change and its existential consequences augmented by the uneven distribution of resources and global inequality which has intensified insecurity worldwide furthermore the covid19 pandemic brought a heightened awareness of how structural inequalities and vulnerabilities shape and aggravate security issues and thus made the interconnections of security and social values more apparent in addition the rapid development of artificial intelligence has actualized various social problems that profoundly impact security such as societal polarization violent extremism and social bias of vulnerable populations in society these developments have reignited the relevance of acknowledging the intertwined character of sustainability and security as essential factors for development and world peace however the association of security and sustainability has proven itself a source of theoretical inconsistencies especially when considering the destructive nature of military conflict which presents deeply rooted assumptions of security that contradict the three principles of sustainability environmental integrity social equity and economic prosperity attempts have been made to define and accommodate this conceptual relation academically and in extensive policy work in the un but several theoretical problems remain one persistent issue is the normative valence associated with the concepts which invokes disharmony when they are combined the normative understanding of social sustainability encompasses a plurality of social values involving multiple stakeholders with conflicting goals is contextdependent and accentuates a mess of diversity security in contrast is heavily influenced by ideals associated with national security which is mainly focused on external threats and territorial security this view radically contrasts the holistic and humanitarian approach of the sustainability agenda which aims to promote peaceful and inclusive societies for sustainable development provide access to justice for all and build effective accountable and inclusive institutions at all levels another theoretical issue is the underlying notion of security as a hegemonic normative commitment meaning that items associated with this concept often take precedence over other issues with the implication that a wide range of societal issues can be reformulated to legitimize a political state of exception accordingly the securitysustainability conceptualizations seem to harbor an inherent predisposition that favors a narrow perception of security indicating a tradeoff arrangement of security and sustainability efforts in effect the states interests remain at the center of security and development aspirations contributing to an outlook of security in opposition to sustainability resolutions one initial conclusion is therefore that there are precarious elements in this connection that work unfavorably for any reformulation which makes one wonder can security be sustainable in response to this theoretical incongruence a growing field of research has raised critical questions about the destructive effects of security on sustainability measures by highlighting the ecological social and economic imprints caused by military operations on local communities several studies have identified the connection between climate change and security where the environment is an arena of amplified conflict and a policy area for increased securitization the issue of normative imprecision within the concepts themselves has also been addressed from multiple angles including the insideoutside relationship between national and social security the positive and negative value of security and conflicting values in the sustainability conceptualizations however a general trend in this research field is a significant compartmentalization of security and sustainability while a substantial focus has been rendered on ecological and economic aspects hence there is a need to address the linkage between social sustainability and security and the conceptual messiness that emerges when laboring on a theoretical understanding of this relationship by this positioning the central contribution of this article is to illustrate with the assistance of three contrasting perspectives paradox coproduction and deconstruction how values and ideological aspects can influence contemporary world politics and affect the conceptualizations of security and social sustainability therefore with the three perspectives as a starting point i want to unpack and explore what possibilities these perspectives suggest for the conceptual manifestation of social sustainability and security while addressing the boundaries and openings they present specifically how is the interlinkage of security and social sustainability affected when the three distinct perspectives are applied and by doing that can we gain a deeper understanding of how conflicting values operate in world politics the article is structured as follows the first section clarifies the methodological approach and how the theoretical perspectives of paradox coproduction and deconstruction have been used as illustrative tools to study the relational dynamic of social sustainability and security after that i will continue with the three perspectives and describe their effects on the conceptual pair the first part addresses the paradox perspective which stresses an essentialist view of values that convolute a reconciliation of social sustainability and security the second part focuses on the relationship between security and social sustainability from a constructivist proposition of coproduction which pronounces reciprocity and cocreation after that the conceptual association is approached from a poststructuralist perspective of deconstruction focusing on the underlying processes that produce meaning while paying attention to the hierarchical positioning of values lastly i will discuss what can be discerned from studying the conceptualization of security and social sustainability using the three perspectives methodological approach this article has proceeded as a conceptual analysis to investigate what boundaries and openings three distinct perspectives of the connection between social sustainability and security might produce the prime focus is therefore not so much on explaining exactly how the conceptual pair of security and sustainability has been discursively discussed in the un but rather in a bricolageinspired process focused on bringing together concepts questions and controversies identifying how the meaning and the effects of this conceptual pair are altered depending on which perspective is applied in this setting the three perspectives function as illustrative tools to understand the performative character of concepts in their contextualized materializations rather than analyzing their textual definitions per se comparing concepts with various valuebased compositions can bring vital information on how their dynamic unfolds in different theoretical frameworks while providing an integrative tool for further theory development furthermore a conceptual analysis also helps to highlight the circular connection between values and knowledgemaking in their influence on governance and security measures the analyzed material consists of five un policy documents listed in full in appendix 1 while the selected documents address the connection between sustainability and security using slightly different approaches reflecting on the specific context in which they were created they provide a generic account of how the conceptual pair has been discussed in the un and holds a central position in the evolution of sustainable development and its strong association with security two of them our common future also known as the brundland report released in 1987 and transforming our world the 2030 agenda for sustainable development released by the un general assembly in september 2015 are considered canonical documents in the un work on sustainable development while presenting valuable insights on how security has been approached from a sustainability perspective three reports were included from the undp the human development report released in 1994 the first report in which human security appears further expanded in human security now also called the ogata sen report from 2003 these two reports are vital documents in the un formulation of human security and have been discussed frequently in academic literature a more recent publication 2022 special report on new threats to human security in the anthropocene demanding greater solidarity released in 2022 brings an updated account of how security and its linkages to social sustainability are conceptualized today in addition relevant academic contributions and grey literature within security studies sustainability and human security have been added to exemplify the divergent standpoints produced by the theoretical perspectives of paradox theory coproduction and deconstruction the literature discussed has been applied to illustrate how the relationship between security and social sustainability is altered depending on which perspective is applied therefore a limitation is the textual body on which the study has based its conclusion however the focus has been on analyzing the contrasting outcomes produced by distinct ideological vantage points rather than providing an exhaustive literature review analytical framework previous research describing the relationship between security and sustainability has often relied on human security expanding on notions of negative and positive security as formulated in the traditionalistwideningdeepening debate while this application is suitable for describing how the un in most parts has addressed security it follows a dichotomous reasoning that fails to encompass the full complexity of security when aligned with social sustainability which includes a wide range of societal aspects to fully comprehend this dynamic this article has applied three perspectives paradox coproduction and deconstruction different values and epistemological orientations underpin these perspectives and represent distinct standpoints of what constitutes true security and sustainability they also allow a more holistic and flexible analysis to conceptualize security and sustainability as a relational process that materializes differently depending on the perspective involved how the perspectives have been analyzed is listed in table 1 the paradox perspective highlights an essentialist understanding of values as absolute qualities pronouncing differences and clearcut categories essentialist thinking often leads to dualistic categorization separating distinct elements with welldefined boundaries this epistemological baseline is influential in political realism and proceeds as a commonsensical approach to how security generally operates in world politics emphasizing explicit categories of enemies and allies with the accumulation of power as a primal concern paradoxes have been approached in previous research from many angles this article has supported its conclusions based on literature from organizational studies to describe the theoretical framework of paradox theory paradoxes in military philosophy rely on literature from war studies and critical security studies in contrast the coproduction perspective describes a constructivist view of security and sustainability as two sides of the same coin the coproduction view is exemplified by the view of development and security described in human security relating to the uns conceptualization of security this approach proceeds from constructivist ideas of values as variables that depend on historical cultural political and social contexts emphasizing the interaction between science values and policy coproduction as a theoretical framework has been widely applied in various disciplines including studies on global sustainability future studies and policy research coproduction is used in this article to illustrate the widening debate in security studies relating to the composition of sustainability and security in the form of human security development and emancipation the third perspective deconstruction offers a poststructuralist lens on the relationship between security and sustainability highlighting the processes that infuse concepts with meaning and valance although initially associated with the philosopher jacques derrida in his work on critical literary analysis this approach has been widely used as an analytical tool in critical research to highlight the processes through which meaning is constructed contingent and therefore changeable accordingly deconstruction provides an approach to the scientific critique of takenforgranted assumptions on the constitution of the world order and how they materialize in policy and highlights questions of power and hegemony three perspectives of security and social sustainability will continue with a more indepth analysis of the three perspectives separately three perspectives of security and social sustainability paradox a paradox can be described as a phenomenon that consists of embedded contradictions between various aspects which seem logical when studied in isolation but absurd the context and meaning are not fixed opens up conceptualizationsacknowledges a power dimension and irrational when appearing simultaneously paradoxes tend to accentuate tensions between competing yet interrelated objectives emanating from contrasting logics that operate at different levels in various time frames these tensions often originate in an essentialist understanding of values as fused with inherent qualities therefore generating polarized eitheror distinctions that appear paradoxical when contrasted to other values accordingly a paradox perspective on the relationship between security and social sustainability emphasizes differences and frictions by associating the concepts with absolute values such as destructiondevelopment and powerinclusion that remain relatively fixed therefore appearing to obstruct a reconciliation however because human security and state security are mutually reinforcing and dependent on each other the connection between the two approaches to security produces a paradox besides providing a distinct comparison tool paradoxes can occur in times of uncertainty and ambiguity where simplified descriptions of a complex phenomenon are applied to overcome cognitive disharmony paradoxical reasoning therefore typically emerges in contexts characterized by a paradigmatic change where challenging old ideas invoke dissonance and perplexity as a policy intention and research agenda sustainable development exemplifies a transformative motion in setting out a supremely ambitious and transformational vision for radical change however the obsolete core competencies that hinder true transformation appear resistant to alteration creating a paradox of development and continuity this is acknowledged in the 2022 special report on human security as a development paradox even though people are on average living longer healthier and wealthier lives these advances have not succeeded in increasing peoples sense of security the un conceptualizations of security thus occasionally appear contradictory and ambiguous while one explanation emphasizes a functional rationale where paradoxical descriptions effectively accentuate differences another conclusion is that the paradoxical interpretation of security emanates from the contested concept of security itself according to merriamwebster the dictionary definition of security is the state of being free from danger or threat which appears unproblematically straightforward however when probed more deeply the concept emerges as vague and highly normative it thus opens up a wide range of politically motivated and occasionally conflicting views of what security in practice means the most prevailing account of security has been recognized as national security which historically has focused on threats and locating danger referents to be secured agents that provide security and means to contain danger from this perspective security is understood in deterministic terms as the pluralistic objectives of individuals and states to protect and prevent future attacks from antagonistic threats as such it displays a stark association with a concentrated effort to enforce foreign and defense policy mechanisms to avoid prevent and win interstate military disputes in rob walkers words this understanding of security operates as a hegemonic logic which has invoked realities and necessities that everyone is supposed to acknowledge but also vague generalities about everything and nothing the perception of military reasoning as situated in a realist ontology that is ubiquitous and implicit yet disorderly and imprecise supports the paradoxical interpretation of security this sentiment is illustrated by the famous quote made by publius flavius vegetius in the fourth or fifth century ad si vis pacem para bellum to secure peace is to secure for war the proverb has supported the ambiguous dogma of what the military mission in essence encompasses and implies circular reasoning where peace is perceived as a prerequisite for war when constructed in this way the paradox is not conferred from a platform of opposition but instead appears as a nucleus as such the paradox is conceptualized not as cast by eitheror thinking but instead forms an integral part of the military organizations core identity this type of paradoxical logic accentuates realist ideas of military actions as structural necessities where states are predestined to act in specific ways although it might appear unproblematic when viewed from a military context the security paradox becomes an obstacle when combined with the core value in the social dimension of sustainability which values life for itself this is partly explained by the ambiguity of the negative connotation of security as connected with destruction while simultaneously being concerned with peace maintenance thus conveying a positive value the ambiguous quality is further reinforced through covert ideas of an embedded power asymmetry operating at the center of sustainability efforts this paradoxical construction appears in quotes supporting ideas of military power as something that can neutralize a potential threat and therefore protect the people as a result this viewpoint displays an image of people needing protection yet simultaneously being capacitated to autonomy emancipation and selfgovernment in essence the historical and political fabrication of security as a national interest appears paradoxical when juxtapositioned with the values of social sustainability it draws a sharp boundary between how the concepts can be merged a paradox perspective thus leads to the conclusion that a foundational aspect of how security operates is oppositional to ideals relating to the social dimension of sustainability to summarize • a paradox perspective proceeds from an essentialist understanding of values that fortifies binary evaluation structures • security is theorized in ambiguous terms of negative values associated with destruction yet is associated with peace maintenance indicating a positive value • boundaries to conceptualizations of security and social values are fortified by a predisposition that views the concepts as tradeoffs with the overall understanding that national security must be prioritized • however one potential opening for this conceptualization is that pluralistic value systems often appear paradoxical it does not mean they cannot coexist coproduction in contrast to the sharp boundaries presented by the paradox perspective the coproduction view offers a broad theoretical spectrum where the interdependency of knowledge culture and power is at the center of inquiry coproduction provides a constructivist framework to expand notions of science emphasizing reciprocity and exchanges between various stakeholders and is a valuable tool for improving critical analysis and addressing normative research analyzing security and social sustainability from a coproduction perspective thus means a coconstitutive approach to producing and organizing knowledge and governance rather than treating them as separate domains accordingly coproduction contrasts the realist ideology that seeks to disconnect elements of nature facts objectivity and policy from those of culture value subjectivity emotion and politics when viewing the relationship between social sustainability and security from a coproduction perspective the outcome is that although social sustainability and security can be seen as derived from very different core values there is a deep connection between them not only are they connected but they are also coconstitutive since a basic level of security is required to realize a sustainable future conversely legitimate security can only be achieved through sustainable development this sentiment permeates the un 2030 agenda and is illustrated by sustainable development goal 16 as an overarching objective to promote peaceful and inclusive societies for sustainable development provide access to justice for all and build effective accountable and inclusive institutions at all levels from a coproduction perspective security proceeds from a normative frame where security is viewed as a positive value associated with a solid emancipatory agenda the positive view of security is a prominent cornerstone in human security originally intended to extend the narrow understanding of national security to endorse a valuebased framework focused on conflict resolution and peacebuilding a vital part of this extension includes a humanitarian approach centered on the peoples wellbeing highlighting the fulfillment of basic personal needs such as being fed fully clothed and safe from harm this concept thus invites an analytical level of security focused on how people and communities can manage their needs rights and values concerning international security however this softer approach to security is not entirely separated from national security since good governance is recognized as an imperative factor for making people feel safe this sentiment is especially prominent in the human security now report where it is stated in several places that human security complements state security therefore the force of violence can be deployed by states that react to threats from extrastate actors to assure people that their human rights are protected and secure another critical point is that even though the level of analysis is focused on the individual the determinants of human security are affected by past courses such as colonization and war while ongoing developments like climate change and trade liberalization generate precariousness that can accentuate future vulnerabilities one essential component in the coproduction perspective of security and sustainability is emancipation according to this view security and emancipation are two sides of the same coin security equals the absence of threats thus freeing people from physical and human constraints making them more emancipated this way emancipation is the key to achieving true security this idea is also notable in the capability approach developed by amartya sen and martha nussbaum who link the social dimension of sustainability with a broad meaning of security through the concept of capabilities referring to aspects of basic human needs the capability approach is closely related to human rights and guided by the principles of social justice and emancipation emancipation is further associated with development ideas which connect insecurity and conflict with underdevelopment since sustained inclusive and sustainable economic growth is essential for prosperity while greater freedom enhances the ability of people to help themselves and influence the world which is vital for development accordingly it is crucial to include social elements in marginalized communities as critical focus areas to build sustainable peace therefore effective states should protect and improve peoples lives in ineffective ones since providing this help will enhance security everywhere the idea in the coproduction perspective is that security and sustainability are both interrelated and cocontingent and that sustainable development cannot be realized without peace and security and peace and security will be at risk without sustainable development a coproduction thus undoubtedly opens up a broad application of how the concepts can be merged however there is also a possibility that the broad implication of a coproduction view can add to conceptual confusion imprecision and vagueness while implying that a diverse range of human activities can be turned into security issues which can justify undemocratic measures furthermore another issue is the view of development and security as cocontingent the overriding logic in this assumption is that development reduces poverty and diminishes the risk of future instability thus contributing to improved global security however development as a necessary precondition for security can lead to intensified climate change with negative consequences for both social sustainability and security furthermore the development concept relates to a particular rhetoric which serves to justify and disguise the prevailing patterns of global hegemony in effect the assumption that the western world is the most developed and accordingly both responsible and entitled to saving the rest of the world is reinforced consequently viewing security and social sustainability as coproduced does not resolve the issue of power asymmetry but instead supports it in a reconciliatory vocabulary to summarize • the view of coproduction understands security and sustainability as coproductive interdependent and necessary the values of sustainability and security are given equal importance deconstruction as discussed in paradox the paradox perspective implies a narrow conceptual boundary due to the fixed core values associated with security at the same time the coproduction perspective described in coproduction suggests a conceptual openness that is too broad still the power dimension is something that neither of the views adequately addresses thus instead of identifying the variables that allow or inhibit a conceptual configuration of security and sustainability another potentially more fruitful question is to ask what security does and how its performance affects the values of the concept to which it is attached this undertaking invites a deconstructive approach that moves beyond scrutinizing specific components of security and social sustainability to focus on the underlying logic that infuses these concepts with valance and meanings deconstruction is a philosophical and literary analysis associated with the french philosopher jacques derrida that analyzes how language produces meaning and what consequences particular readings produce it is not a method a philosophy or a practice but something that happens when the arguments of a text undercut the presuppositions on which it relies and the deconstruction takes on a life of its own accordingly this perspective involves a shift from exploring the meanings of the concepts to questioning what remains to be thought with what cannot be thought within the present to understand where a deconstructive approach might fill the gaps let us briefly return to the paradox perspective and its pronounced distinctions of opposing categories one explanation for paradoxical thinking can be attributed to the western idealization of logocentrism which values presence the factual and real as the highest goal in knowledge production however this ideal is upheld by the constitution of its presumed opposite accentuating binary relations that typically imbue a hierarchical valuation process accordingly how we understand the world and its textual descriptions proceeds from differentiation where every concept is inscribed in a chain or a system within which it refers to the other to other concepts by means of the systematic play of differences these binary constructions are however neither stable nor reflect reality per se and as soon as they are uttered they fall apart ambiguities and paradoxical constructions can therefore accentuate undecidable elements in conceptualizations which open possibilities to transform concepts to displace them to turn them against presuppositions and in that process produce new configurations in other words undecidable elements are neither one thing nor the other and at the same time they are simultaneously both they can therefore illustrate how the arrangements for a particular phenomenons possibility can simultaneously be the conditions for its impossibility thus opening the experience of the impossible thus although the connection between sustainable development and security in most parts is strikingly straightforward it also contains undecided elements that open a deconstructive movement this is exemplified by the following quote from the brundtland report the absence of war is not peace nor does it necessarily provide the conditions for sustainable development the quote portends an undecided and uncertain space between war and peace and that sustainable development is not necessarily achieved through a state of peace this statement therefore implies that the categories of war and peace could be something else thus revealing an undecided element in their conceptual constitution another example is found in a quote from the human development report human security is more easily identified through its absence than its presence and most people instinctively understand what security means this quote identifies security as an absence and something most people instinctively understand what is implied by absence is the opposite of security which is insecurity the implication is therefore that security as a dominant category can only materialize through the continuous fabrication of its presumed opposite insecurity not only is the universalist claim of security as an ultimate and overriding human value reinforced but its association with military force is implicit exemplified by an excerpt from the same report below the battle of peace has to be fought on two fronts the first is the security front where victory spells freedom from fear the second is the economic and social front where victory means freedom from want only victory on both fronts can assure the world of an enduring peace… accordingly the undecided structure of security is what produces and maintains presence and creates a more stable construction for the undecided element of the absence of war this reading therefore fortifies a commonsensical notion of security as a human necessity and justifies a security first perspective forged around its claim to embody truth and fix the contours of the real the undecided element of security appears to attach itself to a deterministic idea where the quest for more security is a chronic condition social sustainability too carries undecided elements in its conceptualization one example is the relationship between the emancipation of individuals and the universality of the common good the liberty and emancipation of the individual are potent ideas in linking social sustainability with security yet humanity is often approached as a single and universal identity described as the people this universal identity is extended in the special report from 2022 to encompass the whole planet the world is not only interconnected but also characterized by deep interdependencies across people as well as between people and the planet the tension between the individual and universal extends the dimension of time where the current generation and the next are approached as a unity with similar needs and demands this contradiction can lead to dark and unintended effects of social change intensifying power struggles and added inequalities the universalist claim epitomizes questions of power further appearing in conceptual configurations through philanthropic expressions of protection human security is deliberately protective it recognizes that people and communities are deeply threatened by events largely beyond their control this type of sentiment reveals an undecided element in the vocabulary of sustainable development that seeks to empower people yet describes them as lacking agency and needing protection a deconstructive reading of the conceptual relationship between security and social sustainability implies that on the one hand these concepts are volatile and open to various interpretations while on the other exhibiting opposing core values that appear impossible to merge however this conclusion simultaneously involves a possibility since society needs security to fulfill the essential components of social sustainability such as governing institutional justice spreading resources more fairly and protecting democratic functions in this way linking security to social values acknowledges how socially constructed identities and ideologies create structural certainties that underpin violent conflicts and consider these questions necessary items on a security agenda in contrast to the coproduction perspective where social sustainability and security are seen as two sides of the same coin a deconstructive approach acknowledges that merging security with social sustainability is possible only on the condition of being impossible security and social sustainability are thus in the process of ongoing cocreation producing a state of dynamic equilibrium in which they hold each other in check while continuously conditioning the existence of the other a deconstructive perspective can thus open a more flexible conceptualization of security and social sustainability in presenting a link between opposing categories as such it can create a framework that gives meaning to contradictions showing how they are perspectival and fluctuating it further highlights how power operates often conceptually construed in benevolent cloaking as development and protection while reproducing hidden assumptions and problem formulations that legitimize unsustainable practices however this perspective also allows for relativistic conceptualizations where the normative valence of these concepts risks diluting the conceptual meaning to summarize • the meaning of a concept is not a decided quality therefore a deconstructive approach focuses on the processes that produce meanings • concepts have an undecided disposition which embodies impossible and possible manifestations of values which removes their hierarchical positioning • when boundaries are not fixed new approaches to conceptualizations are opened while hidden assumptions such as power are acknowledged • because the meaning context and realization are not fixed this can lead to relativistic interpretations and unforeseen deconstructions discussion openings and boundaries the perspectives discussed in this article have been used as illustrations to expose different manifestations of the conceptual connection between social sustainability and security while addressing the boundaries and openings they present as described above the paradox perspective fortifies a dualistic categorization with clearly defined boundaries whereas a coproduction perspective approaches security and sustainability from a pluralistic lens with interdependent elements the third perspective deconstruction suggests an approach to sustainability and security that moves beyond the dichotomous structure of constant tensions while highlighting how power operates through hidden assumptions so what can the illustration of perspectives tell us about the relational dynamics between social sustainability and security in addition is it possible to reconcile these concepts in the following i will consider these questions from the dimensions of values the opposition between fixed and unstable components and the production of power and normative approaches to security and social sustainability dimension of values a critical parameter in analyzing the three perspectives of security and social sustainability is the dimensions of values embedded in the concepts and whether or not they should be treated as an inherent autonomous domain or as an external and contextdependent factor the dimension of values does not have to be an eitheror position nor is it a static condition however depending on how the dimension of values is construed reconciling values with disparate valuebased origins will be either more accessible or challenging if we view values as having an intrinsic quality with distinct conditions normative sources and standards then a conceptual merging will be more complex especially when the values are highly normative and ambiguous values in this perspective become more fixed and inflexible illustrated by the paradox perspective which pronounces differences and binary oppositions however even though values with an absolute and fixed position may cause tensions and paradoxical arrangements they can also teach us something by pointing out potential scopes of friction the other perspective on values is that they are not inherent nor absolute but have an external and hence a variable quality which means they depend on contextual influences and therefore have a more interchangeable character in this setting the values depend on other factors that change dynamically exemplified by the coproduction perspective this means a shift in focus from defining the qualities of a particular concept to studying actual situated practices in the context that can help make conclusions about security and social sustainability for that specific case a deconstructive approach shares this propensity however this perspective focuses more on studying the process where concepts become intricately infused with values while highlighting the hierarchical ordering principle that follows with this structuring this leaves an open dimension where the values of security and sustainability are concurrently decided and undecided however while this undertaking is an essential aspect of any critical interrogation it might lead to so what conclusions that do not help to bring about conceptual clarity the opposition between fixed interchangeable and fluctuating components as discussed in three perspectives of security and social sustainability one problem with the conceptualization of sustainability and security is the inherent value attached to each concept which appears fixed and resistant to alteration yet as illustrated by the deconstruction perspective carries an element that remains in constant motion this constitution invites alternative normative positions which causes conceptual imprecision nurtures ambiguousness and imbues relativistic interpretations however due to the fixed element potential openings are impeded this opposition is characterized by different arrangements of fixed and interchangeable components of security and social sustainability as argued in this article security encompasses a fixed hegemonic logic that obstructs any reformulation to include social values thus a conceptual understanding of security is inextricably grounded on a paradoxical structure emphasizing both negative and positive aspects it has clearly defined boundaries accentuating differences and forming a normative baseline that appears rigid and inflexible in this view security supports an unappealable claim of military violence as the ultimate solution meaning that security takes precedence over other values in contrast social sustainability is a concept consisting of highly interchangeable elements that are not decided displaying a plurality of values and reinforcing a high degree of uncertainty regarding how it should and could be defined in practice this means that the fixed component of security remains relatively unaltered even though it is filtered through the generous lens of the coproduction perspective which ultimately reproduces the dichotomous understanding of security and sustainability it initially set out to challenge in this regard a deconstructive approach might present a solution by offering a view of values as a process in the making and hence not a fixed thing since context is never absolutely determinable because the structure of concepts is ambiguous everything depends upon how one sets it to work which implies that security too can be overturned and situated differently for this to work however it is vital to acknowledge the messiness exhibited by a mosaic reality composed of intricate clusters of competing values originating in different disciplines contexts and political orientations in this perspective the conceptualization of security and social sustainability proceeds from a processual perspective which endorses a pluralistic value system composed of infinite possibilities power and normativity in addition a dimension of power in these concepts arises from the intersection of instrumental objectives in the sustainability agenda and the normative approaches utilized to address these objectives instrumental objectives focus on task completion and strategic problemsolving while neglecting the normative complexities brought to attention through the undecided elements focusing on problemsolving is an approach that is as suggested by vince and broussine a strategy to control uncertainty which is a fundamental part of the normative application of sustainability however a problemsolving approach includes an implicit element of power that carries a compelling influence in policymaking it is therefore essential to deepen the understanding of ideas that motivate different standpoints and the theoretical tools that ground the choice of selecting and implementing policy the paradox perspective acknowledges the accumulation of power as the essential goal for stakeholders in world politics a goal that can never be fully reached the coproduction perspective approaches power from a softer proposition of liberal rationality which strongly favors the protection and betterment of the essential processes of life associated with the population economy and society however as turnhout et al argue a coproduction perspective also allows elite actors to shape processes that serve their interests by pronouncing a view of power that leans on idealistic and humanitarian ideals this view proceeds from a positive view of security tightly connected with ideas of development and emancipation as a prerequisite for joining security with social sustainability however there are problems with this broadening as it tends to reproduce the hidden assumptions on security power and development it initially was set out to challenge these assumptions proceed from the idea of the protector and the protected and cement a power hierarchy which arguably does not sit well with the ambition in the undp report that people should be able to take care of themselves in both cases the comprehension of power strengthens western hegemony and fortifies ideas of development as a linear progression the perspective of deconstruction might offer a solution to the power dilemma by leaning on an understanding of power as something that is never settled but in continous motion understanding power in this setting allows for conceptualizing security and sustainability as a deconstructive movement where the logic of a valuebased position contradicts the position being affirmed in this way the different perspectives define the boundaries of the other and as such they also present openings conclusion the three perspectives described in this article reflect on the underlying tensions formed by disparate ideological foundations which condense into questions of what is to be sustained and what or who is to be secured these are critical questions to address especially considering the complex issues the world is currently facing which require a constant renegotiation of what values society wants to promote to seriously address these questions requires a high degree of conceptual flexibility in responding to the intricate mixture of political motives and ethical challenges that arise when probed more deeply the answer to these questions also sets boundaries and openings for how these concepts can be merged the three perspectives of paradox coproduction and deconstruction show that the conceptualization of security and social sustainability motivates different agendas that can inform how future policy is constructed and can be a productive way to sharpen the analysis of how this conceptual relationship might be approached recognizing the dimension of values that underpin these conceptualizations especially by paying attention to fixed and interchangeable components and how normativity and power operate could ease the way for integrating a conceptualization of security to accommodate the values of social sustainability yet as argued in this article the securitysustainability conceptualizations harbor an inherent predisposition that reproduces a hegemonic perception of security leading to a continuous tradeoff arrangement of security and sustainability efforts another point of departure is understanding the perspectives of paradox coproduction and deconstruction as a dynamic interrelation where various aspects can be highlighted in multiple settings this also applies to the wide range of actors approaching the conceptual pair in policymaking who must deal with this complexity when defining the boundaries and openings for conceptualizing security and sustainability applying distinct perspectives as illustrations for disparate ideological standpoints can deepen the knowledge of how multiple and occasionally competing outcomes are formed beyond dominant categories experimentally bringing together concepts questions and controversies can lead the way for opening up discussions of what is taken for granted in a world of everincreasing complexities while inviting us to reconsider the normative foundations on which any inquiry into security responses to societal challenges is based this article has contributed with an analytical tool of illustrative perspectives on how the conceptual relation of security and social sustainability can be approached however to gain a deepened understanding of how this plays out in the real world the perspectives should be empirically studied in actual situations by analyzing how different actors engage in discursive arguments and how this is reflected in world politics

security and sustainability are prioritized goals in the western liberal world maintaining democratic resources while simultaneously strengthening societys ability to deal with security issues firmly resonates with ideals associated with social sustainability however merging normative theories like security and social sustainability produces conceptual difficulties that are hard to resolve based on key literature in this field and policy documents from the un this article uses conceptual analysis to investigate what boundaries and openings three distinct perspectives of the connection between social sustainability and security might produce the perspectives chosen as illustrative tools are paradox coproduction and deconstruction the paradox perspective pronounces inherently divergent qualities of sustainability and security which implies a tradeoff situation in contrast the coproduction perspective views social sustainability as a critical component in security issues while security in turn is a prerequisite for sustainability a third perspective deconstruction highlights underlying processes that produce and prioritize specific meanings the perspectives of paradox coproduction and deconstruction identify how competing values operate in conceptual configurations highlighting the limitations and possibilities of security measures to accommodate values of social sustainability applying distinct approaches as illustrations for disparate ideological standpoints can deepen the knowledge of how multiple and occasionally competing outcomes are formed while considering the normative foundations enfolding inquiries of security responses to societal challenges

introduction considering western culture and its orientation toward appearance young girls and women are susceptible to the desire to be thin so they would achieve an ideal body shape 12 according to the tripartite influence model 3 women internalize idealized thin body shapes from the media which includes traditional mass media and the internet including healthoriented websites exposure to thinideal content can have a negative impact on women because it is associated with their drive for thinness and eating disturbances 45 in this study we focus on the drive for thinness which is motivation for a thin or thinner body and the desire to lose weight 16 it is considered a risk factor for wellbeing because it is associated with decreased psychological health and the later development of anorexia and bulimia nervosa 78 because of its potential harm it is crucial to understand the factors that are associated with the drive for thinness although previous studies investigated the role of the media in relation to the drive for thinness 159 there is a lack of evidence for healthoriented websites and the role they play in promoting weight loss we intend to contribute to this area by focusing on these types of websites within the theoretical framework of the tripartite influence model 3 moreover our aim is to enrich this model which posits sociocultural influences on eating disturbances by including the role of the individual factors associated with the drive for thinness specifically we examine the role of these websites for the perceived online social support neuroticism and internalization and their direct and indirect effects on the drive for thinness as a result our aim is to extend the knowledge about the role of healthrelated websites in the development of eating disorders by showing how and for whom these online spaces pose a risk based on our conclusions we propose recommendations for prevention and intervention efforts drive for thinness and healthoriented websites the drive for thinness is a motivational orientation toward having a thin or thinner body and a desire to lose weight 16 it emerges as a motivated behavior in order to reduce bodyrelated discontent 10 which is manifested by eating restraint and a preoccupation with body shape and weight 11 it is considered a risk factor to womens health because it is associated with decreased psychological wellbeing like body dissatisfaction 10 bodyrelated anxiety 12 lower selfesteem 8 or perceived stress 13 moreover the drive for thinness is one of the diagnostic criteria for anorexia and bulimia nervosa and it is associated with the later development of both 7811 the ideal of thinness 1 the drive for thinness and related eating disorders are more prevalent in women than in men 14 therefore we focused the study on women considering the potential detrimental effects it is important to understand the factors which exacerbate the drive for thinness according to the tripartite influence model 3 there are three main influences on disordered eating parents peers and the media the role of the media has been highly debated in relation to disordered eating in the past two decades substantial attention has been given to the role of new technologies such as social networking sites eatingand exerciserelated websites personal blogs with proeating disorder content and various healthrelated discussion forums 15 we focus on websites related to weight loss nutrition and exercise these websites act as important sources for general online information related to nutrition fitness weight loss and a healthy lifestyle there are plenty of websites that address these topics including personal blogs informational websites for particular healthrelated themes discussion forums and socialnetworking groups 1617 websites can be focused on weight loss body shaping healthy lifestyle eating dieting nutrition plans for specific illnesses recipes and exercising 151819 visitors may go through content read articles make and read comments and obtain advice and inspiration moreover websites can serve as a social environment where people interact with messages comments and evaluations and they are places where people can receive support from other visitors 20 21 22 however these websites can have a negative impact on women because they display content that is associated with the drive for thinness body dissatisfaction and eating disturbances 452324 specifically some of these websites display proed content that suggests that maintaining an eating disorder is a positive lifestyle choice 25 they also contain positive comments about being thin guiltinducing messages related to food stigmatization about weight and expressions of negativity about being fat or overweight they include content related to dieting and eating restraint and the promotion of a thinideal appearance 1826 this appearanceoriented content can have a negative effect on women through the maintenance of weightand appearancerelated concerns 27 the current study focuses on young female visitors of healthoriented websites in the czech republic according to the data from eurostat 28 54 of czech women aged 16 to 29 searched for online healthrelated information in 2016 which is the year when the data for our study was collected the european average during that time was 60 of young women concerning the general usage of the internet 95 of czech women aged 16 to 29 stated that they used the internet in the preceding three months in 2016 whereas the european average was 96 29 this means that the usage of the internet and the online health seeking behavior among czech women is similar as in other european countries internalization the negative effect of the exposure to the appearancerelated online content can be explained with the tripartite influence model which suggests that the link between exposure to media ideals and eating disorders is not direct it proposes that internalization of the appearance ideals serves as a mediating factor interfering association between media effect and disordered eating 30 media impact on disordered eating via internalization as proposed by tripartite influence model was examined and supported by previous studies 31 32 33 34 35 in the context of developing and maintaining eating disturbances internalization is the process of adopting socially and culturally defined norms about body shape which are commonly maintained as body ideals in everyday social interactions and in the media by internalizing these ideals ones conception of self could be affected because the ideals can come to represent personal standards against which one could appraise self and others 34 since the idealized appearance depicted by the media does not always correspond with ones real body shape inconsistencies can emerge between the internalized norm and the actual body internalized ideals and perceived discrepancies can lead to consideration about how to obtain this ideal body 1 this in turn results in disordered eating several studies investigated specifically drive for thinness and how it is related to internalized appearance ideals in adolescent girls and young adult women internalization is a significant factor associated with the drive for thinness in both categories 18153536 moreover the mediational role of internalization in the association between media exposure and the drive for thinness was supported 1535 however less attention has been given to the individual factors which may be salient in this process and help explain who is susceptible to internalize media content therefore in this study we focus on two factors online social support and neuroticism online social support research has shown that seeking support from others is a frequent motivation for using healthoriented websites and participating in healthrelated online groups 37 38 39 the online space offers various ways to get in touch with others so there are also diverse ways to seek help and receive support social support which in this context is mostly provided as emotional support is expressed through emotions empathy and as informational support like sharing knowledge regarding eating or fitness activities 2140 online social support has been investigated as an important factor among people who struggle with eating disorders for instance women who engaged in an internet weight loss community mentioned encouragement motivation information and shared experiences as significant resources they appreciated the accessibility the anonymity and the nonjudgmental interactions as unique characteristics of internetmediated support 21 moreover examinations of ed discussion forums and edoriented support groups have revealed that these online sites provide relevant information emotional support personal disclosure help friendship peer support and a safe space to ventilate feelings 20223941 though receiving social support is in many occasions a very beneficial process we also examine its potential for the reinforcement of the drive for thinness via increased internalization this process can be described with two theories social identity theory which refers to an individuals knowledge of belonging and the perceived emotional and value significance of group membership 42 and the selfcategorization theory 4344 which depicts how membership in social groups affects an individuals behavior social identity refers to an individuals knowledge of belonging and perceived emotional and value significance of group membership 42 social identity can act as the basis for both giving and receiving social support perceived social support can additionally promote the sense of shared identity and the subjective importance of ones group membership 19424546 subsequently social identity and group membership are associated with the internalization of group norms the norms and attitudes shared within the group are internalized as personal standards and the individuals act accordingly 47 on websites related to weight loss nutrition and exercise users share bodyappearance standards which are demonstrated by the website content and have discussions about ideal appearance and figure 18 with these shared interests the goals the mutual interaction and the social support that are exchanged among visitors the websites have a social character thus consistent with the social identity theory approach the perceived social support from the healthoriented websites can promote a sense of shared social identity and the perception of salience within the website group membership consequently norms and standards regarding body appearance can be internalized even more neuroticism neuroticism is defined in terms of the inclination to emotional reactivity instability perceived anxiety and high vulnerability when coping with stress 334849 individuals who are high in neuroticism are excitable easily upset and prone to experiences that are unpleasant 50 they are also more sensitive to criticism they experience higher levels of rejection and they have lower selfesteem 51 in prior research neuroticism has been connected to the increased drive for thinness in women 5253 to heightened food and body preoccupation 54 to body dissatisfaction 55 to the selfregulation of eating attitudes 56 and even to eating disorder diagnosis 4857 and binge eating 5859 according to fischer schreyer coughlin redgrave and guarda 52 the facets of neuroticism including irritability and difficulty with emotional regulation are risk factors for developing an ed moreover disordered eating is associated with neuroticism because it can serve as a coping mechanism with which neurotic individuals deal with negative feelings 5860 in this study we examine neuroticism as a risk factor for increased internalization which can lead to a stronger drive for thinness the link was proposed by scoffiermériaux et al 56 who hypothesized internalization as a mediator between neuroticism and unhealthy dieting behavior this model was subsequently tested by martin and racine 49 who examined the mediating roles of thin and athleticideal internalization in association between neuroticism body dissatisfaction and compulsive exercise using the sample of 531 college students aged 1844 they found that thinideal internalization mediated the link between neuroticism and body dissatisfaction and the internalization of athletic ideals mediated the effect of neuroticism on compulsive exercise moreover several prior studies have found that neuroticism is associated with higher internalization 49505661 to explain this link roberts and good 50 suggest that women with increased neuroticism compare themselves to attractive people and this comparison is more likely to result in negativity due to their emotional liability this negative effect which arises from the incongruity between the internalized body ideal and the actual body shape can result in an increased drive for thinness as has been proposed by previous studies 5253 therefore we hypothesize that internalization may be a mechanism through which neuroticism is positively linked to the drive for thinness in women research goals this study focuses on the drive for thinness which is considered a risk for womens wellbeing it aims to enhance our understanding of the risk factors that contribute to its development specifically with regard to the influence of media and the role of individual factors in young women previous studies have shown that the media can have a negative effect on women because exposure to its content is associated with their desire to have a thin body shape 159 however these studies mainly investigated traditional media and proeatingdisorder websites there is a lack of research in healthoriented websites which are currently popular these websites display content that is associated with the drive for thinness body dissatisfaction and eating disturbances 452324 therefore our aim is to fill this gap and bring more insight into the association between visiting healthrelated websites and the drive for thinness among women furthermore our study aims to enrich the tripartite influence model 3 which is the theoretical framework that explains eating disturbances with sociocultural factors by incorporating neuroticism and perceived social support as individual factors specifically we test whether web content internalization mediates the effect of these factors we propose that increased neuroticism and perceived online social support positively affects web content internalization which in turn affects the drive for thinness considering that disordered eating can be related to age and body mass index 62 63 64 we also control for both of these factors materials and methods study sample this study uses data from a project which focused on the visitors of websites oriented toward nutrition weight loss and exercise the data were collected through an online survey between may and october 2016 participants were recruited with an invitation on 65 czech websites web magazines social networking sites blogs and discussion forums that focused on weight loss diet eating habits and exercise the original sample comprised of 1002 respondents the project was approved by the research ethics committee of the university the current study focuses on a subsample of 445 young adult women aged 18 to 29 because the ideal of thinness is aimed mainly at women 1 and the drive for thinness and eating disorders are more prevalent in women 14 we focused on women in our study moreover young adult women were the major part of the healthoriented website visitors in the project and we did not have a sufficient amount of data from participants of other ages and genders the original sample of women in the age range from 18 to 29 comprised of 632 participants we excluded respondents based on their motivation for visiting healthoriented websites and because of missing data we excluded women who reported that the reason for their website visits was because of the health issues of someone else in addition participants with a substantial number of missing values for the key variables were excluded and there were no significant age differences between our sample and excluded respondents measures perceived online social support perceived online social support was assessed using three items adapted from graham papandonatos kang moreno and abrams 65 i get advice and support here that i would not get elsewhere it is encouraging to know that there are other people making similar efforts and i feel that other visitors of sites are giving me support with answers that ranged from 1 definitely does not apply to 4 definitely applies a higher score indicated higher perceived support the internal consistency was acceptable neuroticism we measured neuroticism with three items from the short 15item big five inventory 66 the items were i worry a lot i get nervous easily and i remain calm in tense situations participants answered on a sixpoint scale that ranged from 1 does not apply to 6 definitely applies a higher score indicated higher neuroticism the internal consistency was acceptable web content internalization internalization was measured using the question to what extent do the following statements apply to you in regards to these sites with three items that were adapted from cusumano and thompson 67 i compare my appearance with people on these sites i try to look like the people on these sites and the content on these sites inspires me in how to look attractive participants answered on a sixpoint scale that ranged from 1 does not apply to 6 definitely applies a higher score indicated higher web content internalization the internal consistency was satisfactory drive for thinness the drive for thinness subscale from eating disorder inventory3 68 was used the scale consisted of seven items participants responded on a sixpoint scale that ranged from 1 never to 6 always a higher score indicated a higher drive for thinness the internal consistency was satisfactory the latent variable was constructed with the parceling approach specifically we made three parcels combining lowloading and highloading items 69 parcels were computed as a mean of the items bmi participants provided information about their current weight and height bmi was computed as follows weight height 2 results we examined the correlations among the variables perceived online social support neuroticism web content internalization and the drive for thinness the results were as expected the drive for thinness was positively correlated with online social support web content internalization and neuroticism web content internalization was positively associated with online social support and neuroticism additionally the drive for thinness was positively associated with bmi but not with age to test our presumptions structural equation modeling was used with a robust maximum likelihood estimator we used r software and lavaan semtools and semplot packages we tested a model with indirect effects predicting drive for thinness we included neuroticism and online social support as predictors the web content internalization as a mediator of the effect of neuroticism and social support and age and bmi as controls the model had an acceptable fit cfi 098 tli 097 rmsea 004 results are displayed in figure 1 and table 2 perceived online social support from healthoriented websites predicted web content internalization perceived online social support did not have a strong direct effect on the drive for thinness though the effect was weak and marginally significant moreover we found a significant indirect effect for online social support on the drive for thinness via web content internalization neuroticism predicted web content internalization and it had a direct effect on the drive for thinness moreover we found a significant indirect effect for neuroticism on the drive for thinness through web content internalization therefore the link between neuroticism and the drive for thinness was partially mediated by the web content internalization regarding controls bmi positively predicted the drive for thinness but there was no association between age and the drive for thinness discussion in our study we examined the factors associated with the drive for thinness in young adult women who visited websites oriented toward weight loss nutrition and exercise specifically we investigated the perceived online social support of other website visitors the neuroticism and the web content internalization of the body appearance standards and their direct and indirect effects on the drive for thinness our objective was to investigate whether the web content internalization mediates the links among the perceived online social support the neuroticism and the drive for perceived online social support from healthoriented websites predicted web content internalization perceived online social support did not have a strong direct effect on the drive for thinness though the effect was weak and marginally significant moreover we found a significant indirect effect for online social support on the drive for thinness via web content internalization neuroticism predicted web content internalization and it had a direct effect on the drive for thinness moreover we found a significant indirect effect for neuroticism on the drive for thinness through web content internalization therefore the link between neuroticism and the drive for thinness was partially mediated by the web content internalization regarding controls bmi positively predicted the drive for thinness but there was no association between age and the drive for thinness discussion in our study we examined the factors associated with the drive for thinness in young adult women who visited websites oriented toward weight loss nutrition and exercise specifically we investigated the perceived online social support of other website visitors the neuroticism and the web content internalization of the body appearance standards and their direct and indirect effects on the drive for thinness our objective was to investigate whether the web content internalization mediates the links among the perceived online social support the neuroticism and the drive for thinness we found support for our presumption both online support and neuroticism were positively linked with the tendency for internalization which in turn increased the drive for thinness in our data we found a substantial connection between internalization and the drive for thinness our findings are in line with the tripartite influence model 3 31 32 33 which suggests that body image concerns and eating disorders are affected by sociocultural factors and indirectly through the internalization of the medialized body ideals moreover we enriched the propositions of the tripartite influence model 3 by including individual factors this line of research was recently developed in studies that focused on perfectionism selfesteem depression and anxiety 30 31 32 33 34 70 this focus helps to better understand the risk factors which strengthen the tendency for internalization specifically we found that perceived support increased the drive for thinness via its reinforcement of internalization our findings correspond to knowledge regarding ed online groups in which perceived support was connected to a higher sense of belonging and the acceptance of thinideal norms 20223971 ed online groups and communities act as an important source of support that can be difficult to obtain elsewhere for individuals who struggle with ed and body image concerns 3941 however support received from these online groups can be detrimental to womens health because it endorses negative attitudes toward their bodies and promotes extremely thin body shapes as attainable standards haas et al 72 examined the social support on proanorexia websites and discovered that visitors received support for eating restraint and reinforcement for their negative views of themselves and their bodies sowles et al 73 pointed out that members of the proed online community disseminate images that depict thin body shapes and promote the thin ideal by labeling them as their desired goals similar findings emerged from a study by marcus 40 who found that members of a proanorexic community shared photos of extremely thin bodies to motivate users to maintain their diets and to outline the beauty standards of the group in this manner women are encouraged to adopt body appearance standards that lead to a desire for a thin body the findings of our study suggest that these processes apply not only to ed online groups but to healthrelated websites as well healthoriented websites with their opportunities for social interaction enable visitors to receive social support the perceived social support is associated with the acceptance of group norms due to the higher subjective salience of the social group to which the individuals belong 404447 in line with social identity theory 44 the stronger identification with a group would result in the acceptance of group norms and in the case of websites focusing on nutrition and fitnessthese probably supported the thin and fitnessoriented images of the ideal body thus though the perceived support is often seen as a positive aspect of online interaction in these instances it may result in negative outcomes however when interpreting these results the limitations of this study should be taken into consideration due to the correlational nature of the data used it was not possible to draw causal conclusions thus the association between online social support and the drive for thinness may work in the opposite direction meaning that women with a stronger drive for thinness may more often seek social support for their goals and efforts in the online space and specifically via healthoriented websites moreover this finding should also be compared to the results for the direct effect of support on the drive for thinness this effect was rather weak and just marginally significant however it may indicate that the role of support is diverse if we disentangle the indirect effect that positively affects the drive for thinness from the direct effect we find that support negatively affected the drive for thinness to interpret this finding we should acknowledge that perceived support helps to increase overall wellbeing 74 75 76 which decreases the tendency for unhealthy and disordered eating habits 7778 thus perceived online social support can actually function as both a risk and a protective factor on one hand it may contribute to the development of the drive for thinness via increased internalization on the other hand it may also serve as a buffer for this negative effect probably via the increase of overall wellbeing which was not included in this study this presumption could be pursued in future examinations thus we still need to consider other factors which underlie the internalization of the web content our study focused on neuroticism which showed to be positively linked to the drive for thinness and also had an indirect effect via internalization therefore the effect of neuroticism on womens drive for thinness was partially mediated by the internalization of the body appearance standards displayed on healthoriented websites in line with prior studies 495052535661 our findings showed that people with heightened neuroticism are more prone to accepting the norms and probably because of the increased tendency for social comparison tend more to strive to be thin however besides the mediated effect we also found a direct positive link to the drive for thinness this suggests that increased internalization is not the only mechanism through which people with neurotic traits can be more at risk however considering that we found support for the tendency for heightened internalization from the websites and upon the propositions of the tripartite influence model 3 we could expect that the mechanism could be similar in relation to parental and peer norms which have not been measured in this study this poses one of the limitations for our study concerning other limitations it should be stressed that we used crosssectional correlational data based on a sample that was selfselected through healthoriented websites thus though we examined the proposed model for the mechanisms to increase the drive for thinness the research design complicates drawing causal conclusions future research should implement a longitudinal research design to make more reliable causal conclusions and to capture potential reciprocal associations moreover we were not able to control for the effects of additional variables on the drive for thinness these are factors 79 that are related to the drive for thinness and disordered eating and it would be appropriate to control for their effects to obtain more accurate results furthermore we do not have information about the specific content that respondents encountered it would be useful to incorporate objective measures and directly observe the effects of participants exposure to online content finally although the thin ideal displayed in the media and the related drive for thinness is more prominent in women 1 future research could focus on men their internalization of the body appearance norms and their motivations for body change in the current study our aim was to propound a model that comprises of the individual factors that affect womens drive for thinness based on our findings we can formulate several implications according to the theory and the available data we propose the following processes online social support from the visitors of healthoriented websites and neuroticism affect the drive for thinness and these links are mediated by the internalization of body appearance standards thus alongside previous research in this area 18153536 our study supported the predictive role of internalization in the drive for thinness among women specifically our study provided insight into the internalization of the content of healthoriented websites which had not been sufficiently investigated and had not been taken into account in relation to womens drive for thinness our results imply that it is crucial to acknowledge healthoriented websites and their potential impact on women especially in the context of the internalization of body appearance norms healthoriented websites which are not generally acknowledged as harmful to womens body image can be a significant source of body appearance norms and subsequent body image concerns 18 as was discovered in the current study women internalize body ideals from healthoriented websites and this in turn increases their drive for thinness this connection should be actively acknowledged by healthcare professionals it is important for professionals to ask their clients who have edrelated problems about their technology usage and to provide them with space to talk about it 80 thus in the context of the current study healthcare professional should discuss with clients who are struggling with eds their usage of healthoriented websites specifically with a focus on their exposure to the thinor fitnessideal content we also showed that both online support and neuroticism present risk factors because they can increase the tendency for internalization and in turn increase the drive for thinness therefore it is important to be aware of the possible negative effect that online social support may have on women and to address it when preventing or reducing the drive for thinness however the findings of this study showed that online social support can function both as a risk and a protective factor thus when discussing the use of healthoriented websites with ed clients it is important to disentangle the different forms of social support that women receive from the visitors of these platforms in addition neurotic individuals experience higher levels of negative emotions and stress which makes them more susceptible 5253 based on our results we suggest that preventive health programs intervention individual psychotherapy counseling and other health policies can be focused on the reduction of the negative emotions and stress in women these can also help the reduction of the internalization of the body appearance standards promoted on healthoriented websites conclusions this study focused on the factors associated with the drive for thinness in young adult women who visited weight loss nutrition and exercise websites these platforms are currently of high use yet they have not been sufficiently studied in relation to eating disturbances we examined the direct and indirect effects of perceived online social support from fellow website visitors neuroticism and the web content internalization of the body appearance standards on the drive for thinness our findings supported the predictive role of web content internalization on the drive for thinness in women moreover we showed that the perceived online support from the healthoriented websites and neuroticism can pose risk factors because they are associated with a higher tendency for internalization and in turn with a stronger drive for thinness our results indicate that it is crucial to acknowledge healthoriented websites and their potential impact on women and their drive for thinness especially in the context of the internalization of body appearance standards we also discuss the role of social support and its double role of risk and protection our findings can be used to establish prevention and intervention efforts to help individuals who struggle with body image and eating disturbances author contributions writingoriginal draft preparation nk writingreview and editing nk hm and ds supervision hm and ds project administration hm and ds formal analysis nk all authors have read and agreed to the published version of the manuscript

one of the debates about media usage is the potential harmful effect that it has on body image and related eating disturbances because of its representations of the ideal body this study focuses on the drive for thinness among the visitors of various healthoriented websites and online platforms because neither has yet been sufficiently studied in this context specifically this study aims to bring more insight to the risk factors which can increase the drive for thinness in the users of these websites we tested the presumption that web content internalization is a key factor in this process and we considered the effects of selected individual factors specifically the perceived online social support and neuroticism we utilized survey data from 445 czech women aged 1829 m 235 sd 31 who visited nutrition weight loss and exercise websites the results showed a positive indirect link between both perceived online social support and neuroticism to the drive for thinness via web content internalization the results are discussed with regard to the dual role of online support as both risk and protective factor moreover we consider the practical implications for eating behavior and weightrelated problems with regard to prevention and intervention

introduction today tourism has been named as the fastest growing economic sector and the largest income generation that is relied upon as the spearhead of the economies of various countries in the world tourism is able to be a driving generator for the growth of other industrial sectors such as hospitality communication and transportation trade souvenirs culinary etc tourism also acts as a reactor for development in various regions through the provision of jobs income from foreign exchange strategic markets for potential local products support for equitable distribution of infrastructure development and improvement of quality of life in various regions an ideal tourism is tourism that is able to synergize three core stakeholders unnes journals of tourism to move together which consists of society government and the private sector between the three stakeholders the community has enormous urgency that is expected to contribute to the development of tourism the community is the party who owns tourism resources in the form of attraction which includes aspects of something to see something to do and something to buy amenities and accessibility the society with all its sociocultural aspects is also a tourist attraction and has a major contribution in realizing sapta pesona wisata reflecting on the conditions above it is better for the community to not only to be placed as a tourist attraction but also to be empowered as a tourist subject through involvement in all stages and dimensions of tourism development the community as the owner of various tourism resources should not be colonized in their own country because the developed tourism is still controlled by exploitative and capitalist capital owners the community is also a party that directly or indirectly feels the positive and negative impacts of tourism so that community participation is crucial in order to ensure the sustainability of tourism and economic resources to realize tourism that is driven from the community by the community and for the community a strong social capital is very much needed it could increase community cohesiveness social capital is a collection of actual and potential resources related to ownership of a longlasting network of mutually beneficial interaction relationships that are institutionalized and are formed from norms and beliefs social capital is defined as a set of informal values and norms that are shared between community members who support cooperation between them social capital is a factor that connects community members who can promote efficient coordination and cohesiveness between communities in tourism development social capital relates to values and norms goodwill trust networks cooperation social relations and empathy among individuals who are able to form and drive a social unit the high social capital in the tourist destination community will be linear with the high welfare of the community so that the improvement in the quality and strength of social capital is the main key in increasing the communitybased tourism therefore a comprehensive study of the strength of social capital in tourism destination communities has enormous urgency this is undeniable because of the crucial knowledge of the strength of social capital as a reference for the community and stakeholders in planning and evaluating tourism development in order to achieve public welfare several studies have proven the strength of social capital as the main mechanism that encourages and attracts people to participate and move together in reviving tourism in their area some of these studies include research from pongponrat and chantradian borlido and coromina kusuma satria and ana manzilati puspitaningrum andlubis moscardo et al birendra kc etal kencana andmertha baksh et al and musavengane and mutikiti social capital also contributes in realizing sustainable tourism as described in the study of liu et al maruf handayani andummudiyah sunkar meilani andmuntasib andoktadiyani muntasib andsunkar based on these studies social capital has a crucial role in the success of tourism development in various regions one area of tourism that has great urgency in strengthening social capital is the karimunjawa area this condition is motivated by the status of karimunjawa which is a leading tourism destination with abundant natural potential that is excellent for marine unnes journals tourism lovers and also as a national park area that must be preserved according to the decree of the minister of forestry and plantation no 78kptsii1999 therefore tourism development in karimunjawa should be directed towards sustainable communitybased tourism development so that the social capital charging is very necessary this is also motivated by the demographic and sociocultural conditions of the karimunjawa community which is a multicultural area consisting of javanese madura bugis bajau and other tribes this study intended to analyze the integration of social capital in the development of sustainable marine tourism to improve the economic strength of karimunjawa community method this research was conducted in the karimunjawa national park area this research was conducted using a qualitative approach the selection of a qualitative approach is motivated by the purpose of research which is to understand the phenomenon of social interaction from the other side of the institutions that occur in karimunjawa society in depth this is because qualitative research is not only able to describe the surface of a large sample in the population but also able to explore a deep understanding of organizations or special events so that they will be able to capture the meaning of each actors perceptions attitudes and actions in the field this research uses primary and secondary data sources primary data is obtained through field studies while secondary data is obtained through written literature review which can be in the form of scientific journal articles books archival documents statistical data and data from the karimunjawa national park office the research subjects consisted of the general public and tourism practitioners in karimunjawa the management of the karimunjawa national park office tourists the government and ngos tourism stakeholder in karimunjawa the research sample was determined by the snowball sampling method data collection is done by indepth interviews participatory observation and documentation the data analysis was carried out by the interactive method according to milles and hubermans theory this analysis method consists of three main stages namely the process of data reduction data presentation and conclusions drawing furthermore interpretation is held namely by explaining the symptoms that exist and looking for the relationship between the symptoms that have been found in the field result and discussion the overview of the karimunjawa region karimunjawa islands are located in the northwest of the capital city of jepara regency it is separated by a stretch of the java sea the average height of land in the karimujawa islands is between 10100 meters above the sea level the distance from karimunjawa subdistrict to the capital of jepara regency is 90 km astronomically karimunjawa subdistrict is located between 5o499 to 5o819 south longitude and between 110o2732 to 110o4589 east longitude the karimunjawa islands consist of 27 islands which are all part of the karimunjawa national park area administratively it is the part of the karimunjawa subdistrict jepara regency central java province the tourism conditions in karimunjawa tourism activities in karimunjawa have been started since 2006 and are still running today the number of tourists visiting karimunjawa is increasingly linear with the increasing popularity of karimunjawa tourist destinations that offer amazing natural marine beauty tourism activities in karimunjawa consist of land tour activities carried out by exploring tourist destinations on land and on the coastline along karimunjawa and other sea tour in the form of snorkeling and crossing the ocean to small islands in the karimunjawa islands as the time passed by from year to year the development of tourism in karimunjawa is increasingly moving towards the final progress this condition is supported by the increasing of public awareness and participation in reviving tourism activities in karimunjawa the supporting facility from the government especially the electricity network greatly impacts the progress of tourism in karimunjawa moreover it coupled with the increasing sea crossing transportation services that facilitate the accessibility to karimunjawa the more advanced the existing tourism linear with an increase in the number of tourists who come to karimunjawa which can be seen in the table 2 the tourism activities in karimunjawa run and develop through tourism groups in the region the tourism actors consist of the government private sector nongovernmental organizations and the one who have the largest contribution is the local community as a tourist who supports the running of tourism in karimunjawa tourists in karimunjawa belong to the communities formed by the initiation of a community that is aware of the tourism potential social capital in tourism social capital is a network of cooperation in society that could act as a lubricant that facilitates collective action in achieving the goals social capital has several elements as the main foundation which differ from one expert to another however the majority of experts agree that the elements of social capital generally consists of confidence norm and the network in addition to these three elements there are other expert opinions that include elements of reciprocity cooperation social interaction collective action empathy and tolerance from exposure to the stretcher we can draw a common thread that element of social capital consists of three main founda unnes journals tions in the form of a network as input norms and beliefs as input and also output and concerted action as output these three elements are cyclical processes that are interconnected and influence each other strengthening social capital in tourism development can be initiated through an analysis of the actual potential of social capital in a tourist destination community in this study to analyze the actual potential of social capital in karimunjawa it was conducted using theories from giron vanneste to assess social capital giron vanneste collaborate on two factor domains namely the first factor with a focus on the key dimensions seen as dynamic processes and the second factor with a focus on the level of social capital coverage in the structure of tourist destination the first factor to focus on key dimensions of social capital contains three key dimensions consisting of networks norms and beliefs and action these three elements are used as the foundation of the framework in analyzing the dynamic process of social capital as a dynamic process the three elements of social capital are an integrated system with specific functions that are interdependent in the second factor with a focus on the level of social capital coverage in the structure of tourist destinations some experts agree that the level of social capital consists of bonding social capital and bridging social capital but there are also experts who complement the third level namely social linking capital bonding social capital emphasizes horizontal social ties bridging social capital emphasizes horizontal social ties with new groups or actors while linking social capital emphasizes vertical social ties with groups that have power or who have control over the key resources the two factors of social capital are then combined to obtain a more organized and more connected method of social capi tal assessment with this combination we can analyze the actors involved supporters and obstacles to their relationship at various levels in the tourist area the combination provides a platform to reflect on how to increase the collective capacity of tourist destinations to get a more detailed picture of the framework for assessing social capital that has been prepared the writer provides figure 1 the dimensions of social capital in tourism in karimunjawa network the form of social networks in tourism in karimunjawa is the existence of tourism actors in karimunjawa that have been organized and interdependent with each other in karimunjawa there are several patterns and levels of networks formed in tourism activities the smallest network pattern formed is a family or kinship network pattern this network pattern integrates individuals with equality of blood relations in society this network is not official or formal but has a strong connective and able to strengthen cooperation between individuals because it is based on conscience and equality of blood relations this network can be formed by the desire of family members to make ends meet by looking at the tourism potential in karimunjawa and then moving together in the family tourism business the next network pattern is in the form of a neighbor network and a network of close friends this network pattern integrates individuals who have a close location of residence or individuals with friendships that have existed for a long time this network was born and formed because it is supported by the territory of karimunjawa which is not too broad with a population that is not too dense making it easier for individuals to get to know interact and cooperate as is the case with kinship networks this network is not formal and can develop dynamically the next network pattern is a network formed by the initiation of a group of people with similar interests and shared goals this network is more formal than family networks and networks of friends and neighbors this network takes the form of associations communities or groups of tourism actors in karimunjawa this network can move in the economic social educational cultural or environmental fields which can be made up of members of the general public nongovernmental organizations or within the scope of government networks that have an interest in activating tourism in the economic sector in karimunjawa include 1 the community of homestay owner 2 the ship owner community 3 tour package sellers or travel agents 4 motorcycle rental owners 5 car rental group and shuttle service 6 souvenir and culinary merchants association 7 merchants association 8 airport car pickup group 9 indonesian tour guide association as tour guide 10 karimunjawa typical souvenir entrepreneur and 11 entrepreneurs for snorkeling equipment rental those engaged in the sociocultural sector including the dance group in kemojan village and the arts group in karimunjawa the networks were born and developed in the midst of the community from the community by the community and for the community in addition to these social networks there are also social networks in the form of community groups engaged in the environment including the pitulikur pulo karimunjawa foundation karimunjawa community forestry partners karimunjawa supervisory groups karimunjawa and the segoro karimunjawa society in addition there is also the wildlife conservation society which is a nongovernmental organization that is active in several areas with the main mission of educating the community to always preserve the environment one of which is in karimunjawa in addition at the government level social networks are also formed at the national and village level the government as a tourism stakeholder consists of the jepara regency tourism office the central java unnes journals province tourism office the karimunjawa national park office the transportation office the karimunjawa district government the karimunjawa village government and the kemojan village as well as the government institutions under it in addition to the government networks are also formed between the public and the private sector namely with various entrepreneurs who have businesses in tourism in karimunjawa for example small island managers in karimunjawa travel agents from outside karimunjawa resort owners and managers in several tourist attractions in karimunjawa norms and trusts norms and trust have a crucial role in strengthening social capital some norms that are still thick flowing in the pulse of the people of karimunjawa include friendly attitude and mutual harmony among the community being friendly and being friendly is one of the important assets that can integrate the multicultural karimunjawa community in fact the same feeling as a newcomer in karimunjawa helped increase harmony between communities this attitude encourages people to get to know each other and establish intense interactions so as to give birth to feelings of solidarity the friendly and mutual attitude is not only applied to fellow karimunjawa people but also to all tourists who come to karimunjawa so that they are able to build a sense of comfort in themselves the second norm is related to family attitudes and brotherhood between communities this family value is very closely motivated by the condition of the karimunjawa region which is a remote area with not too large an area and the population is not too much this condition causes the majority of karimunjawa people to be born from the same ancestors so that they have blood relations moreover coupled with the process of amalgamation between karimunjawa communities consisting of various community backgrounds the familial ties become wider and stronger this sense of kinship is then able to facilitate the creation of social networks in the form of a family business union that drives tourism in karimunjawa the next norm that becomes the foundation of social capital strengthening karimunjawa community is about the concept of sharing in everyday life various attitudes are not only implemented in the realm of the family but also in the life of the wider community the development of this sense of sharing is effective in strengthening cooperation between communities because it is driven by the perception of reciprocity in the future mutual attitude can be a lubricant for intercommunity cooperation in tourism activities which are realized in the form of business partnerships work teams and subordinates social norms become a pillar for the solid social capital in karimunjawa which in turn is a relief in the people of karimunjawa who can accept whatever happens to them or that they obtain sincerely sincerely and willingly relief attitude implemented by the community is based on the belief that the task of humans is to try with all their strength and fortune that everyone has been guaranteed by god almighty these values of relief are able to move the community to continue to help each other and cooperate sincerely the value of relief is a motivation for the community to maintain good relations with business partners or superiors for example relating to profit sharing in business and also the provision of salary at work the values of relief are also able to motivate people to strike a balance between cooperation and competition in business this returns to the existence of public trust regarding the guarantee of fortune by god almighty that way the community can work together without any stereotypes with business opponents who can instead be partnered with business partners to build broader relations the values of relief are also able to encourage people to become individuals who are open minded and open heart so they are willing to share and cooperate with others religious values are still rooted in the hearts of the people of karimunjawa these unnes journals values of religiosity also encourage people to always maintain good relations with others so that they contribute in strengthening the community solidarity and cooperation religious values also build community perception to jointly realize karimunjawa tourism which prioritizes the preservation of cultural values and local wisdom the next social norm is the values of love for hometown this value is able to move the community to unite and work together to advance tourism in karimunjawa although karimunjawa consists of people from various regional and ethnic backgrounds the value of love for karimunjawa is very high based on the similarity of fate as migrants a sense of love and pride in the hometown allows the community to work together to solve various problems faced it also could prevent the intervention of tourism actors from outside karimunjawa who are not responsible so that it can still be controlled by the local community the feeling of love for hometown is also a driving force for the birth of caring for the environment in the community this sense of environmental awareness is realized through various groups engaged in the field of environmental conservation in karimunjawa the value of environmental awareness is based on the awareness of the people who depend their lives on nature namely the sea and beaches as the main base for marine tourism and the terrestrial environment as a location for daily living the community realizes that the sea is their fortune field so they must maintain their harmony to ensure the sustainability of their economic life the strong norms in the midst of society are also supported by mutual trust between the people of karimunjawa at the local community level trust becomes the glue of effective relationships between communities that strengthen their collaboration mutual trust between communities becomes an amplifier of solidarity and perpetuates the relationship of cooperation in the tourism business circle in karimunjawa both between business opponents between business partners superiors and subordinates and between subordinates and superiors this condition is proven by the strength of the cooperative climate compared to the competitive climate among the community of karimunjawa tourism actors collective actions the existence of social networks that are formed and norms and beliefs that are internalized and implemented by the people of karimunjawa then produce collective actions as outputs collective actions are in the form of cooperation between individuals and groups of tourism actors in advancing tourism activities in karimunjawa in a family or kinship network collective actions can be seen through the efforts of family members who work together in bringing businesses to life as providers of home stays vehicle rentals and tour leaders or travel agents in this familywide business family members coordinate with each other and have different job descriptions for example it is part of the promotion of tourism services whether it be sea and land tour packages home stay rentals vehicle rentals or other services then there are also those who have the duty to provide services in marine and land tour activities both related to transportation accommodation or tour guides in networks of neighbors and friends collective actions are reflected in the efforts of individuals or groups of tourism actors to promote the services of friends or neighbors they work together to promote home stay services vehicle rental tour packages boat rental merchandise and tour guides aside from being beneficial in promotion it is also effective in helping spread information on tourist services for tourists collective actions then occur in every community of tourism actors among the members of the association work together to achieve the goal of which is in the service of tourists in the field where the members of the community will work together to achieve tourist satisfaction then they also cooperate in the promotion of tourism services to get clients in the circle of friends the values of sharing are highly valued so that members can mutually guarantee that other members also unnes journals get jobs in each community all members participate in planning implementation internal evaluation problem solving and policymaking activities including pricing policies and operational standards for tourism services in addition in every community there is also a cash system that must be paid by each member for the purposes of group progress the existence of limited potential in each community of tourism actors then encourages cooperation and realizes collective actions between communities they work together in providing services to tourists because they will not be able to serve their own tours between communities are bound by a sense of mutual need and interdependence so that they are able to move together then the similarity of needs is strengthened by the norms and trust that grows between the associations in addition to tourism service activities in the field collaboration between communities is also manifested in the determination of policies for example the determination of policies regarding the system and operational standards for the administration and service of travel tours in karimunjawa pricing policies or related to tourism promotion activities and cultural events as a manifestation of the values of relief from the people of karimunjawa they are also willing to collaborate with various entrepreneurs who come from outside karimunjawa such as small island managers in karimunjawaagents travel from outside karimunjawaowners resort and managers in several attractions in karimunjawa the community synergizes with entrepreneurs in improving services and tourist attractions in karimunjawa not infrequently these entrepreneurs also provide financial support in various cultural events in karimunjawa to increase tourism promotion however in its relations with entrepreneurs from outside there are still many people who consider entrepreneurs with large capital as heavy rivals so that many people are stereotyped towards entrepreneurs this condition is motivated by peoples dissatisfaction with entrepreneurs and the striking difference in their social strata from entrepreneurs this problem is triggered by the presence of several entrepreneurs who are less able to embrace and hold the community in running a tourism business so that a harmonious relationship between outside entrepreneurs and the community cannot be achieved however so far the community can still go hand in hand with outside businessmen without conflict because the community believes that fortune is something that is guaranteed by god in addition to fellow tourism actors in running the tourism business the association of tourism actors also collaborates with various other groups in the environmental field one of which is the wildlife corservation society in addition to conducting education the wildlife corservation society often collaborates with tourism actors to conduct environmental conservation activities in the karimunjawa area both at sea and on land concrete activities include cleaning the beach the sea planting trees and others in this activity they also collaborated with the environmental groups in karimunjawa namely the pitulikur pulo karimunjawa foundation karimunjawa community forestry partners the karimunjawa community monitoring group and the segoro karimunjawa society collective actions are also manifested in collaboration between the karimunjawa community and the government the government through the karimunjawa national park office works in synergy with the community and all tourism actors and organizations engaged in the environment working together to preserve nature and the environment karimunjawa besides the karimunjawa national park office the community also collaborates with the karimunjawa district government and the village government the jepara regency tourism office the central java province tourism office and the regional planning and development agency this synergy is manifested in tourism promotion activities in karimunjawa such as cultural events or festivals and also in the form of support unnes journals from government facilities to support tourism activities in karimunjawa it also manifested in a number of training and outreach activities to increase the soft skills of tourism operators in karimunjawa however so far the synergy of the community with the department of tourism is still not optimal this is due to the lack of the role of the tourism office in providing assistance and infrastructure support for the tourism community this problem causes the community to have low trust in the department of tourism in addition people also have low trust with the department of transportation this condition is motivated by the still not optimal policies and services from the department of transportation in providing crossing transportation for the public and for tourists this is because the effectiveness of crossings is a crucial requirement to facilitate the mobility of people who want to go home and go to karimunjawa and also has a big impact on increasing the quantity of tourists entering karimunjawa the level of social capital in karimunjawa the level of social capital formed in each tourist destination is certainly different there are tourist destinations in which only one level of social capital is formed but there are also tourist destinations in which can form two to three levels of social capital at once as a fairly complex tourist destination with various actors in it karimunjawa formed three levels of social capital at the same time the three of them support each other it consists of bonding social capital social bridging capital and social linking capital first social capital bonding in karimunjawa is formed by a family or kinship network and a network formed in the membership of various groups of tourism actors in karimunjawa in this social capital bonding the values of kinship and the value of brotherhood and sharing are deeply held by the community in social capital bonding every network in karimunjawa has an inward orientation with very high collective values has a relatively small number of groups has the same background namely the same family or the same work domain and is based on mechanical solidarity in this social capital building family networks family members feel safe feel facilitated and have a high level of care as well as with members in each community of tourism actors secondly as a consequence of differences in potential then organic solidarity is born among the community of tourism actors in karimunjawa it formed strong social bridging capital the bridging social capital formed in karimunjawa is able to unite various groups of tourism actors to work together in providing services to tourists it is the collaboration between the community of tourism actors that enlivens tourism in karimunjawa because of their complementary characteristics for example tour activities will not be held if there are only groups of ships and without involving tour guides it also applies to other groups of tour operators in addition social capital bridging is also reflected in the relationship between the community of tourism actors and all environmental activist groups who have the same goal which is to realize the preservation of karimunjawa nature bridging social capital is also reflected in the synergy between various groups of tourism actors and entrepreneurs from outside karimunjawa this synergy also contributes to improving services and tourist attractions in karimunjawa however the bridging social capital formed between the community of tourism actors and entrepreneurs is not as strong as the bridging social capital that exists between the community of tourism actors this condition is motivated by the negative stigma of society towards entrepreneurs who tend to be exploitative and capitalist the existence of bridging social capital allows each group to be able to establish mutually beneficial relationships with various networks outside the group that will encourage individual progress within the group bridging social capital is based on a sense of togetherness openness and relief unnes journals humanity and pluralism this bridging social capital is very relevant to be developed as a big power in reviving tourism in karimunjawa third social capital linking in karimunjawa is formed through the synergy between the community and the government as a tourism stakeholder in karimunjawa this synergy is formed between the tourism actors with the district government the village government the tourism office and the regional planning and development agency in this synergy the government is positioned as an activity planner and facilitator while the community is the executor collaboration on social capital linking can be seen in its strengths in cultural activities as an effort to promote tourism in karimunjawa social capital linking is also reflected in the synergy between the tourism community and environmental activist groups with the karimunjawa national park office the existence of social capital linking is a community effort to expand hierarchical relations with the government to gain access to power and resources in the policy making process conclusion the strong social capital formed in karimunjawa has a very big influence on tourism activities in karimunjawa the complexity of partnership relations between various tourism stakeholders in karimunjawa based on the strength of norms and trust between stakeholders causes the complexity of the social capital processes formed in karimunjawa the social capital formed in karimunjawa consists of bonding social capital bridging social capital and social linking capital of the three social capital bridging social capital has a very large contribution in reviving tourism activities in karimunjawa and is a type of social capital that is very relevant to be developed as a major force in realizing the progress of tourism in karimunjawa however in fact the three social capital are complementary and mutually reinforcing to each other so that it cannot be separated therefore the community must always increase mutual trust and strengthen values and norms so that they can increase the strength of social capital among the people the government as an authority holder policy maker and facilitator must be more concerned with the various needs and constraints faced by the tourism community in karimunjawa so as to create a good synergy between the community and the government

this study intended to analyze how social capital works in the developing marine tourism in karimunjawa indonesia this research was conducted in karimunjawa the data was collected with snowball sampling techniques the data collection methods used consisted of participatory observation methods indepth interviews and documentation the data obtained were analyzed using the interactive analysis method the results of the study indicate that the strong social capital formed in karimunjawa has a very big influence on tourism activities in karimunjawa the social capital in tourism in karimunjawa is based on many networks that are formed supported by mutual trust and still rooted in various social values and norms in the community that support the strength of existing social capital it results in collective actions in the form of synergy and cooperation between the community and various tourism stakeholders in tourism activities in karimunjawa the social capital formed in karimunjawa consists of three types they are bonding social capital social bridging capital and social linking capital which are complementary and mutually reinforcing so that they cannot be separated however between the three social capitals bridging social capital is the biggest power base in realizing the progress of tourism in karimunjawa

the goal of the study quality of life and wellbeing of the very old in north rhinewestphalia nrw80 is to provide a representative picture of quality of life in the population of those 80 years or older 40 this paper serves as an introduction to the thematic focus of this special issue providing a basic understanding of the nrw80 study and sample all papers in this issue are based upon nrw80 data the aim of this introduction is twofold first a brief characterization of the targeted population is offered with respect to biographical background historical context and the age structure of todays very old individuals in nrw second key aspects of the challenges and potentials model of quality of life in very old age are discussed and the importance of stipulations of what constitutes the good life or successful life conduct are highlighted s76 zeitschrift für gerontologie und geriatrie • suppl 2 • 2021 the population of very old individuals today there is no single agreed upon definition of very old age in the nrw80 study the definition of very old age as a chronological age of 80 years or older has been chosen primarily for pragmatic reasons as it is often the case in populationbased surveys 172740 it has been shown that from about 80 years onwards the probability of a variety of ageassociated changes such as health impairments increases this has led to the wellknown distinction between resourcerich third age and resourcepoor fourth age 12 due to achievements in healthcare social life and technical advances some scholars argue that today people in their 60s or 70s no longer correspond to traditional understandings of old age rather the fourth age appears to be the real age that bears strong resemblance to classical views on old age nevertheless aging and old age can also be associated with positive aspects such as rich experience accumulated knowledge and serenity 2533 for a comparative overview of perspectives on the third and fourth age and risks of such a distinction see wahl and ehni 41 today life beyond 80 years of age may span one or even two more decades for many individuals making the very old a group that comprises a great number of diverse birth cohorts it is paramount to understand differences in early socialization education and life experiences as potential determinants of qol outcomes in very old age however a comparison of age groups within very old age is hampered by quickly decreasing numbers of very old and oldest individuals in the population and a growing disproportionality of men and women particularly in the oldest age groups as a consequence many empirical studies offer limited possibilities to differentiate age groups within very old age even if they do not specify a maximum age for study participation 5 in nrw80 three groups of very old people were considered 8084 years 8589 years and 90 years or older reference studies in the field of aging research have shown that the group of older people is very heterogeneous with respect to for example functional status 22 or social engagement 20 such interindividual differences may be due to differences in life courses it has been shown that earlier life experiences influence not only health but also qol in later life 31930 peoples life courses are influenced by societal factors such as political decisions and historical circumstances happening at a certain time and experienced at different times in their life course for todays oldest old one important historical event was the second world war and its consequences all nrw80 age groups were socialized during times of national socialism and war however participants aged 8084 years and 8589 years today were often young enough to be part of the nazi evacuation scheme and may have participated as soldiers only towards the end of wwii older age groups were likely to have been more actively involved in warrelated combat or consequences of the war in the home country the postwar period was characterized by overcoming the traumas from the war period the younger age groups may have been more influenced by the economic upswing and the worldviews of the allied forces in general the older age groups attained fewer years of education due to the war a large percentage of this age group left school early attaining lower secondary education at best whereas the individuals of the younger age group usually reached higher educational qualifications 24 consequently menbornaround 1930 had difficulties finding apprentice positions or take part in vocational training often ending up in jobs without formal qualifications 4 moreover the majority of women born around 1930 received no vocational training 21 beginning with the postwar period the average age of marriage decreased until about 1970 and afterwards increased 11 and the average age of women when bearing their first child increased in younger birth cohorts 16 there was a peak in the number of children born from women who were born in 1933 with a decreasing trend across later birth cohorts 10 due to the end of wwii many people immigrated to germany as they had to flee from other mainly eastern european countries 28 for comparison of age groups one means for making sure enough individuals of a specific age are available for analysis in survey samples is to oversample rare individuals however the small population number of individuals in oldest age effectively limits the degree of disproportionality that can be achieved in the actual sample especially when the total sample size is large because sample size and selectivity precludes a fuller picture of the heterogeneity of conditions that exists in this age group current studies offer only limited potential to discuss normative aspects of qol in the oldest old in comparison to other ageing studies in germany nrw80 is unique in that it includes individuals in care facilities and uses proxy interviews to represent those unable to answer questions themselves the nrw80 sample nrw is the most populous state in germany counting 179 million inhabitants imcluding 20 old individuals furthermore nrw has a history of immigrants making its population heterogeneous the nrw80 study was designed for robust inference about age group and gender differences and built upon the results of a comprehensive feasibility study 39 a priori power analysis indicated that a sample size of n 1548 would enable detection of small interaction effects between design factors with high power at a conventional alpha level of 005 the population of the study included all people who had reached 80 years of age by 31 july 2017 and whose registered primary residence was in nrw this includes individuals living in private and nonprivate settings the sampling followed a twostep procedure first a sample of 94 communities was drawn from the entirety of all communities in nrw in a second step the registration offices of the selected communities provided a simple random sample of inhabitants amounting to 48137 addresses from the target population the group of potential study participants was defined to comprise n 8040 individuals based on an a priori power analysis and an expected response rate of 2025 individuals from older age groups and men were systematically oversampled ie represented more frequently within the gross sample than would be expected in a simple random sample however equal sample size in each of the six design groups was not feasible due to the low number of men aged 90 years or older in the population computerassisted personal interviews were conducted by experienced and trained interviewers of kantar a total of 1863 interviews were realized assessingbesides qol resources and outcomescentral events in the life course response rates were lower for older age groups and lower for women compared to men however a minimum of 244 observations could be realized for all design groups allowing for robust subgroup analysis design weights were computed for all individuals selected into the gross sample to correct for selection of communities and oversampling of men and older age groups finally calibration weightings were computed for participants in an iterative raking process based on the known demographic structure of the very old population with respect to age gender marital status household size institutionalization and regional characteristics even after applying weighting to correct for the disproportional sampling design and study nonresponse effective sample size in all groups remained large for example the precision of population estimates in the strongly oversampled m90 group in the nrw80 sample is the same as the precision from a simple random sample of 206 individuals in this population group respondents wereonaverage865 ± 45 years old at the time of the interview table 2 shows that in the overall population of very old adults 139 live in an institution the number of very old individuals for which proxy interviews could be conducted was estimated at 88 in the population of the very old overall only a minority of 332 of those 80 years or older show a formal need for care approximately half of the very old population showed medium levels of education while high levels of formal education were found for only one out of five persons in this age segment substantial age group differences were observed with respect to educational background employment history socioeconomic status marital status institutionalization birth of first child and age at immigration the risk of institutionalization increased across age groups oldest individuals attained lower educational levels in comparison to those in younger groups however most heterogeneity in educational level was attributable to gender in the youngest age group the share of women never tests for main and interaction effects used taylor linearization to account for the multistage sampling and linear logistic or generalized logistic modelling for metric ordinal or nominal dependent variables respectively b percentage of refusal to answer or dont know responses of all questions asked at the level of the individual hence differences in the number of questions asked at the level of the individual due to filtering are accounted for in the average score given in the table c interaction between age and sex having been employed was lower within the youngest age group and in women divorce was more common furthermore in the oldest age groups more individuals were widowed of those having children the oldest age groups were older when having their first child than the two youngest age groups of those who migrated to germany the youngest age groups were younger at arrival in germany with increasing age in those between 84 and 89 years and 90 years more than half of the nrw80 participants who immigrated did so shortly after the second world war whereas women were on average younger when ending employment than men no substantial age group differences were observed in both men and women item nonresponsemeasured atthelevel of the individual was generally low in this study on average less than 4 of all information asked from a respondent was lacking due to refusal to answer or dont know responses nevertheless while the share of personlevel refusals did not increase across age groups dont know an original contributions fig 1 8 timing of historical events in the life course of cohorts of the very old and differences with respect to age at key biographical events frg federal republic of germany gdr german democratic republic swers did part of this effect was due to the increasing share of interviews with proxy informants in older age groups however additional analysis showed that age had an independent effect on item nonresponse over and above the effect of proxy informant and cognitive status hence item nonresponse in this study of the very old was rare and multifactorial besides the prevalence of cognitive impairment estimated based on the nrw80 sample was comparable to prior epidemiological findings 13 two out of three respondents showed ageadequate cognitive functioning according to norm data and a similar proportion of individuals were screened or rated as mild cognitive impaired or early dementia a theoretical framework of qol in very old age even though a plethora of qol studies exist on the individual on a group or country level and in many specific subpopulations 26 the qol of very old individuals has rarely been examined and there are few qol models focusing particularly on very old individuals 18 however existing studies 67 suggest that in older peoplecompared to younger age groupsqol is determined by different aspects for example meaningful eudaimonic aspects seem to be important in older adults 12 a detailed investigation of different determinants of very old individuals may help to understand unexpected results such as the wellbeing paradox in old age for example schilling 34 found that the wellbeing paradox in old age results from a change in health resources as well as differences between cohorts with regard to life satisfaction in addition it may be important to identify cohortspecific determinants of qol in very old age as early socialization or differences in the timing of major life events have been found to impact qol at older ages with respect to a broad understanding of qol in very old age wagner et al 40 proposed a framework to integrate major streams of research on subjective aspects of psychological wellbeing as well as the scientific investigation of the basis of economic welfare the challenges and potentials model of quality of life in very old age was based on veenhovens model 38 view questions whereas a separate qualitative study evaluated the societal perspective based on stakeholder interviews the chapo was developed as a conceptual framework to operationalize resources and outcomes that are central to the interdisciplinary discussion of qol in very old age given the heterogeneity resulting from vastly distinct life courses of todays very old population individual values may be idiosyncratic or not congruent with the values of others younger generations or todays society creating a tension between societal groups with respect to the definition of qol and successful aging furthermore chapo conceptually adds to existing frameworks of qol in that it explicitly acknowledges the fact that successful life conductas a systemic qol outcomedepends both on resources and values of the older individual as well as on roles and appreciation of late life by society it allows for descriptive evaluative and normative perspectives on qol in very old age whereas other qol models postulate specific mechanisms that promote or prevent qol chapoat first sightdistinguishes qol resources as potential predictors for qol outcomes however it should primarily be understood as a generic measurement model serving as a basis to categorize indicators as life chances or life results and distinguishing personal from environmental indicators nevertheless the operationalization of nrw80 built on previous empirical evidence to include indicators particularly relevant for this age segment with regard to life chances indicators in nrw80 include individual values or social relations for the person and environment level respectively life results included indicators such as life satisfaction chapo adds to this the notion of successful life conduct as a systemic concept integrating the idea of personenvironmentfit and mechanisms to retain identity autonomy and participation in light of compromised physical and mental capacity that characterize fourth age 42 43 44 here fit refers to a specific positive constellation of resources and demands that foster functionality independence or personal growth successful aging 37 is defined by an autonomous generative active or productive behavior by using respective educational social infrastructural technical or economic resources indicators and determinants of qol are assumed to be different even across age groups within very old age for a number of reasons first very old age today is predominantly female and gender differences for qol predictors and indicators have to be considered 31 second individuals in their beginning 80s may not experience a drastic decrease in individual resources and consequently depend less on environmental resources for qol however the relative contribution of environmental resources for autonomy and qol may be greater in the oldest old discussion the nrw80 study allows making robust statements about age group differences within the population segment of very old adults and strengthens the state of research on quality of life of the oldest old in germany the sampling strategy was successful in guaranteeing a high level of precision of population estimates particularly in the rare and hard to reach group of men aged 90 years or older and sufficient original contributions power to test the small to moderate effects expected in socialbehavioral aging research age groups within very old age differed substantially with respect to health status education past employment socioeconomic and marital status resulting in very diverse conditions for and circumstances of realizing successful life conduct results showed differences in the timing of major life events across different age groups within veryold age the particular age at which significant life transitions were experienced may influence subsequent biographies and qol in very old age for example immigration at different ages may have consequences for the integration into a new community and therefore may impact qol however several limitations of the current data are noteworthy firstly operationalization of qol focused on current status and offered only a limited window to study biographical antecedents secondly with crosssectional data disentangling age or cohort effects was severely limited finally individuals who survived up to a very old and oldest age can be expected to represent a specific subgroup of the respective birth cohorts finally the face of very old age is changing quickly the share of very old men for example is expected to increase substantially across the next decades conclusion the nrw80 study offers a unique possibility to investigate qol in a representative sample of very old adults from the most populous state in germany whereas the share of older people in the german population increases representative studies about qol of this age group remain rare the nrw80 study meets a number of conceptual and methodological challenges of conducting a survey on qol in the very old population the chapo model considers eudaimonic concepts of qol as well as concepts integrating personal and environmental aspects especially relevant in old age a specific strength of this study is the possibility of distinguishing age groups of privately and nonprivately dwelling individuals within very old age whose differences in socialization education and life experiences should exert profound impact on late life qol outcomes hence the nrw80 study identifies needs and determinants upon which policy recommendations can be made to create conditions in which individuals may realize and retain successful life conduct throughout late life practical implications

the study quality of life and wellbeing of the very old in north rhinewestphalia nrw80 aims at giving a representative picture of the quality of life qol in this population conceptually qol research has rarely considered the values of older individuals themselves and societal values and their relevance for successful life conduct empirically comparisons of different age groups over the age of 80 years are rare and hampered by quickly decreasing numbers of individuals in oldest age groups in the population of very old individuals study design and theoretical framework this paper describes the population of the nrw80 study and different age groups of very old individuals with respect to biographical background furthermore using the challenges and potentials model of qol in very old age chapo key aspects of qol in late life are discussed and the importance of normative stipulations of what constitutes a successful life conduct are highlighted in the nrw80 study older age groups ie 8589 years 90 years were deliberately overrepresented in the survey sample to enable robust crossgroup comparison individuals willing to participate in the study but unable to participate in the interview themselves for health reasons were included by means of proxy interviews the total sample included 1863 individuals and 176 individuals were represented by proxy interviews pronounced differences were observed between age groups 8084 years born 19331937 n 1012 8589 years born 19281932 n 573 and 90 years or older born before 1927 n 278 with respect to education employment and the timing of major life events eg childbirth conclusion different life courses and resulting living conditions should be considered when discussing qol disparities in very old age

background sickle cell disease a global health challenge sickle cell disease is an autosomal recessive haemoglobinopathy characterised by ongoing haemolytic anaemia episodes of acute pain caused by vasoocclusion and progressive organ failure it is the most common monogenetic disease worldwide with an estimated 300000 births annually and is recognised as an important public health problem by the world health organisation 1 seventyfive per cent of the global burden of scd occurs in subsaharan africa where the majority of children with the disease do not reach their fifth birthday 2 in contrast the life expectancy in wellresourced countries has significantly improved with almost all infants now expecting to survive into adulthood due to comprehensive care programs however the life expectancy of patients with scd is still 2030 years shorter than the average life span of the general population 3 the netherlands currently counts approximately 1500 scd patients half of which are children 4 most of those affected are from asian or african ancestry with a minority being of middle eastern descent 5 in the netherlands care for paediatric patients with scd is organised in centralised comprehensive care centres to ensure good quality of care 6 vulnerabilities in sickle cell disease in western countries scd predominantly affects racial and ethnic minorities it is wellknown that children from nonwestern ethnic minorities are more likely to live in poverty and reside in families with a lower family income 7 low socioeconomic status is associated with higher rates of illness shorter life expectancy high stress levels low birth weight and many other negative health outcomes 8 in addition to socioeconomic disadvantage children with scd and their families encounter many psychosocial issues including increased anxiety depression social withdrawal aggression poor relationships poor school performance and impaired healthrelated quality of life 9 10 11 12 these psychosocial issues mainly result from the impact of pain and other disease symptoms on everyday life however they are also a result of societys unawareness of scd and the lack of understanding and empathy towards those affected although life expectancy has improved many outcome goals remain unmet this is not only due to the biological burden of acute complications or chronic morbidity such as multiorgan failure but also due to the complex interaction between patients with scd and the socioecological system 13 14 15 scd has historically been described as a black disease 16 this harmful association of the disease with race has resulted in social and ethical consequences that are tied to discrimination 15 for example the pain complaints of racial minorities are less likely to receive adequate attention due to the often complex communication between the patient and physicians or nurses 17 18 19 20 in addition to stigmatisation in healthcare significant gaps exist in both the equity of research funding and philanthropy for scd 2122 evaluating access to healthcare the accessibility of healthcare concerns the level at which people are able to utilise all healthcare resources they need to sustain or improve their health 23 this accessibility is described by four overlapping dimensions physical accessibility of healthcare affordability of healthcare accessibility of healthrelated information and the principle of nondiscrimination 2425 the comparison of amenable mortality rates between countries allows the approximation of national levels of healthcare access and quality 26 the netherlands ranked 3rd in the healthcare access and quality index of the 2016 global burden of disease study 26 from a global perspective accessibility of healthcare might therefore not be seen as a matter of concern for dutch clinical practice the evaluation of the haq index however provides limited insight in accessibility disparities between different groups of society or between patients with different diseases healthcare professionals have firsthand experience of barriers faced by patients when it comes to effective care from professionals anecdotal and seemingly unique stories a picture emerges of the general challenges faced by our healthcare system when it aims to provide access to the highest attainable standard of care to every individual access to the highest attainable standard of healthcare like most countries in the world the netherlands has signed and ratified multiple human rights treaties and conventions the commitments made in these documents are important in the context of healthcare for children as early as 1966 the international covenant on economic social and cultural rights established access to healthcare as a fundamental human right furthermore the committee on economic social and cultural rights obligates states parties to ensure equality in the access to healthcare and healthrelated services they emphasise that children should be regarded as a vulnerable group that require explicit protection 27 in 1989 the united nations convention on the rights of the child reinforced the right of the child to the enjoyment of the highest attainable standard of health to provide additional safeguards for the protection of children 28 in 2019 the uncrc celebrated its 30th anniversary and to commemorate this milestone we aimed to assess its implementation in a highincome country focussing on accessibility of care for paediatric patients with scd in the netherlands as a case study study aim in this nationwide assessment we aim to map barriers and facilitators in any of the four dimensions of healthcare accessibility faced by dutch children with scd and their families by interviewing healthcare professionals we try to identify common challenges and lessons learnt in clinical practice on a grassroots level methods design and study setting in this study a qualitative descriptive design was used the qualitative approach with its focus on subjective experience is best to enhance understanding of the range of problems with healthcare accessibility that patients experience and that healthcare professionals observe interviews were conducted with scd healthcare professionals working in various care settings participants were affiliated with the score consortium of the netherlands which includes all scd comprehensive care centres and research institutes involved in clinical scd research in the netherlands study findings are reported in accordance with the standards for reporting qualitative research 29 this project was approved by the medical research ethics committee of erasmus university medical center and adhered to the declaration of helsinki 30 the participants provided written informed consent data collection three trained investigators conducted facetoface semistructured indepth interviews between february 12th and may 23rd 2019 one week before the interview each healthcare professional received an email explaining the purpose of the study and our specific interest in access to healthcare for children and adolescents with scd interview questions were formulated to probe the healthcare professionals to elaborate and explain the challenges faced by their patients and to provide recommendations on how to solve these issues an interview guide was used to ensure the four healthcare accessibility dimensions were covered and started with the question of how the participant would define access to health the interview guide contained only open questions aiming to freely explore the participants experience two examples of these questions were what do you aim for when informing patients what happens after you have informed the patients the participants initial response was often followed by a probing question such as could you give an example how is this different for patients with scd compared to other patient groups the interviews occurred privately at the workplace of the participants interviews were conducted in dutch and were audiorecorded field notes with initial thought were made by the interviewers after each interview data analysis the interviews were transcribed verbatim and coded followed by a thematic analysis 33 based on field notes initial codes were generated to collate data to main themes through ongoing thematic analysis definitive themes were formulated the transcripts were analysed by three researchers the results were subsequently discussed with experts in the field of healthcare accessibility or the field of clinical paediatric sickle cell care to confirm the accuracy of the analyses the robustness of the research was increased by selecting quotations to highlight or illustrate the themes and link the reported results to the empirical data to increase readability for the general public the definitive themes have been reported as recommendations results sample description twentytwo healthcare professionals from five different academic clinic sites for comprehensive sickle cell care in the netherlands participated in the study none of the potential participants declined to participate in the study the participants mean age was 370 years of the 22 participants 19 were women and 21 where white the average number of years of experience in their profession was 85 interviews lasted on average 38 min table 1 summarises study participant characteristics thematic analyses of the interview transcripts revealed six themes or recommendations on how to improve healthcare accessibility for children with scd and their families in general western countries provide free public healthcare insurance for children to ensure healthcare access for everyone under 18 years of age however depending on countries and healthcare systems some medical services are subject to a statutory personal contribution in addition direct nonmedical costs and indirect costs are generally not reimbursed many participants reported that families had difficulties with costs last month we had a sevenyearold visiting our outpatient clinic on his own we asked where his mom or dad was in the car he replied his mother didnt have enough money to pay for the relatively high hospital parking fee participants felt that the government or insurance companies should ensure that caregivers are fully reimbursed for all extra costs especially for lifesaving treatments such as antibiotic prophylaxis and vaccinations international guidelines recommend broad meningococcal vaccination for children with sickle cell disease due to their functional asplenia as you know they children with scd are at much higher risk compared to healthy children for meningococcal disease unfortunately these vaccines are not covered by health insurance and for most parents €25 the price of a vaccine is simply too much now we provide the vaccines in the hospital budget but this simply cannot go on forever sometimes a certain medication is all of a sudden not covered anymore by an insurance company for example for oral penicillin suspension essential for infants who cannot take tablets suddenly a very high personal contribution was necessary we paediatric haematologists spent many hours together with the clinical pharmacist in order to solve this problem and to avoid these extremely high extra costs for patients fortunately we were able to find a fully covered generic variant which could be imported from a neighbouring country to me this is an issue of equal access to essential health services for all dutch citizens i cannot believe that in a developed country such as the netherlands we obligate parents to pay for their childs muchneeded care apart from this i think access to healthcare is equivalent to access to medication and this is often difficult as patients are obligated to pay additional fees for various medication types due to centralised sickle cell care some families face high costs because of travelling large distances in addition long travelling times may have implications for caregivers jobs as caregivers are often unable to miss a shift or leave work without financial implications or even loss of employment furthermore many children with scd have siblings and there is usually no provision for reimbursement of the costs of their care when the caregivers are expected in the hospital with the child who has scd in cases of single parent households this may be even more difficult sometimes nurses at the ward report that parents do not visit their hospitalised child often enough it makes them a bit annoyed and worried about the childs social situation while i understand their worries i also understand that for some parents its not always easy to take unpaid leaves of absence in order to visit their child in the hospital one mother ended up getting fired for missing too many days at work she was on a fixedterm contract she told her employer about her child with sickle cell disease he had never heard of the disease before and said it was not his problem some parents are already struggling every month to just pay the rent they cannot afford many trips by public transport to the hospital well yes we have a sort of special fund and thenyou have to see of course because you cannot do it too often it is an emergency fund you have to estimate how urgent the need for help is financially i mean therefore we ask advice from our social worker she is in charge of the fund patients can hand in their tickets and receive a reimbursement of the costs of for instance their train ride overall despite universal coverage of medical care in western countries family borne costs of children with scd could seriously affect the familys disposable income these additional costs could increase inequality in the accessibility of healthcare between households that can easily afford them and those who struggle to make financial ends meet 34 reimbursements from government agencies are often insufficient to cover all costs and reimbursement procedures can be quite complicated especially for individuals with lower health literacy previous studies evaluating the impact and financial costs for caregivers of children with other diseases such as diabetes and paediatric cancer show that risk factors of perceived economic hardship include single parenthood lower socioeconomic status and physical distance from the treatment centre 3536 the issue of single parenthood requires special attention even more so because singleheads of household are common in the scd population 37 it is pertinent to recognize that many families struggle to meet the extra financial demands of caring for a child with scd therefore attention must be given to proactive interventions aimed at addressing all extra costs including full coverage of medical treatment support for housework and childcare and access to charitable funding theme 2 reducing the number of hospital visits clustering of appointments on the same day scd requires a versatile and comprehensive treatment protocol with frequent checkups with healthcare professionals from various medical specialties 38 in the netherlands patients visit their paediatric haematologist twice a year to discuss disease progression treatment and preventative care additional hospital visits include checkups with a nurse practitioner examinations like transcranial doppler ultrasound echocardiography and laboratory tests or appointments with medical social workers or psychologists therefore the patients are burdened with multiple appointments throughout the year almost all interviewed professionals mentioned that the frequency of hospital visits can present barriers for optimal treatment and that this might be an explanation for the relatively high noshow rates among the patient population apart from practical and financial barriers high noshow rates were also attributed to the patients inability to fully understand what different appointments types entail and why so many hospital visits are necessary many patients fail to show up at one or more of their checkup appointments i think sometimes appointments are forgotten but i also feel they have too many appointments throughout the year parents do not always understand the necessity of each appointment they think i have already been there three times this year i do not really have to attend this time for the majority of our patients it seems difficult for them to fully understand their illness and that even when they are not facing symptoms of a sickle cell crisis they still have to checkin regularly regular followup care is required for children and adults with scd when consistently followed by a health provider some disease complications are avoidable patients lose vital opportunities for health monitoring and education when regular followup appointments are missed increasing the risk of hospitalisation or mortality recently i saw a female patient of 23 years old who missed her checkups of the last few years because she had few complaints well now she has lost her sight in one eye and there is nothing we can do even patients with few crises vasoocclusive crises and few health issues can develop serious organ damage a recurring remark in the interviews was the idea that scheduling visits to various healthcare professionals on the same day may be beneficial for total accessibility of care not only can this reduce the burden of traveling it might also become easier to involve additional medical experts such as psychologists to improve comprehensive treatment appointments on the same day also make it easier to organise treatment more holistically for example adding a visit to a psychologist and a physiotherapist without obliging the family to visit the hospital more often one participant saw an additional benefit for patients if multiple appointments were offered on the same day during visits the intervals between appointments could provide an opportunity for caregivers and patients to meet with other patients and their families scheduling visits on the same day could offer an opportunity for children and their families to see and meet fellow sufferers which could bring the relief of sharing the burden lessons in this regard can be drawn from care for children with cystic fibrosis which is often organised in annual assessment days on these days patients and their families speak to a number of healthcare professionals including the specialised paediatrician other medical specialists the nurse practitioner pharmacist dietician and psychologist in addition multiple tests are conducted such as imaging and lung function tests applying this approach in comprehensive scd centres would address different barriers of healthcare accessibility and thereby help patients and their families to see all required specialists 3940 theme 3 specialised and shared care bridging the gap although care for patients with scd is centralised many families still visit their local hospital because of large travelling distances to the comprehensive sickle cell centre almost all participants reported a knowledge gap with regard to scd among primary care physicians and general paediatricians in local hospitals due to a lack of clinician training and continuing education parents told me they took their child with a fever to the general practitioner and he said dont worry its just a fever she will get better in a few days she doesnt need any prescription medication by the time they arrived at my hospital she the child had to be rushed into the icu intensive care unit with a sepsis i feel that the risk of bacteraemia and the need for prompt evaluation and treatment is a basic feature of sickle cell disease care it regularly happens that a patient with a crisis vasoocclusive crisis visits the general practitioner with severe pain and that he or she then tells them to just take some paracetamol and then theyll be good to go general practitioners generally have a lack of knowledge of sickle cell disease but in my experience they are quite quick with their referral to a haematologist i feel there is a bigger issue with haematologists in local hospitals because he will think he can handle the patient and doesnt recognise the seriousness of the disease yes thats what i think however some participants shared that they had an excellent working relationship with socalled shared care hospitals shared care is an arrangement between a sickle cell centre and a local hospital or general practitioner paediatricians in our shared care hospital are educated to treat children with sickle cell disease we specialised paediatric haematologists in a sickle cell centre support and supervise these local healthcare professionals whenever a patient does not respond to routine therapy or when there are complications the patient is transferred to our centre communication is very effective many participants felt that shorter commutes to the local hospital would notably improve the compliance with attendance at outpatients clinics especially when compared to theoften longerjourney to the sickle cell centre some patients travel more than 15 hours with public transport to reach our sickle cell centre local hospital visitswith consequently much less disruption to the child and familys everyday routine and without compromising qualityare for me an essential part of delivering good healthcare participants recommended identification of paediatricians in local hospitals with an interest in scd who could serve as a primary contact with the paediatric haematologist in the centralised sickle cell centre and who are able to disseminate knowledge to other local health professionals when needed shared care is about creating a comfortable working relationship between paediatricians and paediatric haematologists if for example all our in the sickle cell centre of the participant inpatients beds are full and i have a child in the ed emergency department with a crisis who needs iv intravenous pain medications i call the shared care paediatrician with sickle cell disease expertise to discuss the possibility of transferring the patient i know the child will be in good hands because they know how to treat a child with a crisis vasoocclusive crisis and they will supervise nurses and other hospital workers in the specific case of migrant children with scd several interviewees highlighted that the transfer from one temporary shelter centre to another can be counterproductive to treatment efforts the geographical location of the shelter determines which general practitioner shared care centre and specialised scd centre a patient has access to a transfer to another centre therefore often means all healthcare professionals involved in treatment are replaced unlucky children switch between medical facilities multiple times during their asylum procedure and receive care from many different healthcare professionals children and families in asylum centres are often transferred to other centres across the country sometimes i see a patient for the first time i order laboratory tests and make a treatment plan but the next consultation the patient does not come as he or she has been transferred to another centre that i think is very distressing the asylum centres are extremely badly organised caregivers have to take a lot of hurdles to make progress … plus you dont have your own doctor so thats really difficult centralised comprehensive scd centres have shown to significantly decrease morbidity and to improve quality of life in patients with scd 4142 however unfamiliarity with patients with scd outside these specialised centres makes the patients more likely to receive inadequate care simultaneously sole access to followup appointments emergency care and inpatient care in the specialised sickle cell centres can be a burden for families living at a large distance from a comprehensive centre shared care constructions have been applied in the management of paediatric patients with many conditions such as diabetes cystic fibrosis idiopathic arthritis and cancer and is based on a closed collaboration between general paediatricians and specialised paediatricians in centralised centres 43 44 45 46 47 the shared care hospitals are linked with the specialised centre by a twoway referral and communication process there are many theoretical benefits in terms of access and convenience the overall goal is to deliver specialised services as close as possible to the patients home without compromising quality in the case of scd primary healthcare providers including general practitioners should be supported to improve their knowledge and understanding of scd furthermore shared care centres should have at least one paediatrician with interest and expertise in scd and be able to treat mild complications including vasoocclusive crises requiring intravenous opioid pharmacotherapy as well as simple infections lastly with special reference to children with scd in shelter centres it is important that these children are visible in the healthcare system and are able to be seen regularly by a healthcare professional with knowledge of their disease theme 4 optimizing methods of verbal and written communication enabling mutual understanding between patients and healthcare professionals patients with scd and their caregivers must perform a variety of tasks requiring adequate healthcare understanding including communication with healthcare professionals reading and understanding of health information interpretation of acute symptoms administration of medication and making decisions regarding treatment options many parents of children with scd are from ethnic and racial minority groups understanding critical information is particularly difficult with a language barrier most healthcare professionals interviewed felt that the available health information materials were often hard to read and that caregivers of children with scd could benefit from having appropriate educational materials about scd during the first consultation we provide parents with an extensive comprehensive guide to sickle cell disease it has excellent information however i think that for a person without any medical background it is very hard to understand participants reported a limitation in methods to confirm caregiverpatient understanding when i speak to them they always nod politely but do they really understand what i am saying several participants noted a lack of written health information in multiple languages primarily spoken by the patient population such as english and french the mother was unable to read dutch and i was unable to provide any written materials in french one centre created a visual decisionmaking educational tool as an aid to enhance communication between the physician and caregiverpatient during the decisionmaking process of initiation of hydroxyurea therapy before the educational tool was developed i could only provide parents with the pharmacy leaflet on hydroxyurea that leaflet is really very scary it contains a long list of possible side effects and the font size is quite small which makes it more difficult to read now i use the visual tool and i feel they the caregivers understand the necessity of the treatment much better and it is easier to address safety concerns clear communication and accessible healthcare information is an important component to improve population health 4849 the who stresses the importance of understandable health information reiterating the right of individuals to have access to health information and health systems that they are able to understand and navigate 50 in addition special consideration should be given to the development of educational materials for population groups with welldocumented low literacy skills ie members of minority population groups and members of immigrant populations theme 5 building strong digital connections improving the use of ehealth and telemedicine the interviewed healthcare professionals described the paradoxical ease with which caregivers handle their smartphone while their low literacy competence interferes with fully comprehending for example an appointment letter from the hospital making use of a smartphone instead of written letters can improve communication between healthcare professionals and their patients since we started inviting patients for their appointments by email text message and by admission letters instead of admission letters alone our noshow rates have declined significantly also it is much easier to remind patients one or two days in advance of the scheduled date almost half of the comprehensive sickle cell centres have established a mobile phone number by which caregivers and patients are able to directly call the sickle cell nurse practitioner during office hours this number which bypasses the front desk of the hospital facilitates a direct link between patients and the healthcare professional the interviews suggested that caregivers preference is to call the nurse directly when requiring support in contrast to the general hospital phones our mobile number does not call anonymously patients can see it is the sickle cell centreand not a debt collector for examplewho calls them which increases the chances they pick up the phone we also use whatsapp which works even better than calling to these messages we often receive a response almost instantly while phone calls are sometimes not answered or returned a direct mobile phone number supports not only communication through phone calls but it also enables the exchange of written and spoken communication using widely used daytoday messaging applications three interviewees mentioned that the option of spoken messages seem to be particularly useful for caregivers with limited health literacy as no reading or writing is required some parents always contact me by voice message they send voice memos with questions and concerns like when is my childs next followup if they need a new prescription or when their child is not well i feel this works really well and lowers the barrier of access to a healthcare professional another advantage of direct calls to the sickle cell nurse practitioner is that patients and their caregivers know whom they can call for advice they can call as soon as they feel the need to thereby preventing the worsening of their childs condition if i explain during a regular followup consultation what to do in case of a vasoocclusive crisis it can be difficult for parents to both comprehend and store the information for later use in case of a stressful event like a painful crisis it can be very helpful to talk to someone you know and who can give you instructions however some healthcare professionals mentioned the specific challenge how to provide caregivers with such a direct line of communication outside working hours some caregivers do not really understand that they can only call the sickle cell phone during working hours in the beginning i worried caregivers would not know whom to call in case of an emergency outside office hours so i sometimes answered my phone outside working hours currently i turn my phone off and have a voicemail which provides the phone number of the emergency department participants mentioned the increased use of ehealth such as mobile applications to monitor and manage health symptoms and an online portal to access personal medical records however this necessitates a certain level of digital health literacy we send quality of life questionnaires to caregivers email addresses one week before the followup appointment of their child unfortunately some caregivers never fill in those electronic questionnaires i feel some dont really have the skills to use digital technologies accessible mobile contact between the scd nurse practitioner and caregivers can increase caregivers capability to manage their childs care the use of ehealth services provides a successful way of helping patients to live more optimally with chronic conditions 51 however innovative technologies should to be tailored to users health literacy skills which often seems to be forgotten otherwise these technological healthcare innovations may further increase disparities between patients rather than bridge them 52 theme 6 the patient in context towards compassion and public awareness and a supportive environment children with scd benefit from preventative measures which include daily use of prophylactic antibiotics immunisations ensuring adequate hydration by drinking plenty of fluids the wearing of warm clothing to avoid chilliness and sufficient rest and avoidance of excessive stress although these measures do not seem difficult to safeguard in a paediatric setting their success depends heavily on the support a child receives from family teachers sports coaches and many others multiple interviewees highlighted that a societal lack of knowledge about scd often interferes with effective preventive treatment some teachers do not allow children to drink from a bottle of water outside of the designated snackand lunch breaks this can be a big issue for patients and their families because they may be too shy to inform about the illness or simply not vocal enough to express the childrens needs to drink regularly participants described the benefit of a social worker in the comprehensive care team who helps caregivers with the educational system the social worker can for example educate school representatives or can attend school meetings keeping in close contact with the school of each patient proved to be an effective approach to increase awareness for better adherence with preventive measures when a child enters primary school our social worker always plans a phone call with the teacher of the child to describe the childs medical needs we feel this helps enormously in preventing crises because the teacher then understands how to help the child stay safe we use a checklist to help parents prepare and remind them of what they need to discuss with their childs teacher such as emergency phone numbers signs or symptoms of pain fever and fatigue increasing general knowledge among key stakeholders and the public is of importance to ensure that preventive and acute healthcare measures are taken in all settings the participants mentioned the following parties as key stakeholders the government municipalities hospitals and general practitioners schools and government authorities in charge of migrants and refugees community outreach and educational initiatives would be an important step to inform key stakeholders and society as a whole about the severity and impact of scd when i tell people about my work with children with sickle cell disease many claim they have never heard about the disease i am always surprised when people know about cf cystic fibrosis but not about sickle cell disease patient numbers in the netherlands are the same i dont understand despite the major advances in treatment that have occurred over the past three decades scd remains a lifethreatening disease that is associated with reduced quality of life broader societal awareness of the severity of scd will increase the likelihood of future government and private financial support for research and the provision of comprehensive and tailored highquality clinical care discussion when evaluating the performance of healthcare systems national averages of performance indicators fail to acknowledge the individual childs rights as stated in the united nations convention on the rights of the child 28 to complement current knowledge on healthcare accessibility in a highincome country we performed a nationwide case study among dutch healthcare professionals in the field of paediatric scd this qualitative study explored the intersecting vulnerabilities faced by patients and their families and how these vulnerabilities hamper access to healthcare rather than solely identifying barriers best practices and lessons learnt were gathered from daily clinical practice supported by existing evidence in the literature content analyses of the interviews with healthcare professionals revealed six themes with corresponding recommendations together the recommendations act on all four dimensions of healthcare accessibility physical accessibility financial affordability accessible information and no discrimination most recommendations fall into two or more dimensions of healthcare accessibility for example patient appointment reminders by mobile phone instead of long or complicated appointment letters improve the accessibility of healthrelated information in addition in line with the nondiscrimination principle clear communication with patients regardless of their perceived health literacy skills prevents inequality in access between patient groups with different levels of education six themes emerged all associated with best practices on topics related to improvement of accessibility of healthcare for children with scd and their families firstly cutting of invisible costs by fully reimbursing caregivers for all extra costs related to the disease of their child secondly clustering of appointments on the same day to help patients seeing all required specialists without having to visit the hospital frequently thirdly improving shared care in order to deliver specialised services as close as possible to the patients home without compromising quality fourthly optimising methods of verbal and written communication with special consideration for families with language barriers andor low literacy skills fifthly improving the use of ehealth services tailored to users health literacy skills including accessible mobile telephone contact between healthcare professionals and caregivers of children with scd finally increasing knowledge and interest in scd among key stakeholders and the public to ensure that preventive and acute healthcare measures are understood and safeguarded in all settings implementing any of the discussed best practices could lead to an overall improvement of healthcare accessibility a holistic implementation of all six themes is necessary to adequately address the intersecting vulnerabilities faced by patients with scd and their families some recommendations will be relatively simple to implement for example clustering of appointments on 1 day or developing easier to read appointment letters while such measures are an important step towards improvement of access to care accessible care cannot be fig 2 six key themes crosscutting the four dimensions of healthcare access sustained without adequate financial support for example the structural improvement of knowledge of scd among healthcare professionals or the providing of sufficient financial means to cover transportation to the hospital are more costly this qualitative study focuses on the experiences of healthcare professionals and not on caregivers or patients perceived barriers to accessibility of healthcare future studies on caregivers perception will be an important extension to the results of this study 53 in addition followup studies might provide an even stronger foundation for future interventions to improve accessibility of healthcare for example how many families exactly face financial hardship these quantitative studies are ongoing in the netherlands in the context of the nationwide dutch research consortium score the smalltargeted sample in this study although characteristic for qualitative research limits the extent to which the findings reported can be generalised to other countries and healthcare systems nevertheless the validity of this multicentre study is supported by the representative sample of healthcare professionals with different occupations caring for children the internal coherence of the themes and its coherence with the background literature for now the six key themes provide recommendations for best practices in the care for paediatric and adolescent patients with scd and their families however medical professionals working outside the field of scd may recognise that some of their patients face similar barriers in accessing healthcare therefore the recommendations we propose may be worthwhile to implement in other contexts as well conclusion this study presents the first overview of both the urgency and the possibility to improve healthcare accessibility for young patients with scd from the perspective of healthcare professionals converged into six key themes our analysis sheds light on barriers and potential solutions to accessing healthcare which may serve as a clinically useful resource to improve care for patients with scd consent for publication na competing interests all authors declare no conflict of interest relevant to the contents of this manuscript

background in wellresourced countries comprehensive care programs have increased life expectancy of patients with sickle cell disease with almost all infants surviving into adulthood however families affected by sickle cell disease are more likely to be economically disenfranchised because of their racial or ethnic minority status as every individual child has the right to the highest attainable standard of health under the united nations convention on the rights of the child it is essential to identify both barriers and facilitators with regard to the delivery of adequate healthcare optimal healthcare accessibility will improve healthcare outcomes for children with sickle cell disease and their families healthcare professionals in the field of sickle cell care have firsthand experience of the barriers that patients encounter when it comes to effective care we therefore hypothesised that these medical professionals have a clear picture of what is necessary to overcome these barriers and which facilitators will be most feasible therefore this study aims to map best practises and lessons learnt in order to attain more optimal healthcare accessibility for paediatric patients with sickle cell disease and their families methods healthcare professionals working with young patients with sickle cell disease were recruited for semistructured interviews an interview guide was used to ensure the four healthcare accessibility dimensions were covered the interviews were transcribed and coded based on field notes initial codes were generated to collate data both barriers and solutions to main themes such as transportation or telecommunication through ongoing thematic analysis definitive themes were formulated and best practices were reported as recommendations quotations were selected to highlight or illustrate the themes and link the reported results to the empirical data

this article is a contribution to opening up the conversation on gender and social work it is concerned more precisely with the conceptualization and usage of gender within social work theory research and practice although a key feature of everyday life within social work gender has what sociologists sometimes call a seenbutunnoticed quality it is frequently overlooked and perhaps more importantly where it is considered gender is theorized in a number of rather limited ways for example social work is often described as a femaledominated profession but one in which men disproportionately occupy senior roles yet mcphail has argued that social work is more correctly described as a female majority maledominated profession because although there are many more women than men in the field they do not necessarily dominate this is an important argument since to describe social work as femaledominated suggests that merely because they are far greater in number women hold more power yet this disregards some vital points first the smaller number of men in the profession may actually hold more institutional power and second a profession like social work is as with many fields involving the care of others devalued third the question of how power works within social work institutions and how this relates to gender is likely to be a lot more complicated discussions about challenging oppression and discrimination within social work theory and practice are some of the few occasions on which gender is openly acknowledged yet these too often rely upon limited accounts thompsons text for example describes gender as a fundamental dimension of human experience revealing an everpresent set of differences between men and women while he does go on to point out that social rather than biological processes produce gender it is largely at the level of attitudes that his suggestions for change are leveled this tends to individualize gender to see it as a personal characteristic and to see gender oppression merely as a form of personal behavior or values in part these points relate to the ways in which gender is defined secondwave feminism for example separated the concept of sex from gender in order to show that gender refers to a set of social expectations that may be challenged however sometimes this notion of gender as a set of cultural practices has been reduced to role or identity so that gender is treated as a preexisting characteristic or property of the individual later feminist theories remind us rather that gender is a social relationship based upon the promotion of hierarchy and one that is reiterated through interactions in everyday life this article pays considerable attention to this notion of gender as a form of practice since it is my contention that much of social work theory actually treats gender as a rather static characteristic after having reviewed some of the more familiar approaches to gender within social work i will go on to open up debates via consideration of materialist interactionist and discursive accounts before finally considering what social work theory research and practice might learn from these how does social work think about gender where social work theory or research does think about gender we see the influence of feminist andor sociological theories ormes book gender and community care argues that the gender politics of social work has to include the relationship between the helper and those who require help and between the individual and the state she highlights the disproportionate representation of women in mental health services elder abuse and those cared for in the community pointing out that these are all areas in which gender is usually ignored or invisible or that when it is noticed the response is usually to suggest that men and women should be treated differently orme argues this categorisation of femaleness and maleness femininity and masculinity as dichotomous opposites does not reflect the lived experience of users of community care services scourfield points out that assumptions about gender difference permeate interventions in social work and he links these with heteronormativity he makes a case for the analysis of gender as a social category since the category relates to questions of social inequality christie similarly argues that within discourses of welfare persons are gendered offering them specific gendered identities and subject positions in relation to men in social work he notes that they are often seen as either good or bad sociological social work texts see gender as referring to a social or cultural set of ideas reflecting normative assumptions but although such texts make reference to gender as a practice they often work at the level of attitudes or values encouraging social workers to reflect upon their own assumptions about gender treating gender concepts at the level of attitudes is a rather individualized approach in which it seems to be an interpersonal characteristic only although there are other texts that consider gender as a practice and insist on its contextualization within late or reflexive modernity there are attempts within social work to think about how gender relates to questions of race class disability age or sexuality but more often gender is treated as a standalone issue an example of this would be some feminist work on care which argues that women need to be released from the burden of caring for dependents although this point about the effects of state and family reliance upon unpaid care is an important one work by disabled feminists has pointed out that the category women includes those being cared for and that these arguments position disabled women and men as a burden others have noted the heteronormativity of such arguments based as they often are on an assumed heterosexual couple however by far the most regular usage of gender within social work is where it is treated as already given that is used as a label referring to an assumed characteristic here the formula runs gender causes x an interesting example of this would be failure to protect moving beyond gendered responses which examines why in professional responses to child sexual abuse mothers are often held responsible via failure to protect in one sense this is vitally important why does some social work practice tend to blame mothers and ignore fathers why are mothers often held accountable for mens abuse of children but in another sense the book never really asks how gender works or is made to matter in these contexts and instead frequently treats it as a monocausal explanation this kind of usage of gender is limited for a number of reasons first gender may take on a thinglike quality and appear to have agencygender causes x second it treats a group as homogeneous but this doesnt ask if all men are therefore more likely to abuse children for example and it doesnt ask whether all men are equally powerful third it doesnt really get to grips with just how gender works in a given situation fourth it may lead to simplistic explanations of course it is important to think about why men overwhelmingly commit most forms of sexual violence but this does not mean gender causes abuse and lastly this is a rather interior view of gender the gender of the person seems to be some kind of characteristic that causes a problem or outcome womancentered practice much of the feminist social work literature treats gender as a basis for similarity and shared purpose hanmer and stathams text women and social work for example develops what they term a womancentred practice and makes the case that since women are the majority of social workers and service users a commonality of gendered experience along the lines of being female their relationships with men children living within the family employment and working conditions forms the basis of social change through social work although the book does acknowledge differences along lines of race age disability class and sexuality this notion of commonality or what dominelli and mcleod term nonhierarchical relationships between the social worker and the womanwomen she is working with has been critiqued for assuming that feminist social work means working with women that empowerment is the only purpose of such work that empowerment resolves power dynamics within relationships and that womens shared experience means automatic rapport hanmer and stathams text mentions lesbian black and ethnic minority women in relation to forms of diversity but their description of womens commonalities relies upon the normative assumptions of whiteness and heterosexuality this sameness problem has been the target of other social work writings lewis research argues that both race and gender are mutually constituted yet within social work they are often treated as separate spheres she argues that gender and race are experienced differently according to context and so may have different meanings and effects even for the same person so just as the category of gender must be one that allows for differences so race too must not be treated as already given as referring to some kind of essential black or white culture in relation to the black female social workers in her study lewis suggests that racial and ethnic categories are simultaneously occupied and resisted as a way of mediating a set of working lives which are overdetermined by race and gender indeed if gender is to be seen in its complexity then this must not be taken solely to refer to women for some theorists in social work it is important to think about work with men and fathers the complexity of mens position within social work notions of masculinity and the category men this also relates to how social work thinks about trans issues and transgender people a point to which i shall return social work gender and intersectionality one response to this assumed gender sameness and the treatment of gender in isolation is to consider intersectionality theory crenshaws argument proposes that the consideration of subordination within single categories like gender prevents analysis of race and gender for black women since the claims of sex discrimination within law are largely based upon experiences of white women in relation to gender only this has been taken up in incorporating intersectionality in social work practice research policy and education which argues that social work should consider how oppressions intersect to form interlocking patterns of injustice this means that attention to gender alone is insufficient since race and class make a difference and it also means that any individual might experience both oppression and privilege while this goes some way to challenging supposed gender sameness the authors accept andersens claim that sexuality does not occupy the same place as race class and gender since it has largely to do with identitycultural issues rather than politicalstructural ones andersen argues sexuality has never been formally used to deny sexual groups the right to vote nor has it been used in the formal and legal definition of personhood as is historically true of african americans and other groups gays and lesbians have never been formally segregated in the labor market nor denied citizenship because of the labor they provide murphy et al while pointing out the need to consider questions of sexuality accept this view and suggest that sexuality cannot be treated as equivalent to race class and gender here then is an obvious problem with some intersectionality theory an argument against a hierarchy of oppressions is contradicted by establishment of another and as schilt notes this separate treatment of sexuality ignores ways in which citizenship is denied to lesbian gay bisexual or transgender people and also that gay men and lesbians who have nonnormative gender presentations who are workingclass andor who are racialethnic minorities are often those who end up being most excluded from legitimate avenues of employment given that authors such as collins argue that what is needed is a framework that not only analyzes heterosexism as a system of oppression but also conceptualizes its links to race class and gender as comparable systems of oppression this suppression of sexuality analysis in a social work text seems misguided poststructural and postmodern feminist social work poststructural and postmodern theories have questioned the notion of identity or experiencebased knowledge that features in some feminist work because poststructuralist theories do not treat language as a reflector of reality but rather a powerful way of constructing knowledge thus any claims that feminist social work should be based upon validating the experiences of women are thrown into question because those experiences are not merely authentic they are motivated linguistic accounts which aim to achieve certain effects and they are open to different interpretations feminist poststructuralists also challenge the notion of womens shared experience since the category woman is itself experienced differently and fractured along race class sexuality disability age and other lines of course this is not merely a poststructural claim earlier feminist debates also centered on potential exclusions of the category woman by race sexuality and so on but here the concern is more with the powerful effects of language use so while sands and nuccios arguments for a postmodern feminist social work based upon difference diversity and recognizing the marginalized do not sound particularly challenging their questions about the potentially oppressive nature of gendered or racialized categories used by social workers raise important concerns regarding the nature of social work knowledge dominelli has argued strongly against individualistic postmodern theory which she says does not consider systematic patterns of discrimination along gender lines she also claims that postmodern feminism assumes that power subsumes any form of opposition this seems a rather limited reading of feminist postmodern theories which are not based on notions of the individual subject at all but are rather concerned with how subjectivity is produced through powerful discourses interested in how dominant knowledge forms arise and in how these may be opposed via various forms of subjugated but not silenced knowledge dominelli however argues for womancentered practice which seeks equality based on empowerment listening to the stories and validating the experiences of women a point that postmodern theories would reject as both naive and asserting a powerful claim about what kinds of knowledge count what such debates demonstrate of course is that what constitutes feminist social work is not agreed whites study argues women social workers anecdotal accounts of their experiences were of feminist identities that were fluid sometimes fragile or even nonexistent she is also critical of womancentered practice because this seems largely based upon community and voluntary models that exist outside of state social work while she is not critical of such feminist work per se white argues that the womancentered model of practice is largely isolated from an analysis of the features of the organisational regime of social work that are associated with its location in the state postmodern feminist social work theories reject the notion of egalitarian power relations as a fantasy that does not engage with the power dynamics that always exist between social workers and clients a point also made in earlier work power is not seen as a oneway street that is something always held by social workers over service users there is no space outside of power relations and so postmodern thinkers call for reflexivity about power within all practices the feminist model of empowerment for example may be criticized because it sees power as somehow given to the powerless service user by the powerful social worker but also because the notion of empowerment has been coopted by neoliberal state welfare so that it replaces any concern for wider structural change with individualized notions of choice queer and trans theory the influence of queer and trans theories on social work has been more limited to date but where this has been addressed then the notion of gender itself is challenged the dichotomous view of gender is brought into question as this is a powerful technology for the regulation of persons social work writings on trans people generally caution against the reification of gender categories with phrases such as gender variant or gender nonconforming also being used yet at the same time there may be a tendency in some accounts to theorize transgender identity based upon developmental stages or gender as something fixed by the age of 3 spade however argues that the vulnerabilities of trans people especially those marginalized due to poverty are the result of legal and administrative systems of domination that employ rigid gender binaries queer and trans theories thus argue that the category gender should be questioned and it is to this that i now turn opening up the debate on gender enough already with gender the reason for such exasperation has to do with the way gender has become operationalized in gender research projects in many of these instances gender is taken for granted as the point of departure for a set of descriptions of social practices understood as an adjective that qualifies established objects of social science gendered work gendered performance gendered play in fact there is little inquiry on the production of difference collins black feminist thought argues that feminist work on gender has largely reflected the experiences of white middleclass women writing mainly about african american womens experiences collins argues that many arguments within feminist theory such as the role of women as carers in the home or the oppressive nature of family life do not consider black womens experiences of work or of the positive role that black families might play in helping to challenge racism this is not to valorize the black family or to deny the significance of sexism but rather to insist that feminism and any account of gender relations must take questions about race on board as well as this absence of race black feminist writers also identify the construction of racial stereotypes within some theories in relation to questions of sexuality too feminist theories have been criticized for their heteronormativity lordes work for example has asked not only why race but also why sexuality and lesbianism in particular has been missing from some feminist accounts rubin too argues that feminism is not necessarily the preferred theory of sexual oppression and that in some cases feminists have proposed a very conservative sexual morality of course this is a complicated picture since rubins objections are in some cases toward forms of lesbian feminism that she found to be restrictive or hierarchical but she is also making a case not against feminism but against theories that see sexuality merely as a derivative of gender material and structural accounts of gender materialist or structuralist accounts focus on institutions such as the family or the workplace in order to examine how gender inequality is produced and reproduced within such settings connells work for example describes gender as the structure of social relations that centres on the reproductive arena and the set of practices that bring reproductive distinctions between bodies into social processes this is because she views gender as a pattern within wider social relations and so is critical of any gender theory that does not consider issues such as education domestic violence or health all of which are gendered for connell then societies exhibit a gender order another example of structural theory is rismans work on family relations risman argues that institutions such as workplaces or the family produce inequality between women and men she makes a case for a focus on material constraints which she sees as lacking from other theories for risman gender is a structure that has consequences for people at individual interactional and institutional levels her study of single fathers is particularly interesting in this respect as they were engaged in homemaking and caring for children indeed risman refers to single fathers work as mothering since she found that responsibility for home and care is better explained by parental role rather than gender risman also says that single fathers described themselves as more feminine than did other men thus for risman a family structure in which there is one male parent determines gender in the sense that this results in a particular sense of self and in work usually associated with women in heterosexual couple families women were far more likely to do this caring work it is possible to raise some questions about this perspective not least in terms of methodology because risman largely tests for gender as a measurable variable this does not allow much space for the negotiation of gender within an interactional context or the role of language in that process indeed risman is rather dismissive of indepth interviews due to the distortions and failures of memory that she sees in such methods however it is also important to acknowledge that rismans view of gender as a structure does not see this as determinative since in some cases those structures and their consequences may be challenged however rismans point is that institutional forms constrain ways of behaving or they have certain gendered consequences such as inequalities between women and men this approach to gender is often taken up in work on stratification of social work organizations here it is argued that the gendered structure of social work with a disproportionate number of men in senior and management positions results in gendered inequality for women in terms of treatment and career prospects yet it would also be possible to argue that such explanations tell us little about how gender works in these settings are men and women treated differently regardless of race sexuality disability class or other issues if the explanation for inequality is merely gender difference then how exactly do gendered ideas about persons arise within social work in the first place how are dominant or oppressive ideas about gender resisted within social work teams or settings is gender the primary factor or point of identification for social workers these kinds of questions which structural explanations often avoid bring us on to the question of how gender is produced through practices the practice of gender for ethnomethodologists a problem with structural accounts is that these assume an institutional form results in gendered consequences but this does not ask how gender is achieved what practices for example produce a gendered institution or society and how are these in fact constitutive of something called gender instead ethnomethodological accounts are concerned with how gender is achieved in everyday life that is with how all people ordinarily achieve a gender status garfinkels study of agnes a person who presented as intersex but later revealed herself to be a transsexual woman was undertaken not to demonstrate the special features of intersex persons or transsexualism but rather to show that for all people sex status is an ordinary social achievement garfinkel argued that social life is rigorously dichotomized into the natural ie moral entities of male and female and so in order to be taken for a normal person one has to be taken for a man or woman but this process involves various cues to do with appearance speech biography and so on that each person gives so for garfinkel members practices alone produce the observabletellable normal sexuality of persons this work was developed further in kessler and mckennas study which argued that the attribution of gender is a primary feature of everyday life and that what they term gender role refers to a set of prescriptive characteristics or expectations kessler and mckenna argue that this process of gendering persons into just one of the two categories is fundamental to social life and yet unremarkable this allows for example for the presentation of gender as a social fact in which some theorists or researchers account for certain behaviors as caused by gender these arguments influenced the doing gender perspective of west and zimmerman which states that gender is the activity of managing situated conduct in light of normative conceptions of attitudes and activities appropriate for ones sex category crucially this emphasizes the concept of accountability because a person engaged in virtually any activity may be held accountable for performance of that activity as a woman or a man to do gender is not always to live up to normative conceptions of femininity or masculinity it is to engage in behavior at the risk of gender assessment in later work on doing difference west and fenstermaker have shown that similar processes apply to race and class west and zimmerman have also been critical of structural perspectives which assume that gender may be undone in order to undo inequality they argue that gender is not so easily abandoned since all of everyday life is accountable in gendered terms risman has suggested that the doing gender perspective is in danger simply of labelling any activity as masculinity or femininity and along with others argues that this may give the impression that nothing can change in the sense identified by butler of gender being treated as a given explanation for phenomena rismans point is important but this would be a misreading of ethnomethodological claims ethnomethodologists explore what ordinary people count as examples of masculinity or femininity and are interested in transformational possibilities after all they see gender as a moral not merely practical order thus deutschs proposal to reserve the phrase doing gender to refer to social interactions that reproduce gender difference and to use the phrase undoing gender to refer to social interactions that reduce gender difference seems simplistic how do we know when gender is being either reproduced or reduced and isnt it possible that both are occurring within any interaction that appears to involve gender within social work ethnomethodological perspectives on gender are rare but there is research that considers gender as practice po¨so¨s work in which probation officers attempted to identify whether speakers in transcripts were female or male demonstrates contradictory views of and methods for identifying gender generally talk about emotions relationships or children were associated with women and objectivity and reticence in speech associated with men po¨so¨argues that gender is situational and casespecific and that more attention should be given to the ways in which it is practised scourfields ethnographic study of a childcare social work team examines constructions of gender and suggests an underlying dichotomy of men as abusers and women as carers women were primarily seen as responsible for childrens welfare and they were expected to protect children from abusive men with the failure to protect discourse a feature men were often described as dangerous threatening or absentirrelevant something that scourfield sees as part of the continued overlooking of men and blaming of women within child protection thus while there are multiple gendered discourses in the culture of the social work office that constitute the knowledge available to social workers these are at the same time both powerfully limiting and open to challenge butler and performativity butlers work on gender echoes aspects of ethnomethodology and doing gender since it is concerned with gender as a set of repeated acts within a highly rigid regulatory frame that congeal over time to produce the appearance of substance however butlers work also demonstrates the influence of poststructural theories and a concern with the heteronormative aspects of gendered practices noting that the heterosexualization of desire requires and institutes the production of discrete and asymmetrical oppositions between feminine and masculine where these are understood as expressive attributes of male and female the cultural matrix through which gender identity has become intelligible requires that certain kinds of identities cannot existthat is those in which gender does not follow from sex and those in which the practices of desire do not follow from either sex or gender of course this does not mean that other kinds of gender do not exist and butler uses the example of drag to show how gender is practised but also that it is always imitative by this she means that drag is no mere copy of an original gender but rather that in imitating gender drag implicitly reveals the imitative structure of gender itselfas well as its contingency in bodies that matter butler clarifies this performative sense of gender arguing that this is not about gender as an individual choice or mere play since performativity must be understood not as a singular or deliberate act but rather as the reiterative and citational practice by which discourse produces the effects that it names this is an important point because while butlers presentation of drag in gender trouble tends to suggest a challenge to traditional versions of gender work by others such as bridges argues that some forms of drag may be used as a temporary joke actually to reinforce normal gender indeed butler herself later noted that drag is not necessarily subversive butlers argument is that gender precedes the individual that is that subjectivity must be taken up through gender so one comes to be a person through being taken for a woman or man when an individual does not appear to be gendered in a normal way then it is that individual rather than the gender order that is questioned in relation to social work green and featherstone have analyzed butlers potential and have suggested that her work helps to challenge dogmatic and morally certain positions within antioppressive theory which they describe as a project that believes in its own innocence and construct s social workers as disembodied carriers of a pure project gender as discourse the emphasis in butlers work on the question of discourse is taken up in a range of theories influenced in part by the poststructuralist turn to language which consider gender as discourse these theories see gender as produced via social and textual practices which regulate the ways in which we may think about men women and others one important implication of this is that gender is not fixed nor is it simply attached to individuals instead people contest gendered meanings and subject positions although in order to be taken seriously they may well have to use familiar and expected ways of expressing themselves further as kessler and mckenna argued and butler acknowledged in her later work the reception of a gendered claim by audience or perceiver matters smiths discussion of femininity as discourse suggests that the very concept femininity is produced through practices and their embeddedness in texts so gender is not merely a structure or ideology imposed upon unwilling subjects but rather it is a complex of actual relations vested in texts this is an interesting point as we hear here smiths joint adherence to both a materialist and discursive account of gender which she sees as mutually dependent since gender is produced within both local and wider social relations that is a discourse of gender relates to peoples actions within localized settings and the organization of their ways of thinking and talking like garfinkel smith insists that gender is a moral order which means that it is coordinated with wider social and economic relations so that femininity is a textual discourse vested in womens magazines and television advertisements and so on the moral order attempts to position women and femininity only in relation to the more valued men and masculinity and for women this implies the need to be considered attractive or desirable a condition of participation in circles organized heterosexually smith refers to play and interplay within gendered discourse in order to argue that it does not prescribe action and yet she also reminds us that social texts establish recognizable concepts and categories so that what is done may be recognized as an instance of what is authorized thus to take up gender within discourse is to be recognized as demonstrating a proper instance of such that is a proper man or woman returning to social work and gender in my research i have argued for an analysis of gender as a practical achievement within everyday social work contexts drawing upon the ethnomethodological and discursive theories discussed earlier i have suggested that gender is neither a characteristic merely acquired and passed on through socialization or reproduction of structural forms nor something inherent in the person rather social work processes involve the production of gender through practical means which relate both to immediate local and wider institutional contexts an example of this would be my analysis of the ways in which notions about gender role are used within the assessment of lesbian or gay foster care or adoption applicants here i have demonstrated how social workers and applicants draw upon and produce ideas about gender in order to categorize identities or lifestyles and i have noted that in most cases the issue of gender role models has to be addressed in relation to gay and lesbian applicants and those applicants as well as some social workers who in other contexts are opposed to notions of gender role must conform since they are held accountable and while there is resistance to gender norms here a standard and institutional discourse dominates one in which adherence to a moral order that upholds expected gender roles is required this is confirmed in other research and reminds us of the ethnomethodological point that where any person is perceived to question standard gender in some way then it is usually that individual or group category rather than the gender hierarchy that is held to account since gender functions as a moral order this approach to the theorization of gender within social work emphasizes its reliance on other categories such as race or sexuality and its active production via interactions involving powerful linguistic claims moving us away from essentialist functionalist and to some extent structuralist accounts in using this article to review various theorizations of gender my point has been to highlight ways in which social work may be limited in the versions that it prioritizes the tendency to treat gender in isolation critiqued in some accounts or to take up a solely structural view indicates a reification of gender and an ignorance of its production through practice my argument has been that bar a few examples social work rarely connects with gender as practice ironic for a discipline so concerned with practical dynamics this then is also an argument for attention to the ways in which gender is produced through social work something that draws upon both the practical and the discursive rather than starting with something termed gender and then looking for its effects this may prove controversial in a field somewhat dominated by antidiscriminatory approaches that is where gender is considered at all yet it is my argument that taking up butlers inquiry on the production of difference may open up possibilities for less restrictive accounts of gender within social works various fields

this article contributes to the debate on gender and social work by examining dominant approaches within the field antidiscriminatory womancentered and intersectional accounts are critiqued for reliance upon both reification and isolation of gender via examination of poststructural queer and trans theories within social work the author then presents accounts based upon structuralmaterialist ethnomethodological and discursive theories in order to open up debates about conceptualization of gender these are used to suggest that social work should adopt a focus on gender as a practical accomplishment that occurs within various settings or contexts

introduction promoting condom use has been a key intervention in preventing the spread of hiv and other sexually transmitted infections when used consistently condoms can be up to 95 effective in preventing hiv transmission consistent condom users are 10 to 20 times less likely to be infected after exposure to hiv than inconsistent or nonusers 1 however condom use remains highly varied around the world one of the strongest determinants of condom use is relationship type condom use is typically high with commercial sex partners but exceedingly low with spouses or regular partners 2 thailand provides a case study that exemplifies such a pattern improving knowledge of the factors associated with condom use particularly among regular and casual partners in sex with regular partners and in sex with nonregular partners is a critical step towards increasing condom use and decreasing transmission of hiv and other stis factors that affect condom use demographic and relationship factors demographic factors such as age gender education and urbanicity have been linked to condom use in multiple previous studies in many countries men are more likely to report condom use than women in part because men are more likely to have sex with casual partners andor sex workers with whom condom use is more common 3 age is also important in understanding patterns of condom use younger people are more likely to have better knowledge of condoms and may be more likely to use condoms 4 urbanicity and higher education have also been associated with better knowledge of condoms 4 condom use in committed partnerships is often very rare for example marital status was the strongest predictor of condom use among women in uganda with currently married women least likely to report condom use at last sex 4 relationship characteristics such as the duration of a relationship and the frequency of new relationships also affect condom use ku and colleagues illustrated the sawtooth hypothesis of condom use where condom use declines as relationships lengthen and successive relationships are less likely to begin with condom usage 5 further previous research in madagascar has explored the fluidity between paid sex interactions and personal relationships with subsequent effects on condom use 6 condom factors other factors such as social norms around condoms and condoms impact on male pleasure are commonly provided reasons for lack of condom use multiple studies from thailand have documented perceptions among men that condom use reduces pleasure of sexual intercourse 7 therefore use of condoms requires a compelling reason such as fear of hiv infection to override the loss of pleasure 8 the availability of other methods of contraception with fewer perceived drawbacks than condoms may also explain unwillingness to use condoms in 2000 the most common contraceptive method used in thailand was the pill followed by female sterilization condom use was uncommon as a main contraceptive method 9 another common explanation for the lack of condom use in regular partnerships is the perception that condoms are primarily associated with disease prevention rather than contraception in regular partnerships condom use is typically higher when one partner is known to be highrisk than when neither partner acknowledges highrisk status 10 also condom promotion interventions among sex workers and their clients tend to be more successful than condom promotion interventions for committed relationships 11 more than onethird of respondents to a 1990 survey in thailand agreed that asking to use a condom with a regular partner is insulting to the partner due to the insinuation that condoms are only necessary when risk of disease transmission exists 8 access to condoms is a key prerequisite for condom use but one that remains understudied the 2006 national sexual behavior survey of thailand found that the second most common reason provided by men who did not use a condom at last sex with a casual partner was not preparedcould not find a condom at the time 12 it was found that increased access to condoms was associated with higher intentions to use condoms in a study of south african secondary students 13 condom access has been improved in many areas through the use of social marketing campaigns which serve to increase availability and decrease stigma 1415 hiv and condoms in thailand thailand provides a unique setting for the study of hiv and condoms due to the fact that the first hiv case in thailand was identified in 1985 and the first indigenous transmission was documented in 1987 16 the thai hiv epidemic was first identified in injecting drug users but quickly spread to commercial sex workers 17 sex workers in thailand are largely brothelbased though sex work is illegal it has a stable existence in thai society 8 in 1989 31 of brothelbased sex workers were hivpositive by 1994 the proportion had risen to 31 14 in 1991 the thai government implemented a national program to encourage condom use in all sexual encounters with commercial sex workers 17 the 100 condom use program included provision of free condoms to commercial sex establishments sanctions against establishments that did not use condoms consistently and a media campaign to provide hiv education and encourage condom use with sex workers 18 additionally multiple large research studies in thailand have explored knowledge attitudes and practices in relation to hiv and sexual behavior 8 as a result of the condom promotion program condom use with sex workers in thailand jumped from 14 in 1989 to 95 in 1993 19 from 1989 to 2000 the number of stis in thailand plummeted by more than 95 20 by 1996 the program may have prevented more than 2 million hiv infections 21 the 100 condom use program has been lauded around the world as a model of a costeffective intervention to prevent hiv and stis 2011 while condom use with sex workers is common in thailand condom use is inconsistent with casual partners and extremely rare among married couples 22 only 21 of sexually active thai high school students reported ever having used condoms 23 for most recent intercourse 27 of high school men but just 05 of high school women reported using a condom 24 qualitative research has found that the main barriers to condom use are interference with male sexual pleasure and the perception of condoms as prophylaxis for use with prostitutes 8 thailands unique cultural and historical context contributes to a setting with varied levels of condom use despite the presence of hiv and substantial government intervention as hiv transmission due to commercial sex declines thanks to the success of the 100 condom use program the relative importance of hiv transmission through casual and regular partners increases therefore the research aim of this analysis is to determine which factors are associated with higher levels of condom use among heterosexual thai males in sex with regular partners and in sex with casual partners methods the 2006 national sexual behavior study provides the data used in this analysis the data were collected by the institute for population and social research at mahidol university in bangkok thailand with support from unaids and the un thailand country team the 2006 nsbs is the third nationally representative crosssectional study in thailand to track sexual behaviors as well as knowledge and attitudes related to hiv aids the respondents were between 18 and 59 years of age the consent form was read and explained to them by the interviewers if the respondents agreed to participate in the survey the interviewers would sign their name in the informed consent form for the record indicating that they had informed the respondents and the respondents had verbally given informed consent to take part in the study the respondents would not sign their name in the informed consent form because in thailand the respondents would not be comfortable to sign document the study protocol including all these data collection and consent procedures were reviewed and approved by the institutional review board of the institute for population and social research mahidol university bangkok data collection the national probability sample ensured equal participation from men and women young adults and older adults and residents of rural areas nonbangkok urban areas and bangkok to recruit nonbangkok urban and rural participants 14 provinces were selected randomly with selection probability proportional to population size within each selected province two districts were selected within each district rural and urban areas were enumerated fourteen of the enumerated urban areas were selected from which four election districts were randomly selected with nine interviews per agesex stratum completed within each election district among the enumerated rural areas subdistricts were identified and three villages in each subdistrict were selected for each village a complete household listing was obtained and three interviews were completed for each age sex strata in bangkok 63 election districts were randomly selected and four households were systematically selected from each district the survey was completed inperson with sexmatched interviewers interviewer teams composed of two male and two female interviewers with one interviewer assigned to each agesex stratum were sent to each geographical location for data collection in all geographical areas the interviewers were sent to different households all household members were listed by sex and age group the interviewer then recruited a household member in the agesex strata assigned to that interviewer if such a person lived in the household but was not immediately available the interviewers made appointments to come back if there was no appropriate person in the household the interviewer moved to the household to the left a total of 6048 surveys were completed of which exactly half were completed by men each strata of age gender and location contained 504 responses the overall response rate was 81 with higher rates among young adults than older adults variables of interest condom use there are two outcomes of interest for this analysis reported condom use by males in relationships with regular partners and reported condom use by males in relationships with casual partners the survey instrument assessed frequency of condom use separately for the most recent regular partner and the most recent casual partner in the past 12 months the response options provided were never sometimes about half the time mostly and always for analysis reported condom use was condensed into a threelevel variable with categories of never sometimesabout half and mostlyalways using a threelevel outcome preserved statistical efficiency especially with the smaller sample size of men with casual partners while preserving the distinctions between different amounts of condom use however logistic regression analysis was conducted using dichotomous outcomes of condom use designed according to the difference of condom use distribution among the two groups we used dichotomous outcome of any condom use vs never use condom for regular partners and we used condom use with half or more sex acts vs use condom sometimes or never use condoms for casual partners the differences between these analyses and the analysis with three level categories mentioned above were found to be small and generally do not change the interpretation of the results we decided that in order to simplify the analysis the logistic regression analysis mentioned here will not be presented other than to describe the few differences partner type regular partners were defined as a partner with whom the respondent had sex for a period of one year or more or if the relationship was less than one year a sexual relationship expected to continue in the future casual partners were not regular partners who were not sex workers demographic and socioeconomic status the demographic and socioeconomic status variables includes age geographical location education occupation type and marital status for analysis age was included as a continuous variable geographical location was collected as bangkok other urban and rural respondents from bangkok and from other urban areas demonstrated similar patterns in condom use as well as other variables of interest so geographic location was reduced to urban and rural categories only education level was recorded as the highest level of schooling completed education levels were condensed in order to maximize power occupation type was categorized to professional sales service skilled technical labor and unemployed among men with casual partners occupation categories were reduced to highskill and lowskill due to their similarities in association with condom use and in order to maximize statistical efficiency marital status was collected as unmarried married and registered married but not registered and widoweddivorcedseparated due to low numbers of widowed divorced or separated men marital status was recoded to three groups single married and registered and married and not registered marital status was not included in the analysis of men with casual partners since 84 of these men were unmarried when marriage is registered the partnership is believed to be more serious than just living together where men usually will still consider themselves as single marriage without registration is mostly custom marriage which is considered to be also more serious than single persons living together as regular partners the attachment of marriage with this degree of seriousness is hypothesized to be more related to trust and fidelity access to condoms the survey included the question in your community or workplace is there a place to distribute free or lowprice condoms for analysis responses were dichotomized to yes vs all other responses condom knowledge and attitudes condom knowledge was measured by asking an openended question about which actions could prevent someone from contracting hiv respondents who mentioned using a condom without prompting from the interviewer were considered to have knowledge of the hivpreventive benefits of condoms attitude towards condoms was measured by asking participants to select the aidsprevention strategy they would choose among reducing sexual activity using condoms consistently or both respondents who chose using condoms consistently or using both strategies were considered to have procondom attitudes partner characteristics the total number of partners reported in the past 12 months was calculated and dichotomized into categories of one partner and more than one partner the duration of the most recent relationship in the past 12 months was categorized as 30 days or less 31 to 90 days and more than 90 days men were asked if they had ever given money in exchange for sex responses were categorized as never more than a year ago and within the past year analysis this analysis included only males because a very high proportion of thai females report just one lifetime sexual partner with whom condoms are rarely used while males report more variation in type of partners and in condom use 12 of the 3024 men participating in the survey 377 were excluded for reporting no history of sexual activity 28 for reporting sexual attraction to males and 313 for not having a casual or regular partner in the past 12 months an additional 24 cases were excluded due to missing information relating to condom access knowledge or attitudes the analytic dataset includes 2281 men of whom 1998 contribute to the analysis of regular partners and 520 contribute to the analysis of casual partners two hundred thirtyseven men contribute to both analysis sets all analyses were completed using sas version 92 25 since the sampling design intended to capture a nationally representative sample the data were weighted to national demographic characteristics chisquare statistics were used to evaluate the differences between proportions among levels of each covariate bivariate regressions provided the crude association between condom use and each of the predictor variables the proportional odds models were built by examining sociodemographic factors and condompartner factors separately and then together variables were eliminated from the full model based on statistical significance and tests of the difference of 2 times the log likelihood the score test for the proportional odds assumption was used to check the fit of the proportional odds models the validity of the proportional odds assumption was also verified by manual calculation of odds ratios using different dichotomous cutpoints in the categorization of condom use possible interactions between sociodemographic factors and condompartner factors were examined and collinearity between variables was evaluated no notable results were found for casual partners models were constructed predicting both high condom use and low condom use since most men with casual partners reported some level of condom use predicting low condom use provided slightly more power and smaller confidence intervals but did not change the magnitude of effects or the variables included in the final model therefore for clarity of presentation we present results for predicting high condom use among men with casual partners and with regular partners as for the conceptual framework for the analysis the independent variables considered will be classified into two groups as well as demographic characteristics as control variables the two groups are 1 risk perception factors related to perceptions of the risks of hivaids and std and 2 condom motivations factors related to the motivation to take preventive action by using condom risk perception variables include education marital status number of partners in the past 12 months duration of relationship or the newness of partners and the experience of giving money for sex condom motivations variables include unprompted knowledge of condom effectiveness in hiv prevention attitude of condom use as chosen strategy to reduce hiv risk and self report access to convenient and cheap condoms as for the control variables which are also used to address the possible bias due to the selectivity of men engaging in regular or casual relations these variables are age location and occupation results the study population consisted of men with an average age of 32 ranging from 1859 overall 15 of the sample had less than a fourth grade education while 13 were educated beyond high school almost all men with less than a fourth grade education were over 35 more than onefifth of men reported having more than one sexual partner in the past year employment in a skilled technical field was most common while 176 were unemployed more than half of the sample were married descriptive analysis revealed differences between men with regular partners and men with casual partners the weighted mean age among men reporting having regular partners was 337 men with casual partners were younger with a mean age of 274 almost half of men with casual partners were aged 1824 men with casual partners had more partners in the past 12 months than men with regular partners among men with regular partners the majority had just one regular partner and no casual partners in the past 12 months few men had one regular partner and one or more casual partners while 24 had more than one regular partner among men with casual partners slightly more than half had no regular partners and 531 had just one casual partner in the past 12 months more than onethird had one regular partner and one or more casual partners in the past 12 months men with regular partners in bivariate analysis all socioeconomic factors and condomrelated factors that we considered were associated with condom use increased age was associated with decreased use of condoms while urban residence was associated with increased odds of reporting higher levels of condom use increasing education displayed a strong trend with increasing levels of education associated with increased use of condoms such that compared to men with less than four years of education men with posthigh school education were 13 times more likely to reported higher levels of condom use the professionals are found to use condoms more than any other occupation except for the unemployed especially those who were employed as labor skilled and technical and salesservice workers were less likely than the professionals to report the higher levels of condom use the attachment of marriage with the higher degree of seriousness is found to be related to condom use being married and registered was associated with a tenfold reduction in the odds or reporting higher levels of condom use being married but not registered was associated with a sixfold decrease in the odds of reporting higher levels of condom use men in regular partnerships who reported having access to condoms were slightly less likely to report using condoms than men without access to condoms condom knowledge and procondom strategy choice were both associated with more than double the odds of higher levels of condom use as was having more than one partner in the past twelve months duration of relationship did not have a significant effect on condom use while recent payment for sex was associated with increased likelihood of reporting higher levels of condom use payment for sex in the long past decreased the condom use adjusting for sociodemographic factors in the multinomial proportional odds model moderated the effect of condom and partner factors the final multinomial model retained age education occupation marital status condom knowledge procondom strategy and relationship duration it should be noted that recent payment for sex remained to increase the likelihood of condom use when logistic regression analysis was conducted using dichotomous outcome of any condom use vs never use condoms the largest magnitude of effect is observed for education level particularly with high levels of completed education being married retained its substantial association with reduced levels of condom use shorter relationships 30 days or less compared to men with casual partners due to the smaller sample size many fewer factors were associated with condom use among men with casual partners age had a very small positive effect on condom use while urban residence did not affect condom use moderate levels of education increased the odds of reporting higher levels of condom use reaching significance for men with a senior high school education compared to those with less than a seventhgrade education the relationships are also found among the junior high and ba to be positive as expected but not statistically significant this may be because of the small number of cases among these two groups it is also possible that apart from formal education skill and informal training may also be important in condom use behavior contrary to the finding among regular partnerships men employed in labor sales or service jobs are more likely to use condoms with causal partners than the professionaltechnical occupation counterparts unprompted knowledge of condom effectiveness in preventing hiv transmission was associated with higher levels of condom use shorter relationships were also associated with higher levels of condom use than relationships lasting more than 90 days finally paying for sex more than a year ago was associated with lower likelihood of using condoms in a current relationship condom access and having more than one partner in the past year had moderately positive effects on condom use but did not reach significance the most parsimonious proportional odds model contained age education occupation condom knowledge relationship duration and history of paid sex however these variables explained less of the variation in condom use compared to the model on regular partners discussion this analysis utilizing data from a national survey of sexual behavior in thailand emphasizes the importance of education in determining condom use in regular partnerships and in casual partnerships among men with regular partners and men with casual partners higher levels of education are associated with higher levels of condom use however condomspecific knowledge is also found to have an impact distinct from years of schooling particularly for men in casual partnerships selfreported condom access was not associated with condom use among men with regular partners but may have a moderate effect on condom use among men with casual partners employment type and duration of relationship were important in explaining condom use in both men with regular partners and men with casual partners but their effects were different in the two groups the finding that access to condoms as measured in this study was not relevant to patterns of condom use is interesting in bivariate and multivariate analysis among men with regular partners and men with casual partners having cheap and convenient access to condoms had very little effect on condom use this result is somewhat contrary to expectation as lack of access to a condom was the second most commonly cited reason for nonuse of condoms at last sex with a casual partner in the same study used for this analysis 12 it is possible that relevance of condom access may not have been captured by asking about community locations for cheap and convenient condoms ie that asking about condom access in the community does not correlate with having a condom available prior to sexual activity this analysis also found that a relatively low proportion of men reported having access to a convenient location for cheap condoms compared to limited previous research in africa that found that 825 and 635 of young men could locate condoms within a tenminute walk 2627 however the importance of education in explaining condom use patterns is underscored by the fact that it was the variable with the largest magnitude of impact in the final multivariate models among men with regular partners and men with casual partners the significance of education in explaining condom use patterns has been established by previous research 2829 similarly among men with regular partners being legally married was associated with much lower condom usage a finding that is consistent with previous research 430 where to use condom use with a regular partner is viewed as an insult to the partner 8 or representing infidelity 30 in this analysis condomspecific knowledge did not fully align with years of formal education after adjusting for schooling knowledge of condom effectiveness was found to be significantly associated with increased odds of reporting higher levels of condom use among both groups of men the effect of knowing the condoms role in hiv prevention was stronger among men with casual partners than among men with regular partners which may be related to higher perceived hiv risk among men with casual partners on the other hand the higher level of condom use among men with regular partners had to be induced by a procondom strategy to promote their condom use one may have to change their condom attitudes first this is not found in the case of men with casual partners employment in lowerlevel jobs such as labor sales and services compared to professional jobs was associated with decreased odds of reporting higher levels of condom use among men with regular partners particularly laborers were found to be significantly associated with the lowest level of condom use these results are similar to previous research establishing lower levels of condom use among laborers farmers and factory workers 28 however among men with casual partners occupations in sales service or labor were associated with increased use of condoms compared to the professionaltechnical occupations this difference is intriguing further research is warranted and should also explore additional characteristics of the mens partners in addition to selected characteristics of the men themselves the study of the selectivity of men who were engaged in casual relationships would shed light to this discrepancy among men with casual partners shorter relationships were associated with more condom use consistent with previous research and supporting the sawtooth hypothesis 5 these men would be more aware of the risk of disease and concerned with pregnancy prevention with their new casual partners in contrast among men with regular partners shorter relationships were associated with less condom use on the one hand these men and their partners may be selective of the most faithful honeymoon period couples on the other hand they may have fertility intentions and want to start a family in contrast to casual partners and opposite to the sawtooth hypothesis regular partners were perhaps more committed and probably had to employ trust strategy even at the very beginning of their dedicated relationship however this finding deserves additional research men with casual partners who had never paid for sex tended to use condoms more frequently than men who had paid for sex in the past these men who never paid for sex may be more selective of those who were more conscious about safe sex and avoiding sexual risks among men with regular partners a history of paying for sex within the past year did not reach significance in the proportional odds model but was significant in the logistic model this suggests that men with regular partners who recently paid for sex are more likely to use condoms in sexual relations with their regular partner further studies are needed to test whether it is possible that these men may still visit sex workers andor may be aware of their possibility of infection findings from this study help to formulate a framework for future studies of the dynamics of condom use among different partners first although the characteristics and motivation of engaging in casual sex is not a public health policy issue understanding the selectivity of those who have extramarital andor casual relation may provide important insight on the subsequent condom use behavior future studies should address all possible demographic and socioeconomic status as control variables when analyzing the dynamics of condom use patterns at least age urbanrural residence and occupation should be investigated second risk perception factors may be more relevant to condom use behavior than condom motivation factors risk perception is associated with formal education in general but if data are available the life skill knowledge and other informal training in particular should be included in the investigation as well most importantly risk perception is also related to the perceived nature and type of relationship and partner characteristics under the theoretical framework of trust and fidelity these factors include the degree of attachment in marriage and partnership and the newness of relations for regular partners the higher level of attachment in marriage is associated with trust and fidelity and consequently less condom use as for the newness of relation again according to the fidelity assumption condom use is rarely seen during the honey moon period the dynamism of condom behavior is that for the casual partners according to the sawtooth hypothesis condom use is seen to be high during the firstmeeting period of casual relation and will decline with duration and strength of relationship how to keep risk perception of casual relation longstanding is the challenge of the intervention design lastly perceived risk is also related to previous or current sexual experience and the primary person to protect from infection self or partner for regular partners current experience of visiting sex worker or perhaps having multiple partners is associated with more condom use probably to protect their married or regular partners in contrast sex with casual partners was found to be more protected among men who did not have experience with sex workers the protection is probably meant for these men themselves rather than for the protection of their partners third condom motivations or factors related to motivation to take preventive action by using condom should also be highlighted in the condom behavior framework in this study knowledge of condom effectiveness in hiv prevention and attitude of condom use as a strategy to reduce hiv risk are found to be associated with higher levels of condom use however further studies on access to convenient and cheap condom sources are still needed this is especially important since the public health intervention with appropriate and effective heath information messages even in population where the majority of people are aware of condom effectiveness in preventing hiv are still to be carefully designed the strengths of this analysis include the substantial sample size drawn from a national probability sample of adults in thailand a country with substantial variation in condom usage due in part to a unique history of condom promotion messages however there were relatively few men who reported having a casual partner in the past year this limitation hindered our ability to determine the true association between condom use and many variables of interest notably less of the variance in condom use among men with casual partners was explained by the factors considered in this analysis however important results were drawn from the analysis of men with regular partners confirming previous findings relating to the impact of marriage and education clearly more research is needed on the use of condoms during encounters with casual partners in thailand particularly since hiv transmission through commercial sex has plummeted following the governments 100 condom use program hiv transmission through noncommercial partners is of increasing importance additionally future studies should explore additional dimensions of condom access that may be more relevant in explaining condom use patterns exploring the determinants of perceived access to condoms may also be fruitful in identifying populations at risk and effective interventions to increase access to condoms apart from the issue of access one should also take into account the dynamics of mens decision or strategy to use or not to use a condom with different types of partners with different stages of relationship and in the family and nonfamily context selfperception of own risk of infections related to their previous or recent relationship with sex workers or other casual partners also shaped their condom use strategy with their current partners continued effort towards determining the factors that are associated with condom use among thai males with their different types of partners and in a variety of partnership circumstances is crucial for designing appropriate and wideranging interventions to increase condom use and decrease transmission of hiv and other stis lastly the findings from this study suggest that policy and interventions to promote condom use to prevent hivaids and stds in thailand need to take into account both the demand and supply side that is not only the availability and accessibility of condom information and services but in contrast to campaign on condom use with sex workers the dynamics and sensitivities of condom use with more intimate partners have to be addressed it is especially important to distinguish regular partners who can be just living together or more attached to each other by registered marriage casual partners who are not paid partners but have intimate relationship need to be delicately attended risk perceptions of hivaids and stds and motivation to preventive action among these partners are not straight forward and interact with partner intimacy and fidelity issues first the national hivaids prevention campaign should start with the fact that everyone has the risk and that there are no specific risk groups regardless of age and sex and inside or outside of marriage second condom promotion should be desensitized by including the broader perspectives of health the focus should be on total health issues including reproductive health and healthy family planning method for spacing healthy childbirth prevention of stis where symptom of disease may not show condom campaign should also incorporate prevention against bv and hpv where sexual relation may not be involved third the program should at the same time tackle the political religious and community barriers concerning the sexual stigma in general and on casual and multiple partners intervention should address the gender bias especially on woman virginity and the family values that might overly stigmatize extra marital relations lastly in general condom campaign should be expressed in the terms of sanitation and health intimacy human relationship family and caring rather than related to sexual diseases

objective this study aims to determine factors associated with levels of condom use among heterosexual thai males in sex with regular partners and in sex with casual partnersthe data used in this study are from the national probability sample of the 2006 national sexual behavior study the third nationally representative crosssectional survey in thailand a subtotal of 2281 men were analyzed in the study including young 1824 and older 2559 adults who were residents of rural areas of thailand nonbangkok urban areas and bangkok two outcomes of interest for this analysis are reported condom use in the past 12 months by males in relationships with the most recent regular and casual partners who were not sex workers chisquare statistics bivariate regressions and the proportional odds regression models are used in the analysis results condom use for men with their regular partner is revealed to be positively related to education knowledge of condom effectiveness and procondom strategy and negatively related to nonprofessional employment status of registered marriage and short relationship duration condom use with casual partner is positively determined by education condom knowledge nonprofessional occupation short relationship duration and lack of history of paid sexthe national survey emphasized the importance of risk perceptions and condom motivations variables in explaining condom use among men in thailand these factors include not only education and knowledge of condom effectiveness and procondom strategy but also types of partners and their relationship context and characteristics program intervention to promote condom use in thailand in this new era of predominant casual sex rather than sex with sex workers has to take into account more dynamic partnerbased strategies than in the past history of the epidemics in thailand

introduction individualand arealevel measures of socioeconomic status are independent factors influencing major diseases and health outcomes 12 in many developed countries composite measures of ses and socioeconomic deprivation such as seifa in australia and carstairs index in united kingdom have been created 34 such indices are useful for geographically targeted resource allocation research and health educationinterventions and can be used to determine funding formula for primary healthcare services social services relating ses with health outcomes and risk factorsbehaviours as well as aid communitybased service providers in terms of pricing and pitching the appropriate services for communities with different ses visual impairment is a worldwide problem with huge socioeconomic consequences 5 individual low ses measured as low income education or social class has been shown to be associated with vi in several studies 6 at a population level distribution of vi may be related to socioeconomic factors 6 this is particularly true in asia where there is rising income inequality in many newly developed countries such as china taiwan singapore 7 both individual and areal level ses were reported to have independent predictive power in capturing community wide health disparities 8 in singapore we have previously reported an association between vi and individualand arealevel measures of ses such as low income education and occupation among indians and malays 910 no study to date however has looked at the relationship of a composite socioeconomic disadvantage index which includes several socioeconomic measures with the presence and severity of vi in singapore we recently created a socioeconomic disadvantage index to measure arealevel ses that reflects the composite socioeconomic circumstances 11 a single composite index would be more meaningful in understanding areal level factors which allows comparisons between groups and useful for geographically targeted resource allocation research and health educationinterventions for communities with different ses the aim of the current study was to investigate the independent association of individual and arealevel ses parameters with the presence and severity of vi in a large and multiethnic asian population in singapore using the individual level ses and the recently created sedi score representing arealevel ses 11 materials and methods study population and setting singapore is an island state with a total land area of 700km 2 12 based on the latest census data singapores total population was 508 million as at endjune 2010 of which 377 million were singapore residents 12 the three major ethnic groups in singapore are chinese malay and indian with the majority of migrants from across asia most chinese in singapore are ethnic descendants of immigrants from the outlying provinces of china with several different dialect groups consisting of hokkien teochew and hainanese cantonese hakka and other minority groups 1314 singapore indian residents encompass persons with ancestry originating from the indian subcontinent including india pakistan bangladesh sri lanka and nepal 1314 singapores malay residents include all people of malay or indonesian origin 15 15 individuallevel ses and covariates data data on individuallevel ses covariates and vi outcomes were derived from the singapore epidemiology of eye diseases program comprising of populationbased crosssectional data including the three major ethnic groups in singapore the singapore malay eye study the singapore indian eye study and the singapore chinese eye study these studies followed the same study design and sampling areas as previously published 1315 they used agestratified random sampling to select participants in each ethnic group and recruited 3280 ethnic malays 3400 indians and 3353 chinese aged 4080 years residing in the southwestern part of singapore including 8 development guide plan areas sampling areas of these studies were chosen in the southwestern part of singapore due to a fair representation of singapore resident population in terms of age distribution housing types and socioeconomic status 111216 written informed consent was obtained from each participant in both studies and the studies adhered to the declaration of helsinki ethical approval was obtained from the institutional review board at the singapore eye research institute education status monthly income and housing status were used as measures of individuallevel ses information on these ses measures was obtained using a standardized questionnaire persons were classified by educational level into three categories 1 primary or lower 2 secondary and 3 postsecondary income was based in singapore dollars and three income categories were created 1 low 2 middle and 3 high housing type was classified as follows 1 small size public apartments 2 medium size public apartments and 3 large public apartments or private housing we created a composite low ses variable defined as primary or below education monthly income less than 2000 sgd and residing in 1 to 2room apartments 17 information on covariates were obtained from a standardized interview questionnaire physical and laboratory examination diabetes mellitus was defined as random blood glucose of 111 mmoll use of diabetic medication or a physician diagnosis of diabetes 1118 hypertension was defined as having a systolic blood pressure 140 mmhg and diastolic bp 90 mmhg or the use of antihypertensive drugs 1119 hyperlipidaemia was defined as total cholesterol 62 mmoll or the use of lipid lowering medications 1120 cardiovascular disease history was defined as a selfreported history of angina heart attack or stroke 21 smoking was categorized into current past and never smoker and alcohol drinking was categorized into drinkers and nondrinkers arealevel ses data an arealevel ses was assessed using a sedi created using 12 variables from the 2010 singapore census through a principal component analysis 1222 details of the process derived socioeconomic indices were mentioned in the previous study 11 out of initial 23 area attributes from the census the following 12 area attributes were included primary education and below not literate unemployed construction industry hotels and restaurants industry clerical workers service and sales workers plant machine operators assemblers cleaners laborers related workers monthly personal income less than sgd 2500 monthly household income sgd 4000 a high sedi score indicates a relatively poor ses assessment of outcomes visual acuity scores were measured by logarithm of the minimum angle of resolution charts 23 vi was defined based on presenting va to take into account vi due to uncorrected refractive error which could reflect low ses based on pva in the betterseeing eye presence and severity of vi was categorized into no vi low vision unilateral low and normal vision bilateral low vision unilateral blindness and normal vision unilateral blindness and low vision and bilateral blindness 27 statistical analyses data analysis was performed using stata version 130 and level of significance was set at p 005 we combined all three ethnic groups for the main analysis ageadjusted prevalence rates of vi and blindness were calculated by the direct method using the year 2010 singapore census population as the standard population 12 we used a multilevel mixedeffects logistic regression to identify an independent association between individuallevel ses and arealevel sedi and the presence of any vi by taking into account the clustering of individuals within dgp areas 28 generalized linear latent and mixed models package was used to analyse different multilevel mixed effects models for the multinomial outcomes of presence and severity of vi low vision and blindness 2930 statistical assessment of interaction between individualand areallevel low ses was performed by fitting models containing crossproduct terms associations were examined after adjusting for individual demographic medical and lifestyle risk factors finally we performed subgroup analyses stratified by age groups gender and ethnic groups we also examined the association of low ses and sedi with characteristics of participants by multivariate logistic and linear regression models results out of 10033 participants 9993 were included for the final analysis after excluding those with unknown outcomes and dgp areas the crude and ageadjusted prevalence of any vi were 2796 and 1962 respectively and that of low vision and blindness were 1900 and 062 respectively vi data were assigned to 8 dgp areas only since the sampling area of simes sindi and sces was located in the southwestern part of singapore sedi scores of the included dgp areas ranged from 798 to 1201 bukit batok bukit merah bukit timah clementi jurong east jurong west outram and queenstown compared to participants with normal vision those with low vision and blindness were more likely to be older female malays had lower ses and higher prevalence of smoking diabetes hypertension hyperlipidaemia and cvd under corrective refractive error accounted for the majority of any vi and low vision and cataract represented a large proportion of blindness the association of both individual and arealevel ses with selected participants characteristics is shown in table 2 low individual ses was associated with older age female malay and indian ethnicity current and past smoking diabetes hypertension cvd and higher sedi scores ever consumption of alcohol was inversely associated with low ses increasing age diabetes mellitus malay indian and low ses were associated with higher sedi scores table 3 shows the associations of both individual and arealevel ses with the presence and severity of vi individual low ses was associated with the presence of any vi low vision and blindness arealevel sedi score was positively associated with the presence of any vi and low vision the odds ratioor of any vi was 211 for low ses and 107 per 1 standard deviation increase in sedi when stratified by unilateralbilateral categories low ses showed significant associations with all severity categories in particular with bilateral blindness and unilateral blindness and low vision sedi showed a significant association with bilateral low vision only there was a significant interaction between individual and areal level ses for the presence of any vi low vision and blindness and all severity categories in subgroup analyses the association between individual low ses and any vi remained significant among all age gender and ethnic groups and majority of the dgp areas although a consistent positive association was observed between arealevel sedi and any vi the associations were significant among participants aged between 40 and 65 years male and individual low ses the results from interaction and subgroup analyses showed that the effect of areal level sedi on vi differed with individual ses and the effect of individual low ses on vi differed in geographic areas discussion in this large populationbased multiethnic sample of asian adults we found both individualand arealevel ses to be associated with the presence and severity of vi independent of demographic medical and lifestyle risk factors in addition we found that the associations between arealevel sedi score and vi to be more pronounced in certain subgroups such as adults aged 4065 years and males to our knowledge this is the first study to use both individualand arealevel disadvantage indices to assess socioeconomic disparities in visual outcomes in asia importantly our findings show that although singapore has the third highest life expectancy in the world and a low infant mortality rate in 2013 31 the association of socioeconomic disadvantage with vi suggests that a similar or worse event may be evident in other developed countries worldwide the sedi score created in our study may provide a methodology for the assessment of the impact of arealevel ses on vi in other asian communities previous studies examining the association of disadvantage index with vi in us europe south africa and australia have shown inconsistent results 25 32 33 34 35 neighbourhood ses was found to be associated with low vision 25 late presentation of glaucoma 36 and severity of glaucoma at presentation 37 but few studies have reported no association of ses with vi 33 or presenting va in those with agerelated macular degeneration 38 our findings are consistent with the epicnorfolk eye study in europe reporting both individual and arealevel disadvantage index to be associated with vi and extends the findings to asian populations 25 however the effects of neighbourhoods are small in comparison with the individuallevel effect of being in a low ses group several studies have shown arealevel socioeconomic disadvantage to be associated with major risk factors of vi including diabetes and hypertension and adverse health outcomes including depression cvd and mortality 39 40 41 42 43 44 neighbourhood environment impacts health outcomes through mechanisms such as availability of healthcare services physical and financial access to health care infrastructure facilities that support healthy lifestyle environmental pollution and attitude towards health behaviour 24546 studies that reported an association between neighbourhood ses and visual outcomes suggested access to care as one of the mediating factors for example those living in areas with fewer eye care services 3547 or those with no insurance coverage 48 were more likely to have adverse visual outcomes in singapore most areas are wellconnected to health care offering vision services and therefore physical access to care is unlikely to explain socioeconomic disparities in vision related outcomes the singapore health care financing system comprises of meanstested government subsidies ranging between 20 and 80 and the balance paid by patients outofpocket or from medisave 49 50 the reason for the socioeconomic disparities in vi is therefore not clear in singapore cataracts accounted for the major cause of blindness in this study an earlier report that showed low ses to be significantly associated with cataract but not with cataract surgery which is readily affordable to most citizens in singapore through government subsidy and medisave payments 5152 socioeconomic disadvantage has been suggested to influence ones ability to access refractive error correction 53 54 as undercorrective refractive error accounted for the majority of vi and low vision in this population the outofpocket costs to correct undercorrective refractive error an outpatient service could explain the socioeconomic disparity in vi in this population inadequate literacy was found to be associated with vi among singaporean malays and those with limited literacy were more likely to be elderly and had lower income 9 therefore poor health literacy and lack of awareness could have contributed to blindness among those with low ses in singapore in addition those in the low ses could have poor dietary habits or poor metabolic profile leading to increased prevalence of major blinding eye diseases such as agerelated macular degeneration or diabetic retinopathy 5556 in the current study consistent with other studies females had a higher prevalence of blindness than males 57 that could possibly be explained by longer life expectancy 58 lesser education 59 greater biological susceptibility to ocular conditions leading to blindness 57 lower prevalence of cataract surgery 52 and poorer visual outcomes following cataract surgery 52 among females in singapore as the need for eye care services such as annual eye examination refractive correction and cataract surgery in singapore is expected to be substantially higher in future due to rapid aging of the population urbanisation and increasing prevalence of diabetes and hypertension more targeted public health interventions such as providing free eye screening services and glasses and increasing subsidises for cataract eye surgery are needed to reduce socioeconomic disparities in vision health the strengths of this study include a large representative and populationbased design and the use of multilevel mixed effects model to adjust for potential individual confounders our study has some limitations though first we derived our sedi score using the socioeconomic indices from the 2010 census data and it might not entirely reflect ses of participants at the time since outcome data were collected from 3 different periods second due to the crosssectional nature of the study design causal inferences cannot be made for example we may not be able to determine if those residing in low ses areas develop vi or those with vi move to low ses areas third findings from this asian population in singapore might not be generalizable to other asian population in the region due to differences in health care systems prevalence of eye diseases and composition of ethnic groups additionally it should be noted that sedi scores reflect the disadvantage of areas that individuals reside in rather than the individuals themselves not all individuals who live in an area with high sedi scores are disadvantaged and similarly a person who lives in an area with low sedi score may be disadvantaged finally a largescale study comprising of a nationally representative population is needed to confirm this socioeconomic association with vi in singapore in conclusion we found an independent positive association between individual and arealevel ses with the presence and severity of vi our findings if confirmed in future prospective studies may have implications for developing targeted public health interventions aiming to reduce the burden of visual loss in those living in low ses areas in addition to individual ses as the study involves human participants the data cannot be made freely available in the manuscript the supplemental files or a public repository due to ethical restrictions nevertheless the data are available from the singapore eye research institutional ethics committee for researchers who meet the criteria for access to confidential data the request can be sent to singapore eye research institute this study was funded by biomedical research council 0813519550 and national medical research council star00032008 singapore the funding agencies had no role in the research presented in the paper and the researchers were fully independent in pursuing this research all authors contributed to the intellectual development of this paper el and ae conceptualized the study ae and cs designed the analytical plan ww analyzed the data and wrote the first draft ae cs cyc mo tyw and el provided critical corrections to the manuscript tyw supervised data collection

to investigate the independent relationship of individualand arealevel socioeconomic status ses with the presence and severity of visual impairment vi in an asian populationcrosssectional data from 9993 chinese malay and indian adults aged 4080 years who participated in the singapore epidemiology of eye diseases 2004diseases 2011 in singapore based on the presenting visual acuity pva in the betterseeing eye vi was categorized into normal vision logmar030 low vision logmar 030 100 and blindness logmar100 any vi was defined as low visionblindness in the pva of betterseeing eye individuallevel lowses was defined as a composite of primarylevel education monthly income 2000 sgd and residing in 1 or 2room public apartment an arealevel ses was assessed using a socioeconomic disadvantage index sedi created using 12 variables from the 2010 singapore census a high sedi score indicates a relatively poor ses associations between ses measures and presence and severity of vi were examined using multilevel mixedeffects logistic and multinomial regression modelsthe ageadjusted prevalence of any vi was 1962 low vision 19 blindness 062 both individualand arealevel ses were positively associated with any vi and low vision after adjusting for confounders the odds ratio 95 confidence interval of any vi was 211

psychological social and cognitive development of their children yet there continues to be a dearth of research on the parenting of fathers especially in early childhood the recent increase in research on father involvement and the development of fatherspecific interventions necessitates a better understanding of the unique contributions of fathering to child development numerous studies have established a sequence of processes from marital conflict to hostile parenting to child aggression with some showing a particularly strong association between these links for fathers but the majority of studies have been conducted with mothers and older children in biologicallyrelated families there is a particular paucity in our understanding of this sequential process in toddlers with little attention paid to these pathways for fathers as compared to mothers understanding the etiological factors that lead to early childhood aggression is critical to prevention and intervention efforts as a substantial percentage of individuals with the most severe conduct problems during middle childhood and adolescence typically begin showing these behaviors between the ages of two and three gaining further clarity of fathers roles in the development of aggressive behaviors is essential to current fatherhood initiatives family systems theory is often used to explain the links between marriage and parenting within this framework families are hierarchically organized systems with multiple subsystems including the interparental parentchild and sibling relationships the interdependence of these subsystems allows for the influence of emotional and behavioral dynamics within the interparental subsystem to impact the parentchild subsystem one theory that has been developed and tested to explain this interdependence is the spillover hypothesis which suggests that a highly conflicted marriages place emotional distress on parents leading to deterioration in parenting quality andor b emotions aroused in one family relationship spillsover into another there have been numerous studies that provide data to support this theory showing that marital hostility is associated with increases in parentchild hostility and parental rejection some studies have suggested that fathers parenting may be more sensitive to marital problems than mothers while others have not to our knowledge only one study has examined the spillover hypothesis in relation to child adjustment in children under age five in biologically unrelated families rhoades and colleagues found an indirect effect of marital hostility when infants were 9 months of age in relation to toddler angerfrustration at 18 months via parental harsh discipline financial strain and family process economic distress has consistently revealed direct associations with marital hostility and indirect associations through marital conflict on parenting studies by conger and colleagues have clearly shown a cascade from financial pressures to marital conflict to hostile parenting the latter of which has been associated with child externalizing problems in adolescents studies highlight the importance of subjective financial strain and worry not simply poverty or low ses on the family system others have found similar results with school aged children and adolescents financial strain appears to be equally stressful and impact marital conflict for mothers and fathers studies suggest that marital hostility may reflect subjective experiences of economic strain that could operate through marriage to intensify the spillover or simultaneously impact the entire family environment researchers have called for examination of these processes in early childhood when the impact of financial worry and family processes may be the strongest importance of parent antisocial personality traits antisocial and other personality traits are defined as a set of enduring characteristics that affect behavior and perceptions numerous studies have found strong associations between parent antisocial traits marital conflict and negative parenting there is evidence of a genetic component to this spillover from marital hostility to parenting as data from twin samples reveal personality traits including aggression explain 33 to 42 of the covariance between marital quality and parenting for both mothers and fathers furthermore geneticallyinfluenced aggressive personality traits are correlated with conflict in the family the potential role of genes in the spillover of marital conflict to parenting and child aggression although there is significant evidence of the spillover hypothesis in the research literature and some evidence of the impact of this spillover to child functioning associations between parenting and child externalizing behaviors also may be influenced by shared genes as children share 50 of their genes with each biological parent the same genetic factors that influence hostile parenting might also affect the expression of child aggression thereby creating an association between hostile parenting and child aggression that is the product of shared genes rather than a direct effect of caregiving metaanalyses have suggested that the heritability of child aggression is in the moderate range hicks and colleagues found that parents pass on a general vulnerability for externalizing disorders that is highly heritable and is equally transmittable from biological mothers and fathers studies of adopted twins reveal that children may inherit a vulnerability to antisocial behavior but are also influenced significantly by the postnatal environment as genes may also account for the association of marital conflict and hostile parenting it is possible that they may explain the entire cascade from marriage to parenting to child aggression the current study the literature supports a study that examines 1 the spillover of marriage to paternal parenting to child aggression in very early childhood 2 the strength of these associations in nonbiologically related families to disentangle environmental and genetic effects on this cascade 3 the unique contribution of both mothers and fathers in the same model and 4 simultaneously considers factors such as parent antisocial traits and financial strain that have clearly been linked to spillover in the research literature this study models the spillover of hostility in the marriage to mothers and fathers hostile parenting to toddler aggression to determine if these environmental pathways are significant in genetically unrelated parenttoddler dyads we test the hypothesis that family financial strain and parental antisocial traits will be significantly associated with marital hostility and hostile parenting and that financial strain will have direct associations to toddler aggression we simultaneously examine genetic risk via birth mother antisocial behaviors we expected that marital hostility would be significantly associated with hostile parenting for both adoptive mothers and adoptive fathers in turn we expected hostile parenting to be positively associated with toddler aggression from 18 to 27 months financial strain would be positively associated with marital hostility and child aggression adoptive parent antisocial traits would be positively associated with marital hostility and hostile parenting and higher levels of birth mother antisocial behaviors would be associated with higher levels of toddler aggressive behaviors at 18 months methods procedure birth mothers were assessed between 3 to 6 months and again at 18 months postpartum adoptive families were assessed when the child was 18 and 27 months old all participants were paid for their time following informed consent procedures interviewers asked participants computerassisted interview questions and each participant independently completed a set of questionnaires full details on the egds study recruitment procedures sample and assessment methods are reported elsewhere measures child aggressionchild aggression was measured using the child behavior checklist 155 version when the child was 18 and 27 months of age for purposes of these analyses am and af reports on the aggression factor were used to best account for both mother and father reports am and af reports were averaged to create a composite measure reflecting the mean level of child aggression am and af scores were correlated at r 27 at 18 months and r 36 at 27 months martial hostilitymarital hostility was assessed using the hostility index of the behavior affective rating scale adoptive mothers and fathers were asked to report on their partners hostility toward them when the child was 27 months of age each parent reported on a 7point likert scale how often in the last year hisher partner acted in a hostile way such as criticize you or your ideas shout or yell at you because heshe was mad at you ignore you when you tried to talk to him or her hit push shove or grab you scores from the 13item hostility subscale were summed to create a marital hostility score for ams and afs am and af scores were significantly correlated and were averaged to create a composite measure reflecting the mean level of perceived marital hostility in the family parenting hostilityafs and ams reported about their own and their partners behaviors on the hostility scale of the iowa family interaction rating scales when the child was 27 months old on the iowa parents reported on their own and their partners hostility toward their child on a 7point likert scale parents reported on the frequency of the behavior in the last month sample items include shout or yell at himher because you were mad at himher criticize himher or hisher ideas hit push shove or grab himher am and af reports of parenting hostility were significantly correlated for afs and ams two composites were created reflecting the mean of self and partner reports for af and am hostile parenting financial strainfinancial strain was reported by am and af separately when the child was 27 months old this measure has been used in previous studies and asks parents to report how much difficulty have you had paying bills each month how much trouble have you had making ends meet higher scores indicate greater subjective experiences of financial strain am and af reports of financial strain were highly correlated the mean of am and af reports were used to form one construct to represent subjective financial strain within the family the financial strain variable was significantly negatively correlated with am and af reported household income adoptive parent antisocial traitsadoptive parent antisocial traits were measured when the child was 18 months of age using an adaptation of the antisocial action scale which is a 13item scale resulting in a sum score representing psychopathy and antisocial behavior sample items include lying comes easily to me i cheat at work or other places i dont care if others get hurt as long as i get what i want items were summed to create scores for am and af birth mother antisocial behaviorbm antisocial behavior was measured using the 38item elliot social behavior questionnaire birth mothers reported on items reflecting their engagement in various delinquent behaviors over the previous 12 months at 3 to 6 months and 18 months postpartum items were summed at each time point to create an antisocial behavior score that was logtransformed to reduce skewness bm reports at each time point were significantly correlated and were averaged to create a mean composite score for bm antisocial behavior additional covariatesseveral additional covariates were examined that could confound results these were adoption openness openness in adoption was examined to account for the potential influence of postadoption contact between birth and adoptive families the level of openness in adoption was measured when the child was 27 months of age using a 7point openness scale that was independently reported by adoptive mothers and adoptive fathers perinatal riska perinatal risk index score was derived using the mcneilsjostrom scale for obstetric complications which assesses 1 maternal pregnancy complications 2 labor and delivery complications and 3 neonatal complications a total was created by summing the frequency of responses greater than three analytic strategy structural equation models were generated with full information maximum likelihood estimate procedures using amos version 180 two sets of models were analyzed the first set tested a simple spillover hypothesis of marital hostility effects on child aggression through indirect effects on af and am parentchild hostility the second set incorporated hypothesized covariates including financial distress af and am antisocial behavior earlier child aggression and bm antisocial traits two additional covariates adoption openness and perinatal risk were dropped from the analyses as they were not associated with child aggression or parenting behaviors in preliminary correlation analyses for modeling we used a multiplerater approach to measuring financial strain marital hostility hostile parenting and toddler aggression which helps ensure that any observed associations are not merely the result of shared method or informant variance to evaluate model fit we used the model chisquare test along with two additional fit indices the comparative fit index and the root mean square error of approximation browne and cudeck results model variable correlations descriptive statistics and correlations among all study variables are reported in table 1 as expected correlations between marital hostility af and am hostile parenting and childrens aggression were small to moderate and significant bm antisocial behavior perinatal risk and adoption openness were all unrelated to child aggression at 18 and 27 months marital hostility hostile parenting and child aggression the initial model specifying a simple spillover hypothesis resulted in a poor fit to the data χ 2 2221 p 00 cfi 76 rmsea 18 allowing for correlated error variances between am and af hostile parenting resulted in a significant improvement in model fit with no appreciable change in the estimates of association between study variables consistent with study hypothesis the direct effect of marital hostility on child behavioral outcomes was nearzero and nonsignificant in the resulting model this direct path was dropped and the final model presented in figure 1 resulted in an excellent fit χ 2 236 p 12 cfi 98 rmsea 07 as hypothesized there was a significant association from marital hostility to both af and am hostile parenting which were individually associated with toddler aggression next we tested the fit of the full hypothesized model as with the simple spillover model the initial model resulted in a poor fit to the data χ 2 4331 p 00 cfi 90 rmsea 06 which was resolved when we accounted for correlated error variance between am and af hostile parenting variables χ 2 2495 p 16 cfi 97 rmsea 03 again the inclusion of this effect and removal of the direct path from marital hostility to child aggression did not alter the parameter estimates for study variable associations model results indicate the paths from financial strain to marital hostility and child aggression were significant af and am antisocial traits were significantly positively associated with both marital hostility and hostile parenting paths from marital hostility to af hostile parenting to toddler aggression and marital hostility to am hostile parenting to toddler aggression were all significant bm antisocial behavior was not a significant predictor of child aggression child aggression at 18 months was significantly positively associated with both am and af hostile parenting at 27 months discussion results of the current analysis support the spillover of marital hostility to hostile parenting for fathers and mothers of biologically unrelated children these findings provide evidence for the importance of the marital and parenting environment on the change in toddler aggression from 18 to 27 months as previously shown the association from marital hostility to parenting may be slightly stronger for fathers this finding has implications for intervention efforts and supports results from early prevention and treatment studies targeting parenting andor maritalcoparenting as intervention targets to reduce externalizing problems in young children given that current results indicate mothers and fathers hostile parenting equally contribute to toddler aggression further exploration of the impact of these kinds of interventions for both parents is warranted financial strain was related to marital hostility which in turn was linked to hostile parenting and child aggression this finding is consistent with other studies in biologicallyrelated families linking subjective experiences of financial strain to conflicted marital relations hostile parenting and child externalizing parents financial worry was also directly associated with child aggression independent of parenting in fact the direct association between financial strain and child aggression is an important finding and suggests parents subjective experiences of financial strain are a pervasive risk factor for child problem behavior within the family system antisocial traits of adoptive parents were significant correlates of marital hostility and hostile parenting for both mothers and fathers this is consistent with several studies suggesting parent personality traits impact the amount of spillover from marital conflict into the coparenting domain and others who have found parent behavior is more powerful than genetics for adopted children the significant contribution of adoptive parent antisocial traits on parenting hostility and through parenting to child aggression was not surprising in light of previous work however this study is the first to establish in toddlers that this chain of events is not likely attributable to genes shared by parents and children antisocial traits were a correlate of hostile parenting in this nonclinical sample in clinical settings with families characterized by higher levels of antisocial traits and socioeconomic distress the contribution of these factors to marital conflict hostile parenting and child aggression may be even greater moreover although these analyses are limited by their predominantly crosssectional nature and sole reliance on parentreported data it is improbable that within a longitudinal design childtoparent effects would be evident with respect to parent antisocial traits it also is not clear whether reciprocal effects would be evident on financial strain although this remains an empirical question there were significant direct paths from 18 month child aggression to am and af hostile parenting which are consistent with other reports of a reciprocal relationship between child behavior and parenting despite their limitations these data are useful in thinking about current interventions that have been shown to be effective and the reasons for their success with respect to treating antisocial traits in parents recent data suggest a link between these parental behaviors and their adverse but malleable cognitions about the child further focus on these cognitions within interventions targeting early childhood externalizing has strengthened already effective treatments such as the healthy family program and the triple p positive parenting program these data also alert the clinician to the importance of parents subjective experience of financial strain on the family system as a whole and the need to assess the impact on both marriage and child adjustment birth mother antisocial behaviors were not associated with child aggressive behaviors in our sample there are several possible reasons for this finding 1 we did not account for genetic effects of birth fathers in our modeling others have found bf antisocial and criminal behavior to be associated with adopted child criminality in adulthood 2 genetic effects may become stronger with age or 3 there may be no direct genetic effect at this young age but genetic predisposition may enhance sensitivity to adverse environmental factors such as marital hostility conclusion this study revealed that marital hostility is associated with hostile parenting of both mothers and fathers which in turn is associated with changes in toddler aggressive behaviors from 18 to 27 months in nonbiologically related parentchild dyads it is clear the broad family environment is important to the development of toddler aggression and thus is an important area for prevention and intervention these findings support the further study of prevention and intervention efforts that target multiple facets of the family atmosphere including parenting and coparenting subjective financial strain and parent antisocial personality traits programs aiming to prevent emerging childhood externalizing disorders would benefit from a focus on comprehensive assessment of fathers mothers and children to understand the broad family context and areas of intervention need key points • whats known past research has shown clear links from marital hostility to hostile parenting to child aggression • whats new previous studies have not examined these links in early childhood for biologically unrelated mothers fathers and toddlers while considering contributing factors of subjective financial strain and parent antisocial traits on the family environment • findings there is clear evidence of the relationship of marital hostility to hostile parenting of both mothers and fathers to child aggression in toddlers even in biologically unrelated parents and children • financial strain and antisocial personality traits contribute significantly to this cascade from marriage to parenting to child aggression • parents subjective experiences of financial strain have direct associations with toddler aggression • implications prevention and intervention programs that target early childhood problem behaviors by focusing on coparenting andor parenting while also assessing the impact of financial strain on the family environment may have the most impact correlations and descriptive statistics for hypothesis variables abbreviations af adoptive fathers am adoptive mothers bm birth mothers

backgroundprevious studies have linked marital conflict parenting and externalizing problems in early childhood however these studies have not examined whether genes account for these links nor have they examined whether contextual factors such as parental personality or financial distress might account for links between marital conflict and parenting we used an adoption design to allow for a clear examination of environmental impact rather than shared genes of parents and children and assessments of parental personality and financial strain to assess the effects of context on relationships between marriage and parenting of both mothers and fathers methodparticipants were 308 adoptionlinked families comprised of an adopted child herhis biological mother bm adoptive mother am and father af bms were assessed 3 to 6 and 18 months postpartum and adoptive families were assessed when the child was 18 and 27 months old structural equations models were used to examine associations between marital hostility fathers and mothers parenting hostility and child aggressive behavior at 27 months of age additionally the contribution of financial strain and adoptive parent personality traits was examined to determine the associations with the spillover of marital hostility to hostile parenting resultsa hostile marital relationship was significantly associated with hostile parenting in fathers and mothers which were associated with aggressive behavior in toddlers subjective financial strain was uniquely associated with marital hostility and child aggression antisocial

introduction this research examines the perspectives of two years cohorts of early childhood studies students studying at isle of wight in the united kingdom and their views on higher education the participants were all mature students and experienced early years practitioners on a top up year studying to gain a full bachelors degree the ba early childhood four focus groups were held with a total of 24 students and a narrative method was used as a way of giving the students freedom to respond in their own ways the students answered the questions about the benefits of he in terms of professional development as had been intended but what was remarkable was what was said about their views of themselves and the personal barriers they perceived whilst undertaking he there were three emergent main themes logistical and financial professional and personal this paper concentrates on the responses that emerged associated with personal issues it focusses on how language was used to reveal these personal views it will consider various theoretical perspectives to explain this phenomenon bourdieus ideas around the linguistic market and a linguistic habitus foucaults discourse analysis and derridas phenomenological approach to language it will explore themes of selfesteem drive theory and the concept of imposter syndrome it will reflect on students feelings about he and how they express these feelings background early childhood education and care in england to provide a background to this study a brief historical account of government policy towards the early childhood education and care workforce should be recounted the unparalleled attention of ecec services nursery places and choices have roots from when mothers participation in the labour market increased during and after the second world war as a result a rapid expansion of nursery provision was recorded which coupled with relevant policy and curricula developments it is important to highlight the highly gendered composition of the ecec workforce in the uk and the lack of societal recognition ey practitioners have the workforce suffered a reputation of being low skilled low status and low paid while other professions such as social workers or qualified teachers enjoy higher status and more favourable working conditions since the childcare act 2006 all early years providers in england have been required to register and be subjected to inspection by ofsted ey practitioners have been subject to increased state regulation and accountability resulting in an increased workload and emphasis on technical competence and performativity despite all these challenges for the ey practitioners some of them are still choosing to enrol to he the private day nursery sector remains a competitive but fragmented market in england the overwhelming majority of nurseries are private voluntary and independent for which there are no requirements to employ qualified staff there has been much debate as to who can work with children and what kind of skills and qualifications nursery workers need these debates are based largely on the nature of ecec policies that seek to improve the quality of early years training and which set the standards that all early years providers must meet to ensure that children learn and develop well and are kept healthy and safe currently the ecec sector is experiencing big challenges in the uk post covid19 lockdowns and global factors eg environmental sustainability and the ukrainian war a number of key difficulties have surfaced such as financial sustainability for education and beyond young childrens emotional and communication skills but also how to support the sector and the ey practitioners what has become clear is the lack of support from the current government resulting in nurseries across the uk being forced to close or reduce their services at an alarming rate nurseries also reported that they are struggling to recruit and retain staff which is what our research findings also highlighted it is in this hostile political and national environment that this research has taken place another significance of the research was that it took place on the iow which is a small island located off the south of england this gave another dimension of the findings the main aim was to find out how the he degree helps the professional work and what the students were planning to do once they have completed their studies therefore the aim of the of project was to explore the ecec sectors perspectives of ecs degrees fd and ba top up and ecs graduates on isle of wight it hoped to map the terrain on the iow to get a better understanding what a graduate looks like and what the degrees offer the ecec sector on the iow the outcome of the research aimed to examine and improve the delivery of both foundation degree and ba top up at iow further education college the research the research was conducted in a further education college on the iow the study took place between 2021 and 2023 and the aims were to  to examine how the ecec sector see the graduate skills  to explore the value of early childhood studies degrees to the sector the expectation was that by conducting this research universities can offer a better tailored programme to students research method it has been claimed by many authors that focus group interviews are relatively common form of data collection in qualitative research but they are not without their challenges due to participants personal and professional responsibilities we were economical on time therefore forty minutes was allotted for each of four groups of six students as recommended by barbour and kitzinger for educational research although the data generated was less than would be expected from individual interviews the benefits of the collective view and the meeting of the psychological and social needs of the students compensated for this the idea that the data represents the truth about the world also can be challenged as it is historically and culturally specific and open to change this subjectivity is embedded within the interpretative paradigm allowing interweaving with the process of exploration rather than the following of a method the questions asked were open to allow the participants to tell their experiences and stories the questions asked were generally about the reason for studying their roles in the educational settings which meant that the semistructured nature of the focus group interviews provided opportunities for the interviewees to dwell on certain topics for example we gained rich data about the reason for staying on the iow to study we were also aware of the intensity when researching human experiences and that one of the fundamental aspects is that the researcher needs to be responsive to potential sensitivity of the interviewee and its possible impact on their emotions it is important to mention that participants knew each other in the focus group therefore their response reflects that they were familiar with each other it is also important to recognise the unintended consequences to this research the aims were to find out how the sample valued he and how ecec degrees were received by the sector however the responses used as the basis for this article were surprising and the level of emotive language used was intriguing as a result the research approach has taken the form of a grounded theory approach it has been the discovery of theory from the data the process was abductive ie observation into theory literature became significant as the data emerged the theory used to discuss the findings was used to account for the surprising or puzzling findings as a result conclusions were able to be drawn from the data about the emotional use of language from unanticipated findings findings the overall findings of the research were divided into three themes these were  logistical and financial  professional  personal the first illuminated participants views on issues they faced regarding practicalities of undertaking an he programme such as costs and travelling the second concerned the impact on professional development in ecec settings these were the expected responses as the aims of the research were to assess the benefits or otherwise of the programme however the third exposed the students selfperception and anxieties in relation to being in an he programme and it is this theme that will form the basis of this analysis from the theme of personal three subtopics emerged these were selfesteem professional development personal development the focus group data from these subtopics are presented below selfesteem many saw their personal and family situations as a disadvantage to studying and as a result did not see themselves as ever embarking on he one summed up the feeling of the group by saying they were …disadvantaged because they have children and other commitments some expressed the view that single parenthood was perceived to be another major hurdle to achieving in he im massively struggling to find anything that will fit in with solo parenting i dont have another person there either… of the perceived barriers some were logistical for example there is no university as such on the iow and the prospect of travelling to the uk mainland to go to university was not relished i havent got the mental capability to leave one of the participants had interviewed at a mainland university but was told in no uncertain terms that placements were difficult and that attendance was crucial and that living on the iow was a disadvantage some saw he as for other people and not themselves and even when they had the opportunity to study at an fe college on the iow they expressed a deficit of agency and power their view of their abilities to fit in and survive in higher he was blunt i personally wasnt ready at nineteentwenty to go to university i never thought id ever be the typical university student one found the prospect of going to a university intimidating i dont think i would have fitted in to the normal university life because its just so many more people and you are in a big lecture hall when one started they felt for the first like week or so i was like i cant i cant do this this is gonna be a nightmare because i was there like i dont know any of these things that theyre expecting you to do however anxieties were relaxed for one when i first started i was never really a university student i didnt really know how to do that but i feel like throughout time its just kind of sunk into my head a little bit despite the lack of status of the ecec sector there was a feeling in the group that after the initial nervousness reduced that their life experience had been useful preparation for university most of us like had children in our twenties and stuff i always wanted to do a degree and im glad now ive waited because actually doing it later on has given it more context professional development one theme that recurred throughout the data was that of confidence in their roles many of the group spoke about their lack of faith in themselves had held them back their feelings about their family situations and a sense that the professional world has left the ecec sector behind came through in this respect one felt that the programme had enabled her to …learn about children gain confidence in working with children to do job better it helped me progress because i was just a bank support worker and im now home coordinator an fda offers the opportunity for students already working in a sector to maintain their employment and study at the same time and this model was welcomed by the participants the students would typically move on to other roles in ecec such as school teaching and social work as well as specialist roles such as occupational therapy and psychology although the options available were appreciated the limitations of the iow were acknowledged achieving a degree was viewed as a way to develop their careers in the childcare sector and move away from nurseries and reception classes to go into a different route from early years but still work with children others were more specific the top up has opened doorsfor example to study for the certificate of education one participant claimed that the professional benefits of he had already paid off well i think just that its well worth it when its the right time for you the managers and supervisors in the sample had come to appreciate the skills and abilities that early childhood he offers these include depth of understanding communication skills and team working however most of the sample looked beyond practising in nurseries and reception classes when they achieve a degree i originally wanted to go into mental health … but now i am happy to see where it takes me however familiar doubts still expressed themselves there was still a feeling that the ecec workforce was still exploitative some felt that early years graduates could be recruited to positions which required only lowerlevel qualifications and therefore felt a level of exploitation saying on the iw schools advertise a lower level and take graduates for lowerlevel work schools recruit staff that need level 3 for their job from graduates to do higher level work for the same terms and conditions personal apart from a sense of achievement the respondents gave other personal benefits to studying in he these varied from the love of studying to validation to self and others all felt it was worth doing they spoke of the value of learning but also of benefits outside of a professional context these personal benefits included improved selfconfidence and resilience and a sense of doing it for myself yeah like ive really achieved something if i wasnt here if i hadnt done it i wouldnt be who i am now due to a feeling that they did were not really worthy there was a clear sense that the big university experience was not a welcome option and that they would not have coped in a larger institution some stated that the experience of he had given them a greater sense of patience and understanding and the feeling of personal achievement was pronounced its made me more resilient… so its helped me personally develop so now i approach other things in my life using the same mindset that i use in the degree and it does work and a renewed sense of confidence i am a different personmore confident id say it definitely brings confidence this spilt over into confidence about the workplace there was a realisation that what they their practice in ecec was of high value from job applications to faith in ability to take on new roles two commented ive got confidence when you fill out application form… your mindset in answering the questions and what theyre looking for i know what theyre looking for because its changed your way of thinking… you can understand what theyre looking for rather than before trying to fake it options and the confidence to apply for them have both increased as ive gone further and further through its opened so many different doorsactually i can do this and i can do that…there are so many options now than what i originally thought one significant finding was the impact on their selfconcept although it was acknowledged that the degree was useful for career development they all felt that it had its own value beyond professional development one state that her perspective had changed the degree expanded my world personal development it has changed the way that i think about everything realising that i am quite capable look ive done it although there was a sense of personal achievement… youve done it for you and nothing else …some felt that the impact on family was important one wanted to provide a role model for her son show the family i am studying he can see me studying and i can see him doing it …also to show my son that if i can do it he can do it too this newfound confidence through he could be positive for their selfconcept beyond the role of parenting for so long all i was a mum…there was nothing that was just for me if that makes sense…this was a chance to prove to myself that i am still capable of doing things like this and to rolemodel to my children that you can do things at any stage of your life also the sense of esteem within the family was evident whereas before they had been servants to the family they now saw a way of gaining appreciation from family members …some of the benefits of he were outweighed by the effort needed in he apart from being pregnant this is the most stressful thing ever its been horrendous i findings summary the language used by the respondents reveals the students experiences on early childhood he programmes on the iow are practical and developmental and they saw significantly wider benefits to he beyond purely professional development they revealed low levels of selfesteem before starting but levels of selfworth were raised by a sense of achievement although reluctant at first the group learned to embrace the more implicit benefits of he such as gains in confidence and authority he for this group gave an unexpected uplift to their sense of selves through achievement at something they initially had little confidence about however this sense of achievement does not manifest itself until students reach a level of confidence where they can see the potential benefits and possibilities having said this it was also acknowledged that the ecec sector does not fully appreciate those in the workforce that achieve degrees it was felt that they are often offered positions where a degree is not necessary there is a recognition that professional progression is possible ie away from nurseries and reception classes but holding a degree is a significant boost to the selfconcept and selfefficacy of students and this should not be underestimated theoretical discussion to conceptualise the responses on the theme of personal several theoretical viewpoints were consulted as a base from which to work on the concept of imposter syndrome was used to show how the participants felt they did not really belong in he to develop this theory on the nature and use of language was used to explain the responses this included general ideas about language and the self cultural capital and discourse analysis finally because there seemed to be some hidden meaning in the language used phenomenological theory on language was used to uncover what the respondents did not say but what was implied through what they did say this process of analysis was used to draw conclusions about the emotional responses of the students and these will be presented after the theoretical discussion the sample will be related to interchangeably as respondents and students throughout the discussion imposter syndrome from many of the statements made by the respondents there seemed to be a sense that although they had successfully and legitimately passed the necessary qualifications to study at level 6 some doubts persisted that they felt they did not fully belong this raises the issue of imposter syndrome young breaks the concept of imposter syndrome into five different categories and two of these are relevant to their feelings about themselves young writes about the perfectionist where the incumbent does not think they are as able as others think they are and then soloist where the need to ask for help leads to a questioning of their own abilities in response to these elements of youngs theory there was no evidence that the respondents thought that others perceived them as having authority in their subjects on the contrary they felt they had to prove themselves to others for example to family members this was also discussed in the study by mikuska and giancola et al where mature students motive to enrol he programme and reported that one of the reasons was to be the role model for their children there was also no feeling that asking for help was a sign of fallibility many of the students felt they had to rely on the advice of the university staff for support and confirmation of their abilities therefore there was little evidence that they fitted the soloist element of youngs theory however the other three elements of youngs theory were more fitting to the respondents in terms of the natural genius there was a sense that they felt others were more justified as being in he than them they seemed to feel that they did not naturally belong whereas others had more of a right or ability than they had to be in he following from this there was no feeling that they were experts in the words of young although they had legitimately achieved relevant qualifications to get where they were there was little feeing that they had become experts in their field likewise there was a sense that they had to put in very high levels of effort to achieve to avoid feelings of being a fraud in the words of young they felt they had to be super persons to justify achievement in he from this analysis it can be concluded that they feel they do not truly belong in education and they must punish themselves to justify their position on the programme the linguistic market in terms of cultural capital the respondents use of language revealed feelings of low levels of ambition and an acceptance of a low market position bourdieu wrote of language as a symbolic market where linguistic exchanges happen this refers to language as cultural capital where a persons linguistic skills determine their position in society through social power relations the language uncovered a sense of limited cultural capital and a perceived low position in social power relations bourdieu wrote of language as an internalised disposition of social background and that this language habitus can lead to success or failure in the linguistic market in language exchanges actors experience a system of positive and negative reinforcements and this affects their strategies of expression the participants certainly expressed an idea of their social backgrounds and cultural capital through their language and there was also a sense of them testing their ideas and beliefs to gain confirmation or rejection with a view to alter and adjust how they communicated in subsequent exchanges this was expressed through statements about the struggle to survive in he due to eg family circumstances and expectations of life after achieving a degree which was also the finding elsewhere some expressed a lack of confidence at being a student or feeling of fitness to go to university but other statements about the eventual benefits of he suggest that the students are testing their feelings to determine if they are shared by others as a way of confirming their view of themselves from this it can be deduced that coming from a low position in the linguistic market they use language exchanges as a way of validating themselves based on the reactions of others discourse analysis in terms of the expression of power through language the respondents expressed both negative and positive feelings foucaults ideas about language are associated with power relations through the meaning of language beyond the speaking itself according to foucault discourse is an expression of the interrelationship of language and society discourse transmits and produces power it reinforces it but also undermines and exposes it renders it fragile and makes it possible to thwart the respondents related to power in two ways on one hand they expressed a sense of powerlessness on the hand they related to a renewed sense of power because of he in terms of the former this ranges from expressing doubts about achieving because of family circumstances and reservations about embarking on he in the first place from being intimidated by others on the programme to feeling that others know more than them in terms of the second respondents who came to embrace an ability to think critically about the opening of career opportunities have also become more confident personally with changes to how they think more generally from this it is clear that the respondents have views about their own agency from a sense of powerlessness to newfound confidence différance what was interesting about the responses was the implicit meanings the students conveyed that were not said explicitly according to derrida words do not fully say what they mean they can only be defined through other words from which they differ literal meaning is impossible and is a form of fiction meaning cannot be present in itself because it refers to other words and meanings the literal proper meaning does not exist its appearance is a necessary function and must be analysed as such in the system of differences and metaphors derrida writes about différance as to defer and to differ ie how what is said defers to other meaning and how it differs from the other reciprocal words by analysing the responses and applying this principle what was not said can be important so in terms of the subtopics the implicit meaning of what the respondents were saying can be speculated on in the past a lack of confidence over communicating in a professional environment yes the way i see it is that its going to open a lot more avenues up for me career options were perceived to be more limited in the past personal development i am a different personmore confident in the past a perception of insecurity it just made me a bit more of a confident person in knowing what i know despite having knowledge in the past this was not recognised realising that i am quite capable look ive done it a perception of inability to achieve academically in the past culture in the person to explain the transformation of the sample concepts from the trajectory equifinality model with be used valsiner outlines several axioms for cultural psychology the first being that perceived stability of experiences is actually dynamic in terms of the samples responses they felt a sense of stability in their family and ecec situations before embarking in he their activities seemed to be isolated and closed but this stability is dynamic and can move subjects tend to slow down time for experiences which are felt as happy and speed up time for experiences felt as sad the sample have come to a realisation that their situation in ecec is not positive it is a semiotic pitfall and are ready to move time on to new experiences second valsiner argues that a person does not belong to a culture but that culture belongs to the person this culture that belongs is utilised for everyday living the sample have lived with one form of culture ie the experiences in their families and in the ecec sector and that has defined their expectations and ambitions the experience of he has changed the culture within them and they have adopted a new culture which reflects new expectations and ambitions this theoretical discussion reveals the perceptions of the students professional and personal situations operating in a female dominated sector noted for its low pay and status and perceived lack of professional status as well as the apparent hazards of ongoing regulation and accountability they feel that they are not justified in entering a professional world because of their personal and family situations they feel that they do not belong in he they express this through emotive languages that illuminates their perceived power position and it is only after they pass a certain tipping point that they realise that the experience and expertise they have accumulated in the ecec sector might be worth something after all from this it can be concluded that before entering he some of the respondents had experienced lack of confidence and anxieties in professional life influenced by the ecec sector and had surprised themselves with their newfound abilities from this they feel agency to extricate themselves from their current situations and adopt a different culture to facilitate their new way of individual living conclusions this research has unexpectedly shed light on the thoughts and feelings through language of professional and personal development of a group of students it has shown perceived lack of confidence and selfesteem low expectations and acceptance of lowlevel roles in the ecec sector however despite an uphill struggle benefits have been derived from studying in he these range from increased selfesteem and professional and personal development the reason these findings are unexpected is because the responses analysed here are highly emotive and personal this is more important because this is not what was originally intended or asked for and a paradigm shift this student groups habitus is of outsiders entering he under false pretences not only do they feel they do not truly belong in education but they also turn this anxiety on themselves to justify their imposition in he and prepare themselves for possible failure coming from a perceived low position in the cultural market they use language exchanges based on the reactions of others as a way of judging the legitimacy of them being in he in some cases views about their own agency emerge and these vary from a sense of powerlessness to newfound confidence their explicit responses are based on hidden anxieties about achievement in education and their professional lives the students have realised their academic abilities and that they can progress into more challenging roles however the students do not see this in a purely professional sense for them he has been a journey of personal change and growth and this should not be undervalued maslow writes about deficiency needs and motivation as the students gain esteem through their experiences in he the search for esteem is diminished from here they seek growth needs and selfactualisation he has satisfied some of the deficiency needs and encouraged them to seek development this is also reflected in alderfers concept of achievement their experience in he has reduced their sense of risk and they feel a new sense of confidence to further their careers the respondents demonstrate a need for autonomyto be a person in their own right instead of subordinating themselves to others they also seek mastery and once tasted they developed confidence to change and undertake more he and develop professionally finally for some they found a renewed sense of purpose after realising they can achieve against actual and perceived obstacles this purpose gave them confidence and faith to develop and extend their professional roles however underlying this is a sense that they need to compare themselves with and to distance themselves from those they perceive to be destined to succeed these conclusions were only possible to determine because of the emotional use of language by the respondents

through empirical evidence we have found that female students reflect their emotions through the language they use this paper examines responses of 24 adult female students in higher education on early childhood studies ecs programmes it draws on qualitative interview data from a recent research project and interactions in meetings the aim of the research was to determine the views of students on perceived benefits of higher education to their early childhood education and care ecec practice in a sector that is notoriously low paid and carries low status the research was undertaken in a further education fe college on the isle of wight in england to establish the impact of he in childhood studies what started as research into early years policy morphed into a very unexpected and emotional response the language used also revealed the insecurities and lack of confidence of this student group as they embarked on and during their time as students in he our experience as professionals working in higher education is that adult female students can express their levels ambition or lack of through their language especially where they feel they do not really belong in higher education and where their prospects of success are tempered by their view of themselves and their perceived ability

introduction transgender women are considered a critical population for hiv prevention while trans women are known to be a population at high risk for hiv the tendency for research to as is evident in the practice of not disaggregating sexual and gender minorities hiv prevention efforts have historically failed to consider the unique needs of transgender women despite their disproportionate impact prep efforts to date have repeated this pattern 1 as prep scaleup continues the dissemination of prep information has struggled to break through to many traditionally hardtoreach target populations such as trans women 2324 considerable effort is thus still needed to determine the populationspecific barriers and facilitators of prep use that are significant to this population 14 and to determine whether certain subpopulations of trans women have different perceptions of prep based on their past experiences or demographic characteristics unique structural and psychosocial barriers such as medical mistrust and discrimination experienced in the context of accessing health care have particular relevance for many trans women and may negatively impact prep perceptions and use intention 2526 due to both contemporary and historic instances of medical maltreatment on the basis of race many intersectional investigations of medical mistrust among sexual and gender minorities have centered on the acute experiences of medical mistrust among black and other nonwhite persons historic abuses affecting black people and black men in particular such as the us public health services study of untreated syphilis in black males are frequently associated with lineages of medical mistrust and avoidance of medical care within the black community 27 28 29 following this the research to date on the influence that medical mistrust has on decision making with regard to hiv prevention and treatment has been largely focused on black msm 30 31 32 33 34 in their investigation of the psychosocial factors associated with willingness to use prep among black msm eaton et al 32 demonstrated that racebased medical mistrust remained a significant predictor of prep use while controlling for other relevant factors such as age education and insurance status in multivariable models in a comparative analysis of black and white msm residing in jackson ms and boston ma respectively cahill et al 33 noted greater levels of medical mistrust among black msm participants relative to white msm particularly with regard to prep adding to these concerns are longstanding conspiracy beliefs about the origin of hiv and global mistrust of the health care and pharmaceutical industries 28313536 but little research has been done to assess how medical mistrust may impact trans womens or specifically trans women of colors perceptions of or willingness to use prep since there is no one universal definition of medical mistrust what constitutes medical mistrust may vary between and within populations whereas research on racial differences in medical mistrust have attributed it to divergent cultural experiences of health care institutions among blacks and whites 37 the experiences leading to mistrust among trans women are likely to differ as well trans women frequently report the experience or anticipation of mistreatment on the basis of gender race hiv status and housing status among other factors this in turn has been shown to inhibit health care seeking and engagement 3839 in response to this there have been calls for global efforts to increase the availability of genderaffirming care to trans individuals 14 genderaffirming care refers to a set of best practices that include provision of health care services such as hormone therapy as well as the use of correct terminology and pronouns providing facilities that are trans inclusive and having healthrelated materials that are relevant to trans individuals 40 the integration of prep services into a genderaffirming health care model is of key interest to these communities however it is unclear whether medical mistrust in trans women of color intersects with the mistrust they may have as trans women this intersection is an important point that has not been addressed in the literature prior investigations have demonstrated that beliefs knowledge and awareness of medical interventions such as prep are necessary antecedents to successful uptake 4142 therefore it is critical to evaluate how and to what extent medical mistrust presents a barrier to trans womens awareness and knowledge of prep as a conditional element toward prep use and whether subpopulations of trans women such as those who are also of a racial minority experience more significant barriers that should be addressed in hiv prevention interventions to this end we sought to analyze differences among trans women utilizing a cluster analytic approach cluster analyses are routinely used to identify unique typologies that may exist among demographically homogeneous groups these typologies are frequently determined on the basis of psychographic characteristics that may not otherwise be apparent and have the potential to be highly consequential in tailoring healthrelated messages 43 methods study design data for these analyses are drawn from a multistep mixedmethods pilot study on the barriers and facilitators of prep use among trans women the first phase of the study involved collecting qualitative data via focusgroup interviews with trans women and individual interviews with medical providers and prep prescribers from these interviews a novel survey instrument was developed and administered to 78 trans women survey participants were recruited through a combination of active and passive means with the majority taking part through chain recruitment the trans women in this pilot sample were hiv negative or of unknown hiv status and may therefore be potentially eligible for prep at least 18 years of age and from the greater philadelphia pa area all surveys were either completed in person by the participants themselves or administered by a member of the research team surveys were done at transfriendly support groups communitybased organizations and a trans health conference open to the public participants gave verbal consent before being given the survey and were provided with a 15 gift card upon completion of the survey temple university and the university of california san francisco institutional review boards independently reviewed and approved this study measures the survey developed for this study contains 75 likertscale items in addition to categorical items ascertaining sociodemographic information and prep knowledge likert items were developed to reflect the several themes that emerged in the course of the qualitative interviews with trans women health care providers and prep prescribers items were formulated as a series of statements about prep medical providers and attitudes about health care the items selected for this analysis reflect themes that have been associated with medical mistrust among trans women such as experiencing being misgendered by health care providers perceived judgment from clinic staff and discomfort discussing sex with health care providers 34 44 45 46 a full list of items differentiated by theme is provided in appendix 1 participants were asked to assign a value from 0 to 10 according to what extent they agree or disagree with each statement sociodemographic characteristics assessed categorically include gender identity raceethnicity highest level of education completed allsource income in the past 30 days whether participants ever exchanged sex for money food housing or drugs whether participants had been homeless or in a shelter in the past 6 months whether participants are currently insured and perceived personal level of hiv risk categorical items to ascertain gender identity and raceethnicity were made nonexclusive allowing participants to identify multiple gender and race categories as they apply knowledge of prep was ascertained through the use of seven trueorfalse questions about prep a knowledge score was computed as a sum of all correct item responses willingness to use prep was assessed via a single item based on a revised version of the ottawa choice predispositiondecision scale 47 at the conclusion of the survey if your doctor asked you right now to decide about using prep how do you think you would answer with responses ranging from 0 to 10 additionally participants were asked if they had taken prep in the past analytic plan to determine potential differences by subpopulation in medical mistrust medical mistreatment prep perceptions and other factors of interest individual survey items were entered alongside key demographics into a twostep cluster analysis 4849 the twostep cluster analysis allows for automatic selection of the optimal number of clusters by determining the natural groupings of a number of independent categorical andor continuous variables once a cluster solution is determined mean differences in continuous items are compared across clusters the twostep cluster analysis also indicates which variables were of greatest input or predictor importance in defining each cluster because twostep cluster models are based on complete case analyses clusters only contain cases with no missing data 50 a primary advantage to cluster analyses over more conventional statistical tests of group difference is the ability to identify population subgroups or segments on the basis of distinct psychographics while potentially being demographically homogeneous 51 once these clusters were defined individual ttests were conducted to determine mean differences in responses to scale items results sample characteristics two distinct clusters emerged in the analysis table 1 depicts the sociodemographic characteristics for the entire sample as well as by cluster differences in demographic characteristics by cluster are noted a majority of trans women in cluster 1 reported their race as african americanblack compared to 12 of cluster 2 differences were also noted by education level where 53 of trans women in cluster 2 reported completing a college education or above while the majority of women in cluster 1 reported high school ged or vocational school as their highest educational attainment women in cluster 1 were also more likely to have exchanged sex for drugs money or food and more likely to have been unstably housed or homeless in the past 6 months differences in health care and prep perceptions by cluster table 2 depicts mean differences in continuous items assessing health care experiences medical mistrust prep concerns and beliefs and intent to use prep table 2 also includes chisquared results for two preprelated categorical outcomes have you heard about prep from a doctor or health care provider and have you ever used prep in general greater anticipation of negative health care experiences was indicated among cluster 2 where members were majority white and had higher educational attainment 32 p 003 conversely cluster 1 members who are majority black with lower educational attainment indicated a greater comfort within health care settings and more positive experiences with doctors 32 p 003 and i know where to get prep in a gender affirming environment m 92 sd 22 vs m 54 sd 39 t 39 p 001 cluster 2 also indicated more concern about health care discrimination and mistreatment on the basis of gender identity 282 p 007 hiv stigma 32 p 003 sexual stigma 33 p 002 and prep mistrust 21 p 05 while clusters did not vary significantly in terms of intent to use prep or prep knowledge there was a significant difference in whether participants in either cluster had heard about prep from a doctor to facilitate the comparison between clusters mean item responses were plotted to visualize perceptual differences discussion results from this exploratory analysis suggest that unique typologies exist within trans women communities on the basis of sociodemographic characteristics as well as attitudes related to trust in health care and concerns about discrimination within the clusters that emerged distinct patterns were observed that link together negative health care experiences fear or mistrust of doctors various forms of stigma and discrimination victimization on the basis of gender identity and hiv status the mechanisms through which these victimization experiences affect engagement in health care are well understood and supported in the extant literature 4652 in this population the confluence of negative experiences that might produce medical mistrust also appears inversely related to whether individuals report knowing where to receive prep in a genderaffirming environment on this basis alone we might conclude that trans women who have access to health care settings that are genderaffirming may experience less medical mistrust and this is to be expected this study is significant however in also diverging from what is expected based on the corpus of literature that has identified significant associations between medical mistrust and race it would be reasonable to hypothesize that trans women of color would be more likely to report medical mistrust and discrimination however we found that greater prep concern and medical mistrust was instead observed among mostly white women with greater educational attainment also while the pilot sample was likely to be too small to capture differences in intention and actual use of prep we did see trends indicating that those with less distrust were more likely to report being willing to use prep or had already tried it they were also significantly more likely to report having heard about prep from a health care provider current studies indicate the oppositethat trans women are frustrated that they have not heard about prep from health care workers 53 by delineating by cluster this study seems to indicate that participating trans women of color were actually more likely to have heard prep messages that had been delivered in genderaffirming transcompetent health care settings of which there are notable instances in philadelphia this is an important finding as a whole the participants in this study represent a relatively prepnaive sample with only 8 currently using prep and less than 20 reporting ever having used prep this is despite relatively high interest in prep and knowledge of prep as measured in the entire sample as well as in each cluster this suggests that continued barriers to prep use are likely to exist in both clusters the fact that the trans women comprising cluster 1 who reported more structural vulnerabilities such as housing insecurity and engaging in sex work indicated more positive health care experiences suggests that efforts to increase access to genderaffirming care for this subpopulation within the trans community are succeeding to some extent conversely among the trans women comprising cluster 2 health care concerns and mistrust appear to have a stronger negative valence it could also be that they do not feel at high risk of hiv and do not feel prep is needed sixtyfive percent of those in cluster 2 said they thought they had zero or almost zero risk of contracting hiv its hard to know if these trans women are truly at low risk of hiv or if not receiving health care in a transcompetent environment lowers their perceived risk because they havent heard about prep from a health care professional they trust this should be further studied it is probable that unmeasured tertiary factors are also defining these two clusters such as where these trans women receive their medical care it is assumed that members of cluster 1 because of economic barriers and lack of private health insurance most likely get health care from a handful of nonprofit or communitybased organizations in philadelphia that treat trans women with greater regularity and are more accustomed to providing transcompetent care members of cluster 2 on the other hand may be more likely to use more traditional health care settings that may not work with trans women regularly and where transspecific needs are not known or not incorporated into practice this at least raises the possibility that any policies and programs that have been implemented to reduce medical mistrust and expand genderaffirming care to the women in cluster 1 could be adapted and replicated to the benefit of the women in cluster 2 similarly while efforts to reduce medical mistrust and increase the availability of affirming care may be effective within the subpopulation represented in cluster 1 there remain significant structural barriers to getting prep that have not been as effectively addressed and these are potentially more consequential in decision making around prep for these women it remains true that providing genderaffirming care is critical for transgender communities and that care must address social psychological medical and legal needs 7 lack of genderaffirming care has been shown to adversely affect health care utilization delaying both preventative and needed care in transgender patients 5254 this is directly related to counseling on and provision of prep without addressing medical mistrust in the health care setting trans women may not be hearing about prep and making informed decisions about whether its use is right for them this study indicates that it is also important to think about the environment in which care is provided meaning that messaging and interventions may need to be targeted to the specific needs of the population many interventions target groups thought to be culturally homogeneous but most groupssuch as trans womenare quite heterogeneous in their attitudes behavior and beliefs importantly this study shows that deconstructing a group and looking at variations in perceptions by clusters reveal important differences in prep beliefs as they relate to medical mistrust these results could be used to more effectively target interventions specifically to the needs of a group that may be most likely to experience medical mistrust and provide a more nuanced look at how understanding and acceptance of prep are entwined in the larger issue of providing genderaffirming health care before drawing final conclusions important study limitations should be noted first this study presents findings from a pilot sample of trans women recruited from a single geographic area the extent to which the results presented in this analysis are generalizable to the larger population of trans women may be limited as a result second due to the methodological constraints of twostep cluster analysis the results presented here only include complete cases this resulted in a further reduction to sample size which compounds the previously noted limitation thus we reiterate that further research is clearly needed a missing value analysis was conducted that revealed no discernable pattern to the missingness of data the decision to use a twostep approach was based on the exploratory nature of this study because twostep clustering is determined automatically according to likelihood distance measures and does not require a priori specification of the number of clusters it was deemed appropriate for this exploratory aim 4849 finally because this study relied on survey data that were selfreported there is the potential that item responses were affected by social desirability bias particularly with regard to selfreported interest in using prep conclusions understanding the barriers and facilitators that are associated with access to health care and medical treatment such as prep is of vital importance to transgender women in addition to demonstrating how medical mistrust may function as one of these barriers the results from this study also support the notion that trans women are not a monolith and that attitudes and perceptions toward health care and prevention strategies like prep are not homogeneous within the population for women who are interested in prep and for whom prep is indicated taking into account how levels of medical mistrust vary within unique subpopulations will help inform strategies for targeting and effectively promoting it to them means plotted by cluster bivariate associations between cluster membership and medical mistrust appendix appendix 1 survey items by question theme

transgender trans women experience unique barriers in accessing preventative health services such as hiv preexposure prophylaxis prep these barriers may be exacerbated by past real or anticipated mistreatment in health care settings but little is known about the relationship between medical mistrust and poor prep uptake and knowledge using a multistep approach this study used a novel survey instrument administered to a pilot sample of 78 trans women item responses on a 010 scale were subjected to a twostep cluster analysis to explore how perceptions of prep and experiences with health care vary among trans women two distinct clusters c1c2 were defined on the basis of race c1 82 white c2 69 black and highest level of education completed c1 53 college or above c2 42 high school diploma or ged analyses suggest that varying levels of medical mistrust exist between clusters higher mean scores on medical mistrust items were reported in c1 a similar relationship was found on attitudes toward prep differences in intention to use prep and differences in past prep use were not significant however c2 members were more likely to have heard of prep from a doctor results suggest that levels of medical mistrust and prep perceptions vary among distinct subpopulations in this community which may affect willingness to use prep interventions aimed at addressing unique perceptions in subpopulations could move trans women from intention to prep use

background reducing health inequalities has been an explicit priority in the united kingdom for over a decade informing operational strategy in the national health service 1 and government policy more widely 2 the causes of inequalities are varied and include environmental social and behavioural determinants the marmot strategic review of health inequalities fair society healthy lives described how health inequalities result from wider social inequalities 3 while the root of inequalities often lies in the broader determinants of health it is also important to evaluate whether health services play a role in perpetuating or ameliorating existing health inequalities even in a universal health care system such as the nhs there is potential for certain groups to receive inadequate care health inequalities can refer to differences in health status outcomes or treatment 4 differences in health are often deemed unfair if these health disparities are adversely affecting those who are already socially disadvantaged 5 this study focuses on exploring to what extent routine data can be used to explore and monitor inequalities in the care provided by an acute trust the nhs constitution sets upper limits for waiting times and it is a patients right to have treatment within this time 6 waiting times can be used as an indicator of access to care a study looking at total hip replacements found that patients who wait longer have poorer postoperative outcomes 7 the evidence on inequalities in waiting times from the uk and europe is in consistentsome studies have shown no relationship between longer waiting times and age sex or ethnicity 8 contrary to this a european study found that a higher education level was associated with shorter waiting times for elective surgery 9 and cooper et al found that inequity with regards to waiting times had decreased since 1997 10 a study looking specifically at cardiac surgery found that those from more deprived areas were less likely to be classified as urgent and as such would wait longer for cardiac surgery 11 additionally a systematic review of invasive procedures for coronary heart disease found that inequalities in waiting times and procedures rates existed in the uk 12 length of stay is often used as a marker of hospital efficiency and can be difficult to use as an indicator of quality of care 13 it is the result of many different factors including clinical sociodemographic and organisational however if there are differences in length of stay between sociodemographic groups the causes of this may need to be investigated for example in a study of total knee replacements those from more socioeconomically deprived areas were found to stay longer in hospital despite similar levels of postoperative morbidity and clinical need 14 it was hypothesised that this may be due to a lack of social support national studies have found that variation in length of stay could be partially explained by indicators of poverty 15 this was also shown for specific procedures such as elective colorectal surgery 16 and total joint replacements 1417 as postoperative mortality is relatively rare 28day readmission rates are often used as an indicator of quality of care though there is a debate over how useful an indicator it is 18 a review of studies which looked at readmission rates found that between 9 and 48 of all readmissions could have been prevented and indicated that the patient had received substandard care 18 an audit of readmissions in an english trust found that a fifth of readmissions were preventable 19 looking at readmissions broadly may not be useful as there are many possible confounding variables however they could be useful if used to identify trusts or areas of care where there are inequalities where more indepth local studies could then be conducted 19 a uk study found that more deprived patients were more likely to be readmitted though the reason for this was not explained 20 research on readmissions has found that for colorectal surgery social deprivation was associated with increased readmissions 16 inequalities may be due to variation in the quality of care between trusts serving different populations or may occur because the quality of care in the same organisation varies according to for example the socioeconomic status or ethnicity of individual patients monitoring of inequalities on a local level could identify problem areas such as systematic discharge delays or readmissions for particular groups which could be investigated and tackled by health professionals and managers routine datasets such as hospital episode statistics provide the potential to monitor inequalities in process and outcome measures of inpatient treatment for example hacker and stanistreet used hes to explore whether certain groups had longer waiting times for ophthalmology and orthopaedic surgeries 21 morgan and hamm used a waiting list database to examine ethnic inequalities in waiting times for certain procedures 22 we measured inequalities in access process and outcome by age sex ethnicity and social deprivation for seven common procedures at a single large acute trust and examined whether such data could usefully be applied more generally to monitor inequalities at the trust level methods hospital episode statistics this study used a retrospective design to explore the feasibility of monitoring inequalities within an acute trust we obtained routinely collected administrative data hes from april 2007march 2010 from the nhs connecting for health secondary uses service we hold section 251 national information governance board for health and social care permission to hold these data for research purposes we also hold south east local research ethics committee approval to analyse the data hes have been collected on all patients admitted to nhs hospitals since 1989 and include demographic diagnostic and procedural data 23 three years of data were used to gain the largest numbers of patients whilst minimising additional confounding because of changes over time in coding medical practice or policy although coding may have improved over the course of these three years which we cannot control for 24 hes records represent the finished consultant episode a period of admitted patient care under a consultant or allied healthcare professional within an nhs trust 23 a stay in a hospital can be made up of one or multiple finished consultant episodes these were linked together into admissions which is the unit of analysis used here transfers in from other hospitals were not included a proportion of the admissions considered in this study would have ended as transfers however posttransfer length of stay and readmissions were not considered in this study procedures and database inclusions inequalities were examined within procedure groups rather than specialities so that patients undergoing similar procedures were compared to each other although patients can have multiple procedures within an admission patients were grouped by their main operative procedure the most resource intensive procedure of the admission 23 this study looked at elective admissions for seven procedures bariatric surgery cholecystectomy coronary angioplasty primary hip replacement inguinal hernia repairs primary knee replacement and mastectomy these elective surgical procedures were chosen in discussion with service leads to include the most common and those that were rapidly increasing in volume and those where inequalities have been reported from national data by including common procedures we would increase the statistical power to identify inequalities should any exist nonelective patients day admissions and patients under 18 were excluded from the analysis to try to reduce the variability in the sample and to take into account some of the casemix within the procedure groups measures of inequalities this study explored variations in access process and outcome measures by age sex ethnicity and social deprivation data on age sex ethnicity and patient postcode are routinely included within hes data on ethnicity however is often recorded as not stated or not known though this improved nationally from 24 missing in 2004 to 9 in 2010 25 due to small numbers in some groups age bands were combined into 3 to 5 groups based on the distribution of age for each procedure area ethnicity categories within hes are based on the ethnic groups used in the 2001 census 23 small numbers made it necessary to combine these into four categorieswhite asian black and other and mixed backgrounds the carstairs index of deprivation was used to determine the social deprivation of the postcode of the patients home address as a proxy for the patients socioeconomic status 23 the carstairs index was used in the dataset as it is available at a smaller area level the lower super output area the scores in the original dataset were split into five populationweighted quintiles based on the national distribution these were combined into 2 groups quintiles 1 to 3 and quintiles 4 to 5 to provide sufficient numbers and enable comparison between the more and less deprived in addition to the four sociodemographic variables which were used to explore inequalities data on comorbidities were used to take casemix into account the dataset included a measure of comorbidity each patient had a primary diagnosis any other secondary diagnoses or comorbidities were used to derive a comorbidity score using the charlson comorbidity index taking into account both the number and severity of the comorbidities that a patient might have 26 the weights used were derived from english administrative hospital data 27 the comorbidity score was dichotomized into a binary variable no comorbidities or one or more comorbidities dependent variables process and outcome measures the process and outcome measures of hospital care used were waiting times length of stay and readmissions waiting time is the time between the date on which the patient was put on the waiting list and the date on which they were admitted and therefore includes any time when an individual might be suspended from the waiting list a patient does not attend or if a patient is unable to have surgery because of ill health 23 it is only valid for elective patients with planned admissions nonelective patients were therefore excluded from all analyses conducted for this study length of stay represents the number of days the patient spends in the hospital during their admission the continuous variables length of stay and waiting times were tested for normality common normalising transformations of the data such as the reciprocal square root and natural log were unsuccessful and binary variables were therefore created from these continuous variables under the nhs constitution patients should not wait more than 18 weeks from referral for treatment however this could not be used to define a prolonged waiting time as too few people waited longer than this time 23 75th percentiles were therefore used for each procedure group the 75 th percentile was also used to define a prolonged length of stay a similar study looking at waiting times used the median as a cutoff point but we used the 75 th percentile as the tail of the distribution was of more interest 21 75th percentiles have been used in other studies to define a prolonged length of stay 16 readmissions were measured using the derived field of unplanned readmissions within 28 days of discharge those patients who died were excluded from the analysis when readmissions were analysed readmissions were not explored for inguinal hernia repairs as there were too few readmissions data analysis the data analysis was conducted using spss v18 statistical significance was set at p ≤ 001 to take the multiple analyses into account descriptive statistics were used to examine the distribution of the variables for the whole population and for each procedure group logistic regression was used for each procedure group to explore the relationship between each of the explanatory variables and the process or outcome measure multiple logistic regression was then used to explore the independent effects of the explanatory variables and to adjust for comorbidity power and sample size calculations power is the probability of rejecting a false null hypothesis ie it is the ability of the test to find an effect that is there power calculations were conducted retrospectively for one of the analyses the relationship between social deprivation and a prolonged wait for coronary angioplasty as pell and pell et als 2000 study found a similar relationship 11 sample size calculations were also made using this study as a pilot to determine how many years of data would be needed to detect an effect power and sample size calculations were calculated retrospectively using g power 312 for logistic regression this program uses the methodology described in hsieh block larsens 1997 paper 28 rather than using complex calculations for logistic regression this method is based on comparing proportions and then adjusting for a multifactorial model by a variance inflation factor 28 results characteristics of the population the characteristics of the population including age sex social deprivation ethnicity and comorbidities are described in table 1 the waiting time length of stay and readmission rate varied substantially across the seven procedure areas examined mastectomy had the shortest median waiting time of 20 days while knee replacement had the longest of 88 days those patients undergoing bariatric surgery cholecystectomy coronary angioplasty or inguinal hernia repair tended to have a short stay with a median length of stay of 1 day length of stay was longer for those undergoing a mastectomy hip replacement or knee replacement the procedure with the highest readmission rate was bariatric surgery with 77 readmitted within 28 days and the lowest was inguinal hernia with 3 readmitted the 75 th percentiles of waiting times and length of stay that were used to define a prolonged wait or prolonged stay for each procedure are indicated by the upper limit of the interquartile range in table 1 logistic regression univariate and multiple logistic regressions were carried out to determine whether inequalities existed in waiting times length of stay and readmission rates for the seven procedure groups table 2 shows an example of one of these regression models the adjusted odds ratios for the relationships between age sex ethnicity and social deprivation are shown in tables 34 5 6 age there was little evidence of inequalities in waiting times in terms of age for any of the procedures only for cholecystectomy were those who were 4554 years old significantly more likely to have a prolonged wait of over 74 days compared with those who were 1844 years old there was a largely consistent trend towards a more prolonged stay as age increased with the exception of bariatric surgery this was most extreme for those undergoing hip and knee replacements with those over 85 being far more likely to stay over 7 days than younger patients the only procedure for which there was a significant relationship between readmissions and age was hip replacements those who were 7584 years and 85 years were more likely to be readmitted within 28 days than those who were 1864 years sex in general women did not significantly differ from men with regard to waiting times length of stay or readmission rates for coronary angioplasty however women were significantly more likely to be readmitted within 28 days compared to men ethnicity overall different ethnic groups did not seem to experience significantly different waiting times lengths of stay or readmissions rates the only significant difference was that black caribbean or african bariatric surgery patients seemed to be more likely to experience a prolonged wait of longer than 64 days than white bariatric surgery patients social deprivation there was little evidence of systematic inequalities by social deprivation for coronary angioplasty those from the two most deprived quintiles were 166 times more likely to have a prolonged length of stay of over a day power calculations and sample size calculations posthoc power calculations were conducted for the analysis of social deprivation and waiting time for coronary angioplasty the analysis had a power of 047 based on this study a sample size of 4132 would be needed to be able to detect with 80 power and alpha of 001 an odds ratio of 13 for the relationship between social deprivation and having a prolonged wait for coronary angioplasty in this study we used three years of data which gave a sample of 2238 coronary angioplasty patients therefore to get 4132 patients approximately 6 years of data would be needed discussion findings this study explored whether routine data can be used to monitor inequalities in an acute trust based on a case study we found little evidence of inequalities in waiting time length of stay or readmission rates by sex ethnicity or social deprivation for common surgical procedures in the trust we did identify some differences which may warrant further investigation overall we conclude that there are challenges in using routine data to monitor inequalities at this level due to limitations in sample size that reduce the power to detect differences we also identified problems of data validity and relevance in studying inequalities we identified most variation in relation to age older age groups differed from younger age groups for almost all procedures for length of stay and for readmissions after hip replacements this is likely to represent differences in clinical need as older patients will take longer to recover as well as social support at home contributing to some delayed discharges we found that people aged 45 to 54 years were more likely to have a prolonged wait for a cholecystectomy without additional clinical information this is difficult to interpret it is possible that this group has less of a pressing clinical need compared than those who are 1844 and therefore waited longer for the procedure the only evidence of inequalities by sex was for readmission rates for coronary angioplasty where women were almost twice as likely to be readmitted gender differences have been observed in many different aspects of coronary artery disease and coronary heart disease in terms of epidemiology diagnosis treatment and outcomes 29 mortality and readmission rates have been found to be higher in women than in men following coronary revascularisation 3031 one study however found that once baseline clinical risk and body size a proxy for blood vessel size were taken into account this was no longer significant 31 in this analysis we did not look at the diagnosis code for the readmission to see whether it was related to the procedure this may have provided more clinical information as to the cause of the readmission the only significant difference by ethnicity was that black african or caribbean patients were more likely to have a prolonged wait than white patients for bariatric surgery this may be due to residual confounding that could not be taken into account for example we did not have information on primary care trust of origin or clinical factors that could impact on the waiting time there was no evidence of systematic inequalities by social deprivation except for coronary angioplasty those from the most deprived areas were 17 times more likely to have a prolonged length of stay of over 1 day there are many explanatory factors that could take account of this for example these patients could have a different baseline clinical risk although patients from more deprived areas may be less likely to be classified as urgent 11 strengths and limitations the strength of this methodology is that by using easily accessible routine hes data potential inequalities can be monitored to ensure that the healthcare system is not reinforcing existing inequalities in health it is a simple way to establish whether certain groups are likely to wait longer stay longer and be readmitted adjusting for other factors the data also allowed for inequalities to be examined by procedure the main limitation of using routine data to monitor inequalities on a trust level was that the study was underpowered using data from one trust did not provide a large enough sample to detect a medium effect though it would have been able to detect larger effects for some of the more common procedures this problem is exacerbated for rarer events such as readmissions the acute trust that we analysed is one of the largest hospital trusts in englandif it is difficult to use three years of data from such a large trust this method for monitoring inequalities is likely to be problematic in smaller trusts more years of data may have given more patients but changes in coding medicine and population over the years would make the analysis more complex pooling data from trusts in a county or neighbouring trusts may make this analysis more feasible though it is hard to estimate how many trusts you would need to pool together due to the variation in trust size the small numbers also meant that the grouping of age bands ethnic and social deprivation groups was necessary which may oversimplify the patient population and hide inequalities within the groups data on social deprivation showed a skewed distribution in our population with a high proportion of people from more deprived areas which will have limited our power to detect a social gradient using routine data also means that the data quality and validity of the data can be problematic there is for example the possibility with an administrative database such as hes that variables have been miscoded 32 missing data may be particularly problematic with 10 of admissions in this study having missing ethnicity codes and it is possible that this may introduce bias if some groups are more likely to be missing data however studies such as this which demonstrate the potential uses of hes data for ethnic monitoring may help to improve the collection of these data 33 as is the case with many studies using routine data the data were not collected for this purpose and therefore many variables that would be of interest were not available for example though we attempted to take into casemix by taking into account comorbidities and by looking at inequalities by procedure it is very likely that this did not take all the variation of casemix into account more data on clinical status may have helped to control for confounding when looking at length of stay and readmissions other limitations included that there is no clear way to dichotomize the outcome variables length of stay and waiting time using 75 th percentiles may not inform us of the clinically important differences for example the finding that people from more deprived areas were more likely to spend two or more days in the hospital following a coronary angioplasty may not be clinically important additionally multiple tests were performed and therefore it may not be surprising that significant results were found though a p value of 001 was used to try to take this into account even where inequalities were found using routine data can make it difficult to determine whether these inequalities are inequitable the main aim of this work was to explore the feasibility of monitoring inequalities not inequities however the inequalities may be providing equity more indepth clinical data which would not be found in routine administrative dataset may be needed to work out whether these differences are delivering equity or not for example this analysis found that older age groups differed from younger age groups for almost all procedures for length of stay this is most likely to represent a natural difference in clinical need as older patients will take longer to recover therefore this inequality is not necessarily inequitable to determine whether it was inequitable further investigation would be needed into why they are being readmitted and if these readmissions could be prevented conclusion it is one of the core aims of the nhs to provide quality care regardless of age sex ethnicity and social deprivation monitoring of routine data could play an important part in ensure that services are equitable this study found that there are difficulties in using routine data from one acute trust little evidence of inequalities in service provision within the trust were found it does identify however areas where there are statistically significant differences which may warrant further investigation this methodology shows us that different groups of people may differ in their treatment but it does not tell us whether this difference is fair or what other confounders may be causing this difference these inequalities should be viewed as a launching point for further investigation by healthcare workers and managers abbreviations aor adjusted odds ratio ci confidence interval hes hospital episode statistics nhs national health service or odds ratio spss statistical package for social sciences uk united kingdom competing interests kml and hw declare no competing interests ab and pa work for the dr foster unit which receives some funding from dr foster intelligence authors contributions kml carried out the analysis and drafted the manuscript ab provided statistical advice and helped to draft the manuscript ppa participated in the design of the study and helped to draft the manuscript hw conceived of the study and participated in its design and coordination and helped to draft the manuscript all authors read and approved the final manuscript

background reducing inequalities is one of the priorities of the national health service however there is no standard system for monitoring inequalities in the care provided by acute trusts we explore the feasibility of monitoring inequalities within an acute trust using routine data methods a retrospective study of hospital episode statistics from one acute trust in london over three years 2007 to 2010 waiting times length of stay and readmission rates were described for seven common surgical procedures inequalities by age sex ethnicity and social deprivation were examined using multiple logistic regression adjusting for the other sociodemographic variables and comorbidities sample size calculations were computed to estimate how many years of data would be ideal for this analysis results this study found that even in a large acute trust there was not enough power to detect differences between subgroups there was little evidence of inequalities for the outcome and process measures examined statistically significant differences by age sex ethnicity or deprivation were only found in 11 out of 80 analyses bariatric surgery patients who were black african or caribbean were more likely than white patients to experience a prolonged wait longer than 64 days aor 247 95 ci 136449 following a coronary angioplasty patients from more deprived areas were more likely to have had a prolonged length of stay aor 166 95 ci 125220 conclusions this study found difficulties in using routine data to identify inequalities on a trust level little evidence of inequalities in waiting time length of stay or readmission rates by sex ethnicity or social deprivation were identified although some differences were identified which warrant further investigation even with three years of data from a large trust there was little power to detect inequalities by procedure data will therefore need to be pooled from multiple trusts to detect inequalities

introduction the inclusion debate over equal opportunities and respect for differences has become increasingly notorious in contemporary society included in this discourse are people with disabilities who have been organising themselves to guarantee the fulfillment of their rights one of the rights that this group mobilises for is access to inclusive education furthermore studies in the sociology of health indicate transformations in the concepts of health and illness over time showing that the states of health and illness are social constructions produced reproduced and transformed in relation to reality in an elucidating way the understanding of the sociological model can be presented in two moments the first moment is characterised by the idea of health and illness as opposite situations illness as an absence of health was one in which medical support was constant therefore a sick body was one whose performance differed from what was expected thus disability was the second moment in the sociological model that differentiated support and accessibility for medical followup in this context assistive technologies are tools that reveal the deficiencies of environments not the inefficiency of people therefore the bodies of people with disabilities are socially active and exhibit behavioural diversity building new social identities for people with disabilities who recognise their rights to be and participate in social life in a unique way as a result people with disabilities organise themselves in the struggle for rights with repercussions across all social strata and especially at school public manifestation of the bodys inefficiency through disease influenced by the second moment of the sociological model of health and disease in relation to access to education stainback and stainback state that inclusive education can be defined as the practice of including everyone regardless of their talent disability socioeconomic origin or cultural in providing schools and classrooms where the needs of these students are met for these authors inclusive education is beneficial for society and not just for people with disabilities since everyone is sharing the same space it is possible for example for people with disabilities to prepare for life in the community for the community to prepare itself to fully receive people with disabilities for their teachers to improve their professional skills that children in general learn from each other and that society becomes aware of diversity and consecutively defends equality for all people in the view of the authors in segregated places diversity cooperation and respect for those who are different are not valued harming motivation to learn and selfesteem following this purpose mantoan warns that specialised institutions and spaces restricted to a specific public prevent people from realising and knowing the richness of the experience of difference and inclusion for the author experiencing inclusion means understanding differences and therefore the school must be a space for everyone in which the conception of the subject as a singular being is advocated who learns in his own time and way that is in the understanding of an inclusive school students learn from their capabilities without exclusion comparison or hierarchy of levels of knowledge in the words of mantoan the inclusive school recognises in the student the being that constitutes the difference and that nothing is foreseen in his learning therefore this school does not fit a model to be followed or reproduced we are all simulacrateachers in this context understanding the conceptual paths of inclusive education is important to understand the concept its dynamics its transformations and its directions it is in this universe therefore that we place this article which aims to demonstrate how the concepts of health illness and wellbeing dialogue with the process of educational inclusion for people with disabilities the objective is to analyse how in brazilian politicalnormative texts educational inclusion is addressed from the perspective of promoting social wellbeing to do so as a method of analysing public policies we deepened the assumptions and theoretical foundations of the policy cycle approach formulated by the english sociologist stephen j ball and collaborators the policy cycle approach is an analytical framework for understanding educational programs and policies from their formulation to their implementation in different contexts and their effects according to this approach the policy cycle is composed of five contexts dynamic and interdependent i the context of influence ii the context in which the text was produced iii the context of practice iv the context of resultseffects and v the context of the political strategy thus in line with the intention of this study we intend to reconstruct the context of influence that made possible the emergence of the discourse of inclusion and problematize the context of text production through the analysis of politicalnormative texts besidesit should be clarified that this delimitation which emphasises the context of influence and the texts production is an analytical strategy in view of the scope of this work however we emphasise that the contexts described in the policy cycle are inseparable dynamic and interdependent finally it should be said that to support the research with a qualitative approach document analysis proposed by cellard was used as a methodological resource for data collection searches were carried out for brazilian laws decrees ordinances and government programmes published between 2000 and 2023 that dealt with actions for the educational inclusion of people with disabilities the research complies with brasilian resolution 5102016 which determines that submissions to the ethics committee are unnecessary when public domain information is used method the search for brazilian normative texts on the inclusion of students with disabilities was carried out using the document analysis method this research was carried out through visits to the official websites of the brazilian government throughout the second half of 2022 as a procedure for document analysis we relied on the propositions of cellard for this author a global approach to documents is carried out in two stages i the preliminary analysis in which five dimensions of the document must be identified the authenticity and reliability the nature and key concepts and internal logic and ii the actual analysis in which with the assembly of all the parts of the preliminary analysis detailed readings are made in view of the interests of the research therefore intending to investigate how in brazilian political and normative texts educational inclusion is approached from the perspective of promoting social wellbeing the document analysis was carried out in two moments i the moment of the preliminary analysis had as a result what is exposed in table 1 in the results section and ii the moment of the actual analysis which was based on the concept of the policy cycle approach and did not lose sight of the fact that the text production context already incorporates andor expresses in one way or another another what is proper to the context of influence finally we add that a literature review was carried out on the propositions of studies in the sociology of health which understand health and disease as social material and cultural contexts of the subjects the results of theoretical interweaving and data analysis are described below ethical procedures in this study all rules were followed stated in the directive of scientific research and publication ethics of higher education institutions ethics committee permission of this study is taken with the decision of the ethics committee of the fluminense federal university through plataforma brasil dated june 11 2023 and numbered 4769014 results and discussion first of all it is necessary to understand the discussions involving the word disability more than the word its concept which is the word plus its meaning in context is at stake in fact what is at stake is a long historical process that gave it multiple meanings and interpretations which were or are the basis for the formulation of public policies that assist people with disabilities furthermore in the mediaeval era between the 5th and 14th centuries disability was a consequence of gods wrath becoming a reason for persecution by the inquisition of the catholic church still without a medicalscientific basis disability was often explained with religious or mythical support linked to a sin or curse later on in the modern age the first conception of disability based on the medical model emerged this model removes the religious aspect that brought great moral barriers but summarizes disability as a deviation from the individuals organic pattern one can then observe the beginning of the transition from a religious to a scientific approach according to studies by diniz the medical model was a discursive creation of the 18th century and since then being disabled has meant experiencing a body outside the norm in the 19th century the first intentions to educate people with disabilities emerged they were referred to and cared for in specialized institutions and special classes with a lasting impact on the history of education this was considered and is still being discussed as the most appropriate way to assist students with disabilities or those who do not fit into the structure of education systems the model of schooling people with disabilities in segregated institutions was still based on the idea of an inefficient body that demands health care therefore reaffirming the notion of disabilities as a public manifestation of the disease from the second half of the 20th century onward specifically from the late 1960s onward a proposal for a new model of social coexistence was disseminated with integration as its principle this principle sought to integrate people with disabilities so that they could adapt to the functioning of social institutions whether teaching or not in order for there to be integration there had to be an understanding that accessibility adaptations were not necessary to receive people with disabilities without considering their individuality sassaki describes that integration works with the principle of normalization which postulates that every person with a disability has the right to experience a style or standard of life common to their own culture however in educational integration there was no concern for the full participation of people with disabilities in school they were offered the experience of watching the right to be remain and participate of people without disabilities historically we can say that school integration is the precedent of inclusion although it is still easily identified in supposedly inclusive pedagogical practices in school integration the student is received at school without any necessary adaptations in this scenario it is up to the student with disabilities to adjust to school the school does not change as a whole but students have to change to adapt to its demands furthermore in brazil at the end of the 1990s the principles of integration began to appear in national legislation highlighting the excerpts from the legislation that deal with the rights to education it appears that both in the federal constitution of 1988 in item iii of article 208 and in law nº 8069 of 1990 which establishes the statute of the child and adolescent in the item iii of article 54 one of the duties of the state was foreseen as the guarantee of specialized educational assistance to people with disabilities preferably in the regular education network according to nozu and bruno the use of the adverb preferably enabled the construction of a range of interpretations within the scope of special education policies opening gaps for different interest groups to defend varied positions regarding the schooling of public special education students later on in the 1990s the terminology called inclusion already present in europe and the united states arrived in brazil opposing the medical model the person with a disability came to be perceived beyond the absence limitation or lack of resources and meanings that are merely strict to the standard of normality established by society the social model of disability emerges the social model of disability emerged as an alternative to the medical model which recognizes injury illness or physical limitation as the primary cause of social inequality and the disadvantages experienced by the disabled ignoring the role of society in marginalizing individuals thus the discussion on disability went from a strictly biomedical field confined to medical and rehabilitation knowledge to also be a field of the humanities thus disability began to be addressed by the social model as a complex concept that recognizes the potentiality of the disabled body but also denounces the social structure that oppresses the individual the social dimension of disability presents the concept of barrier as everything that hinders andor prevents the full social participation of people with disabilities in this sense the barrier is in the environment and can be classified as attitudinal architectural or communicational this perspective leads to the understanding that disability is not in the person or in their disability condition but in what in a social dimension leads to exclusion in this context assistive and communication technologies make it possible for people with disabilities to exercise individual and collective autonomy the social model of disability echoes in the educational field and points to learning possibilities and educational assistance in the regular education system for students with disabilities due to their specific conditions in this context there is the elaboration of national and international documents and the holding of important conferences with the theme of inclusion it wasis intended to advocate a society in which rights and access to means places and knowledge are more equitable or available to all that is an inclusive society inc mn mlusion is a concept that requires a detailed examination it is possible to advance that in its amplitude it is not restricted only to the inclusion of people with disabilities but extends to other historically marginalized individuals and groups such as women blacks the indigenous the nomads and the home affective in brazil for example there are laws that criminalize violence against women racism and homophobia and there are affirmative actions that seek to include black and indigenous students in school and academic spaces sassaki argues that inclusion is a bilateral process in which people who are still excluded and society in partnership work to bring about the equalization of opportunities for all this author argues that the practise of inclusion rests on principles that were uncommon in society at the end of the 20th century such as acceptance of differences appreciation of each person coexistence within human diversity and learning through cooperation inclusion therefore is a process that contributes to the construction of a new type of society through transformations small and large in the physical environments and in the mentality of all people moreover inclusion is not limited to the educational field it is present not only in expressions such as inclusive education but also in fields such as inclusive leisure inclusive transport and so on in this sense recognizing the breadth of the concept of inclusion we chose as a methodological and theoretical approach the discussions that deal with the inclusion of people with disabilities global learning disorders and giftedness or high abilities in the educational field and starting with the analysis of brazilian politicalnormative texts we point them out below as mainardes suggests there is a symbiotic relationship between the context of influence discussed above and the context of text production while the first manifests itself behind the scenes it is in the context of text production that the policy is expressed in such a way that the general public has access to its materiality it is therefore the context in which discourses are converted into texts themselves which is also marked by all kinds of struggles and disputes as well as negotiations agreements and alliances another important aspect which should also be highlighted is that texts are not necessarily internally coherent and clear and can also be contradictory they can use key terms differently that is the political text as an expression of politics as text is not in this way neutral and objective far from it it is the materialization of different interests in constant tension in accordance with these notes we intend to examine how the brazilian educational policy in its various politicalnormative texts indicates ways to enable opportunities for people with disabilities global learning disorders and giftedness or high abilities to carry out their training in any level or modality of education with legal guarantees of access permanence and participation due to the limitations of this work we chose only the brazilian politicalnormative texts published between 2020 and 2023 years the chosen laws and decrees are described and analyzed preliminarily through the proposal of document analysis by cellard in table 1 starting with the analysis of the texts the first point to be considered are the advances made in 2001 by the national guidelines for special education in basic education instituted by resolution nº 022001 cneceb it recommends resource rooms as a locus to develop the specialized pedagogical support service carried out by special education teachers in a complementary or supplementary way to the curriculum using specific equipment and materials at that time efforts were already being made to ensure that this type of teaching took place in regular education and was not separated from it however it was only in 2008 with the approval of the national policy on special education in the perspective of inclusive education that it became evident that special education is a modality that must permeate all teaching stages and not be a substitute andor parallel to regular schooling the 2008 policy was published by the ministry of education and is the result of a working group formed by specialists in the field of education despite its relevance in the development of policies for special education it is a document without a formal character in the legal system not being published in the form of a decree for example the importance of the national policy on special education in the perspective of inclusive education lies in the internationally agreed commitment to a nonsegregated teaching model influencing in addition to other documents the salamanca declaration and the convention on the rights of persons with disabilities a central aspect of this policy is that specialized educational assistance now has a specific organization providing for the availability of specialized professionals in the area and organization of times spaces and resources necessary for the learning process of each student as a result of this policy decree 65712008 changed budget predictability and encouraged inservice training for teachers therefore it can be considered as a factor responsible for the increase in enrollment of students with disabilities global learning disorders and giftedness or high abilities in regular schools as well as a stimulus to the development of inclusive strategies regarding higher education the decree does not change the budget allocation of universities since it would need to indicate the forecast for the creation of vacancy codes for hiring specialized professionals with regard specifically to the availability of a budget for accessibility and inclusion actions in higher education it is worth highlighting the centrality of the include program which from 2005 onwards was carried out through a partnership between the secretariat of higher education and the secretariat of education continued literacy diversity and inclusion both from the ministry of education the last one extinct in 2019 the program made resources available from the registration of universities in specific notices through the assistance provided by the include program universities could then create and consolidate accessibility centers however since 2010 the inclusion selection no longer occurs and the budget allocation is made available according to the number of enrollments of students with disabilities we can say that the include program is directly linked to the repercussions and influences of the world declaration on higher education in the 21st century vision and action this is because the indication of the creation of accessibility centers made in the include is one of the ways to ensure what is proposed by the declaration to higher education institutions which is the offer of educational material and solutions that are able to contribute to overcoming barriers that prevent or hinder the access and continuity of studies for students with disabilities still on the creation of accessibility centers in public institutions of higher education decree 76112011 regulates what was an indication of the include program the decree determines the need to structure accessibility centers in federal institutions of higher education which aim to eliminate physical communication and information barriers that restrict the participation and academic and social development of students with disabilities in the introductory text of this decree it is explained that its preparation is based on article 24 of the convention on the rights of persons with disabilities and its optional protocol this article stresses that states parties shall ensure that persons with disabilities may have access to higher education in general vocational training in accordance with their vocation adult education and continuing education without discrimination and on equal terms another decisive milestone for guaranteeing the rights of access and permanence of special education students in brazilian educational institutions was the enactment of the brazilian law for the inclusion of persons with disabilities law no 131462015 also under the influence of the guidelines of the convention on the rights of persons with disabilities and its optional protocol it aims to ensure and promote under conditions of equality the exercise of rights and fundamental freedoms by persons with disabilities with a view to their social inclusion and citizenship regarding higher education the law no 131462015 points out measures that aim to guarantee equity in the selection processes for access and permanence of special education students in undergraduate courses in the country following what was exposed in the law no 131462015 on equity in selection processes there was in the following year the publication of law 134092016 which provides for the reservation of vacancies for people with disabilities in technical courses of secondary and higher level of federal education institutions finally we highlight that in 2021 law nº 14191 of 2021 included in the law of guidelines and bases of education the guarantee that the human linguistic cultural and identity diversity of deaf deafblind people is respected with hearing impaired signers deaf people with high skills or giftedness or with other associated disabilities to this end the aforementioned law brought with it aspects that guarantee these students the option of bilingual education for the deaf offered in brazilian sign language as a first language and in written portuguese as a second language in bilingual schools for the deaf classes bilingual schools for the deaf common schools or in centers of bilingual education for the deaf as demonstrated there are in fact significant correspondences between the broader context of influences and the context itself of the production of political texts aimed in this case at promoting inclusion in the educational field correspondences that did not happen again without conflicts tensions negotiations and alliances involving different actors on multiple scales this is because these texts decontextualize and translate a large part of the concepts and guidelines that emanate from the arenas and texts identified in the previous section as those arising precisely from the context of influences therefore we can say that as a social construction the new conceptions about health and disease give a new meaning to disability which gradually comes to be considered one of the subjects multiple identity markers moving away from the immediate association with the concept of disease understanding disability as not limiting individual potentials educational inclusion in politicalnormative texts is now approached from the perspective of promoting social wellbeing as a form of full participation of people with disabilities in all dimensions of community life conclusions and recommendations as demonstrated advances in concepts about health illness disability diversity and inclusion are responsible for transforming the quality of life and wellbeing of people with disabilities and their families this has been a reflection of the move away from the mediaeval idea of disability as punishment guilt incapacity and illness and towards an inclusive paradigm that recognizes the right of all to be unique in terms of potential and limitations in this sense both the possibility and the limitation are part of the existence of all people who in interaction can produce contexts to promote skills considering the model of the sociology of health and disease at first disability was considered the public manifestation of the disease expressed by a body that behaves differently than expected and is therefore abnormal then in the second moment the functioning of the body differently than expected gains the transforming potential of society through the experience based on the diversity of being and functioning in the world in a comparative way disability as a disease directs the focus to the solitude of existence in isolation without decisionmaking autonomy over ones own existence while disability as an identity marker in diversity broadens the focus to plurality collectivity the sharing of responsibilities and the effective participation of all in an equal situation the gradual sense of nonsegregated social belonging and the empowerment of people with disabilities allowed for the organisation of movements for the right to participate in public life in the sphere of education students with disabilities have progressed from total isolation to segregation to integration and inclusion in the case of the brazilian law of inclusion students are guaranteed the right to access permanence and participation in their educational trajectories despite the fact that this right is still deficient in terms of its application the argument that physical mental and spiritual wellbeing depend on experiencing feelings of belonging individual valuation freedom to be desire and want is concentrated at this juncture consequently there are phases of being wishing and wanting in the process of school inclusionthe stage of being in the inclusive paradigm entails the freedom to be different without the individuals difference constituting a value attribute in this sense the manifestation of the right to be is the production of a law that regulates education on the basis of rights moreover wishing is related to the possibility of making independent decisions throughout existence consequently the desire to select where how when and what to study being able to specify how and which obstacles can be identified mitigated and overcome wishing to alter practises and structures of exclusion wishing to reinvent education and higher education the desire stage is contingent on the satisfaction of the preceding stages we differentiate between wanting and wishing with the latter being a projection for the future such as aspirations to be realised or conquered how to desire prior to being the educational inclusion of people with disabilities is an unfinished process barriers to participation are constantly fought and produced in all social spheres and school is no different on the other hand the detailed analysis of the course of this phenomenon in brazil allows expanding the desires and wishes of doing inclusion it allows us to wish that in addition to the right to exercise citizenship formal education feeds the desires dreams and goals of students in equal opportunities returning to the theoretical and analytical framework of the policy cycle approach desire is manifest in the production of effervescence in the context of influence the first context desire mobilizes organized collective actions and strategies for the production of new political texts that systematize desire according to context the contexts of practice resultseffects and political strategies are guaranteed by the right to be who one is therefore both people with disabilities and those who fight for them are strengthened by previous achievements reflected in new concepts in the field of sociology that said the data presented corroborate the argument that the inclusion of people with disabilities in educational spaces is a multifactorial sociological phenomenon with individual and collective impacts in the areas of economy education labour relations the resignification of faith and the redefinition of the role of medicine in modernity therefore the inclusion of people with disabilities as a strategy for individual wellbeing is a complex social transformation process with impacts in different spheres including the wellbeing of people without disabilities who experience directly or indirectly the transformations resulting from the fight against prejudice and discrimination

this article aims to demonstrate how the transformation of the concepts of health illness and wellbeing interacts with the process of educational inclusion for people with disabilities the reflection is based on the conceptions of the policy cycle articulated with the concepts of inclusion health and wellbeing and has as material for analysis brazilian politicalnormative texts that guide the process of educational inclusion of people with disabilities it is intended to reconstruct the context of influence from scratch using the policy cycle approach that enabled the emergence of the discourse of inclusion from the perspective of social wellbeing and to problematize the context of text production and the context of practise through the analysis of public policies aimed at the educational inclusion of people with disabilities based on sociology of health studies which understand health and disease as the subjects social material and cultural contexts this study understands that the new conceptions of health and disease give a new meaning to disability distancing it from its immediate association with the concept of disease considering disability as not limiting individual potential educational inclusion is approached from the perspective of promoting social wellbeing as a form of full participation by the disabled person in all dimensions of community life thus it is concluded that inclusion widely understood contributes to the construction of a cultural political ethical and epistemological project aimed at social emancipation autonomy and the guarantee of human rights thus valuing various aspects of the demands for equality in differences

introduction the relationship between child nutrition and maternal social capital has not been widely explored in developing countries only a few studies have been made in peru vietnam ethiopia and india there are several ways in which maternal social capital can determine the nutritional status of a child for example by increasing the possibility of access to different services such as health care information and education by allowing access to assets such as money provisions and food and by helping mothers to maintain physical and mental health another possible mechanism by which maternal social capital can improve a childs health and nutrition is through social networks these networks allow mothers to know more because of information transfer to think differently because of behavioral influences to do things differently and to feel differently because of emotional support two definitions of social capital were used for this study the first and wider definition describes social capital as a set of intangible attributes present in a society that favor entrepreneurship trust reciprocity and social action according to shared norms according to putnam et al social capital has two key elements structural social capital and cognitive social capital the first reflects the links and connections that people have in a community by being active and participating in internal activities the second reflects the sense of being part of the community by addressing the confidence in the community social cohesion common local guidelines and recognition of reciprocity the second and more recent definition visualizes social capital as informal relationships of trust and cooperation formal associativity in organizations of different types and the institutional framework of a society that fosters or inhibits relationships of trust and civic commitment the hypothesis used for this study was that maternal social capital can be effective in improving a childs nutrition especially when physical and human capital are uncommon thus this study aimed to determine the social capital of mothers with young children and to determine the association between maternal social capital and isidro a parish on the ecuadorian coast that suffered the impact of an earthquake in 2016 therefore questions about social capital include receiving help after the earthquake methods study area and sample size a crosssectional study was conducted in san isidro a rural parish located in the province of manabí on the coast of ecuador in september 2017 san isidro parish has 10987 inhabitants and its area is 296 km the climate is tropical dry and humid and the average temperature fluctuates between 24°c and 26°c the economy of the parish is based on agricultural and livestock activities the sample size was calculated by using an estimated prevalence rate of chronic malnutrition of 247 in rural coastal children of ecuador a 95 confidence interval and a precision of 50 and 10 for missing data the minimum sample size required was calculated to be 314 children aged 059 months the study was conducted at public daycare centers and schools for all procedures performed on children the presence of the mother was required children with diseases or conditions that have an influence on nutritional status were excluded from the study questionnaires the questionnaire for this survey consisted of three sections the the second section was based on the latin american and caribbean scale for food security it included questions about food security the third section based on the social capital assessment tool of the world bank addressed information concerning the familys social capital the questionnaire was adapted and validated to san isidros culture to ensure its appropriateness trained nutrition students collected data via personal interviews directed to the childrens primary caregivers usually the mothers anthropometrics and blood samples researchers observed the recommended technical standards and criteria throughout all steps of the anthropometric evaluation childrens and mothers weights and heights were measured as described elsewhere in summary weight was measured with portable electronic microscales height was measured with a portable stadiometer and length was measured by using a length board the precision of the instruments was 100 g for weight and 01 cm for lengthheight zscores for lengthforage weightforage and weightforlength were calculated by using the who 2006 child growth standards for children under 5 years a sample of venous blood was collected from each child and hemoglobin values were determined with a spectrophotometer variable description the dependent variable chronic malnutrition or stunting was determined by the heightforage zscore ≤2 standard deviations anemia was defined as a blood hemoglobin level of 110 gl for children 659 months of age at sea level the questions for cognitive and structural social capital considered the relationships that the family particularly the mother had with other members in the community eg after the earthquake covariates for this study were childrens ages mothers age number of children maternal education level family income and food security these covariates are directly and critically related to childrens nutritional and health status maternal education is expected to improve a childs nutritional status by changing preferences and resource allocations and by improving childcare practices a higher family income is related to an improved childrens nutritional status probably because of access to higher quantities of nutritious and tasty foods it also relates to the access to better health services the number of children in a household was considered to be a proxy of family size the reason being that number of children is related to their nutritional status because of the competition with other children for attention care food and sometimes scarce resources statistical procedure bivariate analysis and multivariate logistic regression models were used to measure the association between social capital and dependent variables using in relation to structural social capital after the 79magnitude earthquake in april 2016 645 of the anemia sample and 638 of the chronic malnutrition sample received and provided help a low percentage of mothers were part of a community organization approximately 40 of mothers participated in community activities and 30 of mothers had borrowed money in both samples in cognitive social capital analysis a higher proportion of mothers liked their community and were willing to live more years in that community finally descriptive analysis of food security variables showed that more than half of households were worried about the scarcity of food in the previous 3 months in addition approximately 20 of households reported that they were out of food because of a lack of money in the previous 3 months and were forced to reduce the quantity of food for someone aged less than 18 years in the previous 3 months social capital and anemia the prevalence of anemia was higher in children whose mothers were part of a community organization than in children whose mothers were not in bivariate and multivariate analysis a mother being part of a community organization was positively associated with anemia the other variables were not significantly associated with anemia in bivariate or multivariate analysis social capital and chronic malnutrition the prevalence of chronic malnutrition was lower in children whose mothers had borrowed money than in children whose mothers had not in addition a lower prevalence of chronic malnutrition was observed in children from households who were helped after the 79magnitude earthquake than in children whose families did not receive help in multivariate analyses receiving help after the earthquake was associated with a lower prevalence of chronic malnutrition in addition children whose mothers had borrowed money were less likely to have chronic malnutrition than children whose mothers did not discussion this study provides data on the relationship between a mothers social capital and their childs nutritional status the reciprocity relationships observed in the support received by the community after the 2016 earthquake and having borrowed money from family friends or community members were protective factors for chronic malnutrition however being part of a community organization increased the prevalence of anemia after the multivariable analysis the results show that receiving help from community members or helping them after the earthquake showed a protective effect on chronic malnutrition by helping people who were affected by the earthquake some resources may have been directed to address the needs of children of the households before other matters the fact that a mother borrowed money may have been a demonstration of the community solidarity and was shown to have a protective effect on the nutritional status of a child this money may have helped mothers to access more resources for food health services and hygiene supplies similarly some studies have shown a protective effect of social capital on the nutritional status of children one study in peru analyzed the relationship between maternal social capital and the nutritional status of children it found a positive relationship between maternal structural social capital and a childs nutritional status a child whose mother was part of a community group was 11 cm taller than children whose mothers were not part of a community group likewise in rural areas in laguna philippines children whose mothers had higher maternal social capital scores had a lower probability of a poor nutritional status regardless of the community they belonged to additionally weightforage and heightforage were found to have a significant association with maternal social capital in rural areas a study in rural ethiopia has shown that support from two or more individuals was associated with meeting a minimum level of dietary diversity in the present study some contradictions were found with the hypothesis that maternal social capital can be related to a childs nutrition improvements most research has focused on the association between a mothers social capital and child nutrition whereas research on the relationship between a fathers social capital and child undernutrition in developing countries is sparse in recent years the importance of a fathers role in child nutrition has been recognized for instance a study found that a fathers financial contributions to child nutrition and health care enhanced their childrens nutritional status similarly the nutritional condition of mexican american children was favorably connected with the fathers engagement in feeding practices this study is a first approximation of the relationship between social capital in mothers and nutrition of their children in a rural area of ecuador moreover it can be the beginning in the development of similar studies that could address the effect of social capital on health outcomes however results from this study may lack external validity because of the limited study area other weaknesses are the sample size for some categories which may influence the results of the associations and the crosssectional study design which is not the best for causation analysis between social capital and anemia or chronic malnutrition it is highly recommended that information be gathered in several points in time for further causation analysis finally this study did not analyze the relationship between social capital and parenting practices variables that could influence the results of the association between social capital and anemia or chronic malnutrition on children conclusion maternal social capital and the nutritional status of their children in a coastal rural community of ecuador seems to be positively related structural social capital or bonding social capital had a protective effect on chronic malnutrition this study emphasizes the importance of improving bonding social capital in community intervention programs the study also found that bridging social capital was associated with a higher prevalence of anemia and had no impact on chronic malnutrition these mixed results highlight the need for further studies focused on the different types of social capital and how they affect health in deprived areas of economic and social inclusion and schools and childcare centers of san isidro for providing the facilities to conduct surveys with the parents and their children included in this study the researchers also thank the congregation hermanas hijas del amor divino san isidro health centers director primary healthcare technicians and the education circuit coordinator from san isidro for supporting the data collection data

introduction social capital is considered an important determinant of health and overall wellbeing however to the best of the authors knowledge literature relating social capital to malnutrition in developing countries is still relatively small this article examines the relationships between social capital and chronic malnutrition and anemia in a population of rural coastal children in ecuador methods a crosssectional study in two groups of 246 and 282 children under 5 years and their families was performed anemia and chronic malnutrition were analyzed as outcome variables variables about social capital were identified on the basis of the social capital assessment tool of the world bank bivariate and multivariate logistic regression analyses were conducted results the prevalences of anemia and chronic malnutrition in the children were 150 and 128 respectively at the multivariate analysis the variable mother has borrowed money had an inverse association with chronic malnutrition prevalence ratio pr 043 95 confidence interval ci 020090 receiving and providing help after the earthquake of 2016 was significantly associated with a lower prevalence of chronic malnutrition pr 052 95 ci 028097 but not with anemia however a mother being part of a community organization was associated with a 190 times higher prevalence of anemia 95 ci 104348 in children than mothers who were not part of a community organizationthe relationship between maternal social capital and the nutritional status of their children in rural communities seems to be positively related however a mothers participation in community organizations increases the prevalence of anemia in the children these mixed results highlight the need for further studies focused on the different types of social capital and how they impact on health in deprived areas

introduction according to united nation habitats projection nigeria population will be around 500 million by the year 2050 this projection is premised on a number of factors firstly the population of nigeria is rising at an increasing rate ie geometrically without adequate measures to control it secondly there is a popular orientation among most nigerians that the number of children one has shown hisher level of relevance in the society thirdly the nigerian legislation permits one man to have up to four kids from one woman and supports polygamy these factors have led to high birth rate which is supported by advancement in the medical sciences that has reduced child mortality rate the resultant effect of these orientations is that nigerians is tending towards population explosion this can be attested by the infrastructural break down experienced in the major cities of lagos abuja port harcourt etc despite the availability of modern medical practices that can curb population explosion through effective birth control measures like proper family planning programme it was observed that most childbearing nigerians may not be aware of these birth control measures also the majority of them could be skeptical about various family planning programme that are being rolled out by the government and some nongovernment organizations sequel to this it is timely and urgent to investigate the predictors of the public acceptance of family planning programme among childbearing nigerians an understanding of these predicting factors will help in effective and efficient population control policy formulation and implementation it will help strategy implementation from the economic point of view which will help in designing a longlasting and formidable development plan for nigeria hence alleviating social problems that emanate from overpopulation like unemployment urban congestion etc nigeria being the largest economy in africa and also the most populous black nation in the world there is dearth of empirical studies that investigate the factors predicting the public acceptance of family planning programme focusing on the childbearing group who constitute the majority of the active population of the country therefore there is need to conduct a countryspecific and contextspecific study in this direction more so from the extant literature studies on health marketing that were anchored on healthbelief model from the subsaharan africa context is very scanty so there is an urgent need to explore the applicability of healthbelief model on family planning programme acceptance in nigeria research objectives the broad objective of this study is to investigate the predictors of public acceptance of family planning programme in nigeria in specific terms this study seeks to a identify the factors that have dominating effect on the public acceptance of family planning programme in nigeria b determine the effect of the identified factors on the public acceptance of family planning programme in nigeria research questions a what are the factors that have dominating effect on the public acceptance of family planning programme in nigeria b how has the identified factor influenced public acceptance of family planning programme in nigeria literature review relationship between perceived susceptibility and public acceptance behavior perceived susceptibility refers to subjective assessment of risk of developing a health problem the hbm predicts that individuals who perceive that they are susceptible to a particular health problem will engage in behaviors to reduce their risk of developing the health problem individuals with low perceived susceptibility may deny that they are at risk for contracting a particular illness rosenstock opines that others may acknowledge the possibility that they could develop the illness but believe it is unlikely rosenstock further asserts that individuals who believe they are at low risk of developing an illness are more likely to engage in unhealthy or risky behaviors individuals who perceive a high risk that they will be personally affected by a particular health problem are more likely to engage in behaviors to decrease their risk of developing the condition the hbm predicts that higher perceived threat leads to a higher likelihood of engagement in healthpromoting behaviors based on the foregoing we therefore hypothesized as follows h1 there will be a positive and significant relationship between perceived susceptibility and public acceptance behavior towards family planning program relationship between perceived severity and public acceptance behavior perceived severity refers to the subjective assessment of the severity of a health problem and its potential consequences the hbm proposes that individuals who perceive a given health problem as serious are more likely to engage in behaviors to prevent the health problem from occurring perceived seriousness encompasses beliefs about the disease itself as well as broader impacts of the disease on functioning in work and social roles for instance an individual may perceive that family planning does not promote healthy behaviour but if he or she perceives that there would be serious consequences as a result of being poor and others then he or she may perceive nonadoption of family planning to be a particularly serious situation therefore we hypothesized as follows h2 there will be a positive and significant relationship between perceived severity and public acceptance behavior towards family planning program relationship between perceived benefit and public acceptance behavior healthrelated behaviors are also influenced by the perceived benefits of taking action perceived benefits refer to an individuals assessment of the value or efficacy of engaging in a healthpromoting behavior to decrease risk of disease if an individual believes that a particular action will reduce susceptibility to a health problem or decrease its seriousness then he or she is likely to engage in that behavior regardless of objective facts regarding the effectiveness of the action for instance individuals who believe that adopting family planning promotes healthy behaviour are more likely to adopt family planning program than individuals who believe that family planning will not promote healthy behavior on this basis we hypothesized as follows h3 there will be a positive and significant relationship between perceived benefit and public acceptance behavior towards family planning program relationship between perceived barrier and public acceptance behavior healthrelated behaviors are also a function of perceived barriers to taking action perceived barriers refer to an individuals assessment of the obstacles to behavior change even if an individual perceives a health condition as threatening and believes that a particular action will effectively reduce the threat barriers may prevent engagement in the healthpromoting behavior in other words the perceived benefits must outweigh the perceived barriers in order for behavior change to occur perceived barriers to taking action include the perceived inconvenience expense danger and discomfort involved in engaging in the behavior for instance lack of access to affordable health care and the perception that a family planning pill or device will cause significant discomfort may act as barriers to adoption family planning program based on the aforementioned we therefore hypothesized as follow h4 there will be a positive and significant relationship between perceived barrier and public acceptance behavior towards family planning program relationship between selfefficacy and public acceptance behavior selfefficacy was added to the four components of the hbm in 1988 selfefficacy refers to an individuals perception of his or her competence to successfully perform a behavior selfefficacy was added to the hbm in an attempt to better explain individual differences in health behaviors the model was originally developed in order to explain engagement in onetime healthrelated behaviors such as being screened for cancer or receiving an immunization eventually the hbm was applied to more substantial longterm behavior change such as diet modification exercise and smoking developers of the model recognized that confidence in ones ability to effect change in outcomes was a key component of health behavior change therefore we hypothesized as follows h5 there will be a positive and significant relationship between selfefficacy and public acceptance behavior of family planning program theoretical framework the theoretical framework that was used to frame this study is healthbelief model healthbelief model is a psychological health behavioral change model developed in the 1950s in regard to the uptake of health services the model suggests that peoples beliefs about health problems perceived benefits of action barriers to action and selfefficacy explain acceptance of healthpromoting programme hbm asserts that the rationale behind taking any action to promote or accept any health education programme is based on how strongly they feel that they are vulnerable to the healthrelated issue on ground whether the suggested health intervention programme is of value whether the effectiveness of the treatment is worth the cost which barriers to overcome in order to institute and maintain specific behavior influence by significant person who may have been susceptible to the same healthrelated issue showing the need for action hbm postulates that an individual could accept certain healthrelated programme on the basis of perceived susceptibility perceived severity perceived benefit perceived barrier and selfefficacy this study adopts hbm because it is in line with the main objective of this study and has high applicability in the health marketing and social marketing studies empirical review social marketing has become a vital tool in creating awareness and changing consumers healthy behaviour the issue of how effective it is has become a major concern to researchers because many companies or businesses have resorted to these programs to enable them achieve their objectives and satisfy the changing needs of the consumers and often it becomes difficult to evaluate the success of social marketing programs as they aim to change however afework on his study on the perceptions of people about family planning the social marketing experience in ethiopia aimed at analyzing the role and practice of social marketing as an approach to address issues related to attitudinal change about family planning based on the idea of social marketing and its application to positively influence the behavior through changing attitudes of individuals related to family planning and contraceptive use the study was developed with the methodology applied for preparing instruments of data collection sampling and data analysis it was found that marketingmix as designed for social issues such as family planning has a key role to play to positively develop the attitude towards the concept and bringing favorable changes in the behavior of individuals also that individuals responsibility towards society and usage of family planning services was also found to be associated with social marketingmix in other words it concludes that as the social marketing activities and programs increase the attitude towards family planning will become more favorable among the society members rukundo in the study on the role of social marketing in family planning in rwanda opined that social marketing through the use of social media is set to understand how it can create awareness through social marketing campaigns use of promotional mix in order to address behavioral change the study involved the problem identification which is witnessed by the high population increase in rwanda from 712 million people as per current statistics and despite the government campaigns against population pressures and its consequences of poverty famine shortage of land diseases and poor access to education has resulted into poor quality of life the research was conducted in 2 district of rwanda and 20 respondents were selected in each based on convenience sampling data collection design was made up of primary and secondary sources and the study found that 908 of respondents revealed that practicing family planning helps families to improve their wealth and health 892 pointed out it helps to reduce unwanted pregnancies and 858 pointed out that it reduces poverty in families based on the findings still social marketing media has not attained maximum capacity to address social marketing programs as weak points were shown in media coverage accessibility and cost communication clarity and the general development of media infrastructure all of which hinder social marketing effectives and recommended that there should be appropriate programs to increase literacy on social marketing agendas especially those who had limited education this increases the knowledge and prepares people to have open understanding to any intended programs therefore it recommends that social marketing programs should be constantly reviewed evaluated through the benchmark indicators such as progress efficiency effectiveness and impact they have heard to the population in relation to the set objectives another study by samad madichie and nwankwo on the role of social marketing models in family health interventions in pakistan stated that social marketing techniques have been used extensively in international health programmes especially for contraceptives and oral rehydration therapy the paper analyses the performance of two social marketing programmes for hormonal contraceptives in pakistan using different models for interventions to achieve somewhat similar goals the models used for social marketing interventions include the manufacturers model and the nongovernmental organisation model their results indicated that both programmes were effective in increasing contraceptive usage with no evidence to suggest that either the manufacturers model was more sustainable or the ngo model more effective in serving the poor population again mustafa et al carried out a research on the family planning knowledge attitude and practices among married men and women in rural areas of pakistan the paper presents the findings of a qualitative assessment aimed at exploring knowledge attitudes and practices regarding family planning and factors that influence the need for and use of modern contraceptives a descriptive exploratory study was conducted with married women and men aged between 15 and 40 overall 24 focus group discussions were conducted with male and female participants in three provinces of pakistan the findings reveal that the majority knew about some modern contraceptive methods but the overall contraceptive use was very low therefore it concluded that the need for qualified female healthcare providers especially for long term family planning services at health facilities instead of camps arranged occasionally and recommended that addressing issues around access affordability availability and sociocultural barriers about modern contraception as well as involving men will help to meet the needs and ensure that the women and couples fulfill their childbearing and reproductive health goals furxhiu kusaku and cera in a study on how social marketing influences behavioral change attempt to explore and describe some of the ways social marketing practices and instruments have been used to influence behavioral change according to them social marketing is being observed as an approach that is increasingly being used to achieve positive impacts on the behavior of individuals and groups and to help sustain these over time their main purpose in the article was to present some of the aforementioned evidence brought up by previous researchers trying to establish effective practices social marketing approaches should implement in order to achieve desirable behavioral results the study was explorative in nature and focuses on the important role social marketing principles and practices play in fueling behavioral change and achieving behavioral goals they also discuss some of the barriers social marketing models face as well as recently developed social marketing frameworks such as strategic social marketing and communitybased social marketing throughout their exploration they were reminded social marketing s main goalto introduce and absorb financial marketing s principles tools instruments and techniques in order to influence a target group s behavior in a wide range of areas such as health care environment and education with the aim of benefiting society as a whole also bach and alnajar in a study on the impact of social marketing on public behavior maintained that social marketing utilizes the traditional commercial marketing strategies to influence public behaviors effectively so as to bring about greater socialpublic good while similar to commercial marketing social marketing does not attempt to maximize profit or sales rather the goal of social marketing campaigns is to change a behavior in the society which will benefit the overall public such as persuading people to use only efficient lighting so as to conserve energy or persuading more individuals to use seat belts to this end they concluded that it is crucial for social marketers to ensure that they use effective marketing plans and strategies such as the 4 ps of the marketing mix in combination with other factors such as policies and partnerships in order to make the social marketing program or campaign a success finally the paper explored how social marketing can have a significant impact on public behavior if social marketing campaigns are deployed keeping in view traditional marketing strategies and plans also chin and mansori carried out a study on social marketing and public health a literature review the objective of the paper was to provide the concept of social marketing and public health through the intensive literature review their study focuses on the discussion and justification regarding the social marketing and public wellbeing it explains the integration between these two disciplines through the literature review given that the research illuminates an individuals perceptions regarding public health awareness and disease early diagnosis using social marketing approach considering this theory of planned behaviour social cognitive theory protection motivation theory and health belief model were applied to understand the behavioural change and intention towards the intended healthy behaviour furthermore model of communication is used to ensure an effective communication process and the target audience decodes the intended healthy behaviour message duboviks and kite in a study on the effectiveness of social marketing in hiv prevention a literature review argued that one of the most important issues in social marketing today is the evaluation of its effectiveness and its ability to prove that social marketing interventions have led to consistent behavioural changes the paper aimed to analyse available evidence on the effectiveness of social marketing in health outcomes and improvements in health behaviour change with particular emphasis on the effectiveness of social marketing and the methods used to evaluate it in the context of hiv prevention qualitative and quantitative content analysis were used also the adopted form of flow of information through the different phases of a systematic review was applied during paper selection it was found that majority of social campaigns included in the review run poor approaches to measuring the effectiveness of social marketing interventions such as measuring changes in health outcomes and health behaviours of the target audience only after its implementation which weakens the evidence of its effectiveness and ignore various factors such as product availability to target audience cultural factors and target audience knowledge on the issue however campaigns creators are recommended to take into account that in order to create an effective social marketing intervention it is necessary to carefully explore the target audience and provide the best possible exposition of behavioural products to target audience during the campaign in another systematic review done by mohsen shams in iran on social marketing for health theoretical and conceptual considerations stated that social marketing is an approach to persuade people to accept ideas and attitudes perform healthy behaviors refer to health facilities and receive health products in this study the theoretical considerations and practical steps for planning implementing and evaluating the interventions based on the social marketing approach was discussed he studied four researches designed and implemented based on the social marketing model based on the formative research the social marketingbased intervention was designed and the interventions resulted in statistically significant reductions in the two target behaviors in the intervention group as compared with the control group he therefore concluded that successful in the health market it is required to consider the key principles and techniques of social marketing such as consumer research audience segmentation exchange theory competition thinking and marketing mix by decisionmakers managers and care providers therefore recommended that the future policy should be focused on empowering them to apply this approach as an important solution for health issues source researchers conceptualisation figure 2 materials and methods the research design for this study is survey design and the unit of analysis comprised childbearing nigerians in enugu state nigeria childbearing nigerians are those nigerians that are still having children and have the tendency of giving birth to more children quota sampling technique was adopted and the sample size was 246 respondents which was determined using cochrans formula data were collected through a structured questionnaire and multiple regressions were used to test the hypothesized relationship between the independent variables and the dependent variable resultfindings the table below shows the model summary of the regression analysis the table showed a correlation coefficient of 845 which is a positive strong correlation the r square tells how much of the variance in the independent variables is explained by the model the value is 714 expressed as a percentage this means that our measurement model explains 714 of the variance in the dependent variable this is quite a respectable result adjusted r square value provides a better estimate of the true population value the value is 708 which indicates that the numbers of independent variables and the sample size of this study are large enough for a study of this magnitude the table below reveals the analysis of variance of the regression analysis anova value assesses the statistical influence of the result this tests the null hypotheses that multiple r in the population equals 0 ie p 05 the anova in this study is 1130735 which is statistically significant at 000 this implies that the research model is a goodfit also because the pvalue is less than 005 the model is significant in the oefficient table the collinearity statistics column shows the tolerance and the variance inflation factor of the regression tolerance is an indicator of how much of the variability of the specified independent variable is not explained by the other independent variables in the regression model values less than 01 indicates that the multiple correlation with other variables is high suggesting the possibility of multicollinearity in this study two independent variables have tolerance slightly higher than 01 which is very negligible since others have tolerance values higher than 01 also the variance inflation factor of the regression model shows that two independent variables have vif value slight above 10 which is also negligible the smaller the value of significance and the larger the tvalue the greater the contribution of that predictor in this model perceived susceptibility perceived severity perceived benefit perceived barrier and selfefficacy were all significant predictors of family planning programme acceptance from the magnitude of the tvalues we can see that perceived severity has the highest effect follow by perceived benefit selfefficacy perceived susceptibility and perceived barrier in that order more so standardized coefficients beta were calculated because they provide insight into the importance of a predictor in the model the beta value for perceived benefit indicates that perceived benefit had the strongest on public acceptance of family planning programme while perceived severity showed the second strongest relationship selfefficacy showed the third strongest predictor perceived susceptibility showed the fourth strongest predictor and perceived barrier showed the fifth strongest predictor discussion from the result findings perceived susceptibility perceived severity perceived benefit perceived barrier and selfefficacy are the major predicting factors of public acceptance of family planning programme among childbearing nigerians it was found that respondents that perceived that they are vulnerable to social problems relating to lack of proper birth control tend to accept family planning programme also individuals who perceived social problems that emanate from over population as dangerous accepted family planning programme more so respondents that have assessed the value or benefit that result from controlled population and small family size accepted family planning programme furthermore individuals who have perceived the inconvenience expense and danger of population explosion and large family size accepted family planning programme lastly individuals who perceived that they are competent to successfully avoid large family size that result in population explosion accepted family planning programme recommendations we recommend that health and social policy makers in nigeria should sensitize the childbearing parents in the rural areas about the essence of family planning programme and make available social marketers and entrepreneur that will help do an awareness campaign rigorously more so health marketers and social marketers should let the childbearing nigerians to be aware of the dangers of overpopulation both on their health and on the economy in conclusion this study has identified major predicting factors of public acceptance of family planning programme in nigeria also it has provided an empirical support that perceived susceptibility perceived severity perceived barrier perceived benefit and selfefficacy have significant and positive effect on the public acceptance of family planning programme the implication for theory is that hbm has been proved to be empirically relevant and applicable to study relating to health and social marketing world health organization health topics family planning

nigeria there exist scanty empirical studies on family planning programme public acceptance from the social marketing view in order to fill the literature gap predictors of public acceptance of family planning programme were investigated the research design for this study was survey design and the unit of analysis comprised childbearing nigerians in enugu state nigeria childbearing nigerians are those nigerians that are still having children and have the tendency of giving birth to more children quota sampling technique was adopted and the sample size was 246 respondents which was determined using cochrans formula since the study population is infinite data were collected through a structured questionnaire and multiple regressions were used to test the hypothesized relationship between the independent variables and the dependent variable from the result findings perceived susceptibility perceived severity perceived benefit perceived barrier and selfefficacy are the major predicting factors of public acceptance of family planning programme among childbearing nigerians in conclusion this study has identified major predicting factors of public acceptance of family planning programme in nigeria also it has provided an empirical support that perceived susceptibility perceived severity perceived barrier perceived benefit and selfefficacy have significant and positive effect on the public acceptance of family planning programme we recommend that health and social policy makers in nigeria should sensitize the childbearing parents in the rural areas about the essence of family planning programme and make available social marketers and entrepreneur that will help do an awareness campaign rigorously

introduction background twothirds of respondents to the american health information national trends survey between 2008 and 2017 reported turning to the internet first for health information 1 similarly 69 of canadians reported using the internet to search for health information in 2020 2 and the proportion of adults seeking online health information in other organisation for economic cooperation and development countries more than doubled between 2008 and 2017 3 the use of ohi can improve quality of life and is generally associated with positive outcomes such as increased empowerment of seekers and their families and improved health outcomes 4 5 6 7 based on the results of a recent systematic review on the outcomes of ohi seeking several contextual factors associated with these outcomes were identified such as age education income and ehealth literacy 8 another contextual factor is social support defined broadly as support accessible to an individual through social ties to other individuals groups and the larger community 9 social support is an important factor because one of the ways people use ohi is to support family members or friends with health conditions 10 in fact recent studies report that 61 66 of ohi seekers are proxy seekers meaning they seek ohi on behalf of someone else 1112 moreover findings from a study exploring internet use trends between 2008 and 2013 showed a significant increase in the use of family and friends to obtain health information 13 however while proxy information seeking has been explored in the literature especially as it relates to health information little is known about its relationship with the outcomes of ohi this is a critical knowledge gap previous research examining how to reduce negative outcomes of ohi suggests that ohi seekers may be able to overcome low ehealth literacy by discussing the information they find with others 14 people are sometimes more likely to turn to their social circle to make sense of information they find rather than discuss it with a health professional 1115 members of a persons social circle may help them overcome informationseeking barriers and illness challenges 15 by better understanding how people and their social circles use information together information providers can better adapt the information to meet both their needs and public health interventions can target patients friends and family with information for dissemination and use 16 accordingly the purpose of this paper is to contribute to our understanding of the role of social support in online health information outcomes by focusing on the outcomes of proxy ohi seeking this review will focus on the intersection of 3 main constructs proxy information seeking social support and ohi outcomes proxy information seeking information seeking encompasses all the information that comes to a human being during a lifetime not just in those moments when a person actively seeks information 17 in active information seeking mode monitoring and directed searching are ways to answer known information needs there are intervening variables that may be related to personal characteristics social or interpersonal issues or environmental considerations 18 they can be defined as those who seek information in a nonprofessional or informal capacity on behalf of others without necessarily being asked to do so 15 proxy seekers may also be experts such as health librarians or health care professionals with the specialized knowledge or skills to use the information with the person with whom they share a personal relationship 19 the role of proxy information seeking has been explored in the literature and has also been referred to as surrogate seeking or lay information mediation 1220 in one of the earliest models on information seeking behavior wilson 21 used pathways to explain different patterns of information seeking in his model the user encounters information systems that can be technology and mediators and these systems connect the user to information resources or actual information of 10 pathways proposed in this model 2 indicate seeking that is conducted by a mediator to fulfill an information request 21 this phenomenon is also described in mckenzies 22 2dimensional model of information practices of women pregnant with twins in her model one of the modes of information practice is by proxy where the person interacts with information through another agent including intermediaries or gatekeepers such as friends or family members social support social support is one of the positive products of social relationships that may have shortand longterm effects on health for better and for worse depending on their quality and quantity 23 a 2004 model by uchino 24 describes 2 broad dimension of support structure and function structural aspects of support are the extent or composition of ones social network and the interconnections among them functions have 4 aspects that are highly related to each other emotional informational tangible and belonging most relevant to this review is informational support which includes the provision of advice or guidance and may provide direction and carry an emotional message when received from a close source informational support could be construed as supportive unsupportive or mixed depending on the context 25 26 27 social support has consistently been linked to better health 242829 several theories have been proposed to explain why this occurs for example social support can act as a mediator of stress that reduces its impact thereby improving mental health 23 several studies have reported that those who perceive low social support experience increased stress and report a greater number of stressful events while those who feel more satisfaction with their received social support report fewer emotional problems 30 31 32 33 another theory to explain the link between social support and better health is the provision of informational support which encourages the receivers to manage their health if we use pregnant women as an example those who were more satisfied with perceived and received social support initiated prenatal care earlier than those who were less satisfied 34 pregnant women who received more informational support from people in their social network delivered babies with higher apgar scores and higher birth weights 3435 online health information outcomes a theoretical framework on ohi outcomes and the factors associated with these outcomes was developed by pluye and colleagues 8 based on a systematic review with a framework synthesis this framework was derived from previous research by the authors and combines the information theory and psychosocial theory of behavior it includes 4 types of contextual factors that influence ohi outcomes individual factors social and technical factors relationships with professionals and education health and social services it also includes 4 levels of individual outcomes of ohi seeking situational relevance cognitiveaffective impact use and subsequent healthwellbeing outcomes of use of information these levels are presented in figure 1 for each level different types of outcomes were identified and validated using systematic mixed studies reviews and qualitative quantitative and mixed methods primary research studies 103637 however this framework is focused exclusively on an individual perspective it is the same person that starts the ohi seeking process and experiences the outcomes of this process studies that tested this framework therefore focused on people who used the ohi for their own health care and reported the health outcomes they themselves experienced little is known about what happens when the information need is to answer a question about someone elses health or what is involved when the information is used with someone else 14 therefore to adapt this framework to the context of proxy ohi seeking we are interested in 4 sections of this framework influencing factors of ohi seeking ohi seeking behavior including information needs ohi use and outcomes of ohi use intersection of the 3 concepts there appears to be no comprehensive conceptual model on the outcomes of proxy ohi seekers using ohi to provide social support reifegerste et al 38 modified and extended the existing comprehensive model of information seeking with concepts of social network ties to predict proxy information seeking and the resulting social support intentions they developed hypothetical scenarios of people with varying severity in depression and with varying relationship closeness structural equation modeling was used to test the associations between the healthrelated factors proxy health information seeking intentions and social support intentions they hypothesized that support is the resulting action of proxy ohis this is an important study that modifies an existing information seeking model to proxy seeking however seeking and support were measured only as intentions moreover the demographic characteristics were not found to be relevant potentially due to the low variance of the study sample therefore our review aims to build on this work by further exploring the context of proxy ohi seeking and the outcomes of using ohi to provide social support methods design a mixed studies review was conducted using a databased convergent synthesis design in which qualitative and quantitative data were analyzed together using a qualitative thematic analysis 3940 a mixed studies review is ideal in this context because the evidence is from diverse fields of inquiry and it uses diverse methods to provide a rich and highly practical understanding of complex health interventions 4142 framework synthesis was then conducted to produce a revised conceptual framework eligibility criteria table 1 lists the inclusion and exclusion criteria that were deemed appropriate for identifying relevant studies a ohi online health information b icu intensive care unit sources and search strategy papers were searched in 5 databases from inception to may 25 2021 a search strategy was compiled with the help of a health librarian and included 2 main concepts ohi and proxy ohi seeking or social support the term surrogate seeking was discovered after reviewing articles from the first 4 databases and was thus added to the scopus search strategy the sets were combined using boolean operators depending on the database being searched as presented in table 2 the search was limited to english and french languages with no limit on years all the records were transferred to a reference manager software and duplicates were removed using the bramer method 43 after the selection stage additional potentially relevant records were retrieved by tracking the citations of the selected documents selection of relevant studies the 775 records were then imported into distillersr a webbased application for conducting systematic reviews for selection 44 for each record eligibility codes were assigned according to the criteria described in table 1 for every included record the corresponding fulltext publications were retrieved subsequently full texts were imported into distillersr again and coded using the same eligibility criteria included studies were then exported into nvivo data extraction and synthesis of included studies characteristics of the included studies and results related to the role of social support in ohi seeking and outcomes were coded in nvivo a deductiveinductive analytical approach was adopted for thematic analysis of the extracted evidence 45 a coding manual was developed following the framework proposed by pluye et al 8 that included characteristics of proxyohi seekers context of proxyohi seeking use of ohi by proxy seekers and outcomes of ohi use for the seeker and recipient the codes were then progressively clustered into major themes and subthemes framework synthesis the initial framework in figure 1 was revised following the qualitative synthesis stage an iterative collaborative process was adopted over a series of meetings all major themes were placed into textboxes and added to the figure representing the initial framework alternative figures were proposed until consensus was reached among the authors the framework was then reviewed by 2 peer reviewers and presented at 2 research meetings and the feedback received was used to produce the final framework results characteristics of included studies of 775 unique records identified in our search 28 were deemed relevant and included in our review those referred to 15 quantitative studies 10 qualitative studies 1 mixed methods study and 2 systematic reviews over half of the empirical studies were conducted in north america the corresponding 28 fulltext articles were divided into 3 groups depending on who the focus of the study was ohi proxy seekers ohi recipients or both full details of the study characteristics are in presented in multimedia appendix 1 renderx characteristics of proxy seekers the results of a telephone survey of 18750 european citizens show that 61 of those seeking ohi searched on behalf of someone else and of those 266 exclusively searched on behalf of someone else these surrogate ohi seekers were more likely to live with others and more likely to search on behalf of their partners children or other family members rather than for friends or colleagues 11 this finding was echoed in several studies that reported that the proxy seeker was most often a member of the same household or with whom the person had close ties 1215 46 47 48 49 50 51 this was especially highlighted in relationships where the proxy seeker considered themselves responsible for someone elses health we found 5 studies that focused on informal caregivers who reported higher and more constant proxy seeking behavior than noncaregivers 465253 a study exploring information seeking in families affected by multiple sclerosis describes the disease as a shared concern or responsibility that necessitates sharing information about it 54 dutta et al 55 described 3g households in singapore where the children and grandchildren play vital roles as sources of health information for grandparents several other proxy seeker characteristics influenced ohi seeking behavior one important factor is gender 7 studies reported that most people who searched ohi on behalf of others were female 11154850545657 proxy seekers were generally younger and more educated 11154748535658 although 1 study reported that age education and income were not significant factors that influenced proxy ohi seeking behavior 59 another factor is related to the proxy seekers experience with ohi respondents in several of the included studies were reported as having higher health literacy 1254 and engaging in frequent ohi seeking behavior 11 information needs and triggers of proxy seeking ohi seeking was triggered by different reasons and at different times in the included studies the proxy seeker may be asked explicitly to search for ohi on behalf of someone who is unable to search for themselves who has a complex health situation or who needs to confirm information they had found online themselves 51556061 on the other hand more studies report that the proxy seeker initiates the search unsolicited out of interest 1561 when they do not have enough information to support a person living with a health condition 4754 immediately following a diagnosis 62 63 64 65 or following a visit with a health care provider 6266 finally the proxy seeker may also initiate the search themselves as a coping mechanism to help deal them with their emotions following the diagnosis of a loved one 5361 table 3 information needs and triggers of proxy seeking excerpt code the carer may be asked to search for information on behalf of the person with cancer this mostly occurs in situations where the patient does not have access to the internet or is not internet savvy or the person with cancer finds they are too ill to search 61 explicit request both patients and caregivers also mentioned that they surfed the internet again at specific moments later during the lung cancer treatment trajectory such as during chemotherapy at the appearance of new symptoms or disease progression or when having to make a choice between 2 treatment options 63 to make a decision a high percentage of the 795 caregivers had used the internet to search for information about the disease of the patient they were taking care for in the last year prior to the survey 47 to support someone with a health condition for gina a 26yearold chinese participant her role as a granddaughter constitutes her interpretation of his a as she mostly seeks out information for her grandparents jamila a 37yearold malay woman seeks out health information from the internet when one of her family members is not feeling well 55 out of interest or obligation patients and caregivers mentioned that their need to seek information often arose once they had time to rest and think about what they had been told often at a time when their questions could not directly be answered by the treating specialist anymore once you have come home you have forgotten half of what you have been told which is exactly the moment you would want to ask something 63 following a health care practitioner visit carers also tended to act as gatekeepers of information and constantly sought new information as a means of coping 53 coping mechanism a his health information seeker how proxy seekers use ohi proxy seekers used ohi to better understand someone elses illness or to help themselves feel more empowered in their role as caregivers 49646567 several studies reported the sharing of information between caregiver and patient either directly by sending them a link or printout or indirectly by discussing the information found 495057606468 one study describes sharing and resharing the information among a social network so that it reaches a larger number of people 55 or so that a larger number of people are involved in making sense of the information 57 one aspect of providing informational support involves acting as gatekeeper and controlling incoming information flow for the person 15 an included literature review exploring the role of caregivers of cancer patients identified this role in 3 included studies potentially as a way to manage the cancer experience of the patient 61 families developed strategies for controlling information sharing either explicitly with the patient or implicitly especially if the information was potentially distressing or could lead to conflict 5463 proxy seekers used the information in discussion with health care providers at a clinical visit 4955616264 this led to asking more questions and feeling more empowered during the visit as well as involving the provider in the interpretation of the information 496167 in some cases it led to requesting more testing or to trying a new treatment plan 6269 on the other hand especially if the provider was not receptive to discussing the information it also led to confronting or challenging the providers decision 62 proxy seekers also used the information to provide emotional 5162 and material support especially as informal caregivers 4661 to the person they used the information to change that persons lifestyle for example mothers in 1 study cooked healthier food and encourage their families to walk together as a form of exercise 55 in another study the authors report that family members used the information to exert control on the patient using techniques such as pushing or guilting 68 outcomes of ohi use the outcomes reported by the included studies were overwhelmingly positive empowered by the informational they received proxy seekers and effected individuals felt better informed and more confident were able to discuss the information with their health care providers and request different management options 616269 information helped people make a health behavior change like quitting smoking 15 it also helped lessen worries about their own health 1566 one study described a 87yearold participant who reported she feels calmer when her grandchildren print out information and explain treatment options for her 55 people described how having proxy seekers care so much about their health made them feel supported 51 and allowed them to have someone to talk to about their health 64 negative outcomes were rarely reported a literature review found limited reports of patients anxiety or decisions to refuse cancer treatment 61 there were 2 studies that reported that the proxy seekers themselves experienced more anxiety sometimes because of information overload 6566 the proxy seeker and the person did not always have the same approach to ohi in situations where the person did not want to know or ignored the information this led to tensions and conflict 5468 revised conceptual framework figure 3 shows the revised conceptual framework after the review the following paragraphs describe proxy seekers their motivations how they seek information and their outcomes who proxy seekers are proxy seekers are more likely to be female and are also more likely to share health information with others as they are considered the central nodes of health information within a community 7071 moreover they are more likely to be more educated with higher ehealth literacy and frequent internet users in general proxy seekers are likely to be in frequent contact with the people for whom they are seeking ohi and to report strong social ties with these people why and when does proxy seeking occurs the ohi seeking process is triggered by an explicit or implicit information need explicit information needs may be communicated to the proxy seeker with or without a request for informational support proxy seekers who are also informal caregivers may initiate ohi seeking as part of their caregiving responsibilities the proxy seeker may also initiate the search themselves out of curiosity for reassurance or as a coping mechanism to help deal with their emotions following a diagnosis of their loved ones how proxy seekers use information when proxy seekers find a situationally relevant information object that they understand or agree with they can use it to provide social support for someone else this support is most commonly informational either by sharing the ohi found directly or discussing it with the person to help them make sense of it support may also be emotional or material such as offering to cook meals the proxy seeker also acts as an information gatekeeper by filtering the information for the person to reduce stress due to information overload outcomes of ohi use by proxy seekers using the information will lead to separate outcomes experienced by the person and the proxy seeker which are generally positive for example feeling more confident discussing the information at a clinical visit in situations where the information is conflicting or unsolicited it may lead to negative outcomes such as increased worrying or worsening of an interpersonal relationship discussion principal results to our knowledge this is the first review to explore the outcomes of proxy ohi seeking and use of ohi to provide social support to others we adapted a framework on individual ohi outcomes to proxy seekers and described and explained the context use and outcomes although there are 2 included reviews that reported interesting results they did not fully address our question the first explored the role of the internet in supporting and informing caregivers of people with cancer 61 and the second explored how informal caregivers of children with health care needs used internetbased health care services and resources 72 another relevant review that explored the proxy ohi seeking behavior of parents for their children and describing a conceptual model was not included in our review because parents are also proxy decisionmakers for their children 73 another recent study adapted the existing comprehensive model of information seeking to surrogate health information seeking but did not explore the outcomes of social support 38 comparison to existing models on ohi seeking outcomes in his revised 1996 model wilson 74 added information processing and use our conceptual framework goes further and in addition to describing the context of information seeking behavior by the proxy seeker also explores ohi use and outcomes similar to the ohi outcomes framework by pluye 8 our framework includes factors that influence information seeking behavior and leads to 4 levels of outcomes the use of ohi in our framework revolves around types of social support and the health and health carerelated outcomes are reported by both the proxy seeker and the affected person moreover we identified 2 additional consequences of informational support sharing misleading information and acting as a gatekeeper to the information our findings echo those of other studies exploring offline proxy health information seeking in situations where the information need is explicit and the proxy seeker has high health literacy informational support is associated with positive emotional support and other outcomes are generally positive first people who can discuss the information they found with others are more likely to better understand the information use that information to make decisions about their health care and experience better health outcomes such as reduced worries 75 76 77 78 other potential outcomes include improvement in the receivers health buffering of potential negative outcomes and increase in perceived social support 93279 this is especially true if the provider has higher health literacy than the receiver in that they are better able to explain contextualize or validate the information 8081 some people may prefer information avoidance defined as any behavior designed to prevent or delay the acquisition of available but potentially unwanted information 82 which may lead to tensions between the proxy seeker and the affected person second for the seekers themselves these outcomes include a change in their relationship with the person and feeling more involved in the health care of others 83 moreover social support providers who reported feeling more satisfied with their interaction with the person and who felt better about themselves after providing informational support were more likely to continue doing so and more likely to seek information from other sources 83 negative outcomes for the seekers reported include increased anxiety due to information overload this is defined as when the information processing demands on time…exceed the supply or capacity of time available for such processing 84 in situations where the informational support is unsolicited and the person does not feel that the information is relevant to their situation interpersonal tensions may develop 14 this may also occur in relation to sharing sensitive or intimate information with family members for example a study examining the effects of discussing information on sexuality and contraception on motherdaughter relationships reported that a strain in the relationship may develop 85 in addition sharing misleading health information from unreliable sources may also lead to negative health outcomes as described in 2 recent systematic reviews 8687 more specifically in this context the seekers do not intend to cause harm and are in fact spreading misinformation that may lead to delayed care decreased quality of life and increased risk of mortality limitations there are some limitations to our review unlike in a systematic review only 1 reviewer carried out the selection phase so some relevant studies may have been missed however our goal was to revise a framework and not necessarily to be exhaustive similar to other reviews there may have been underreporting of negative outcomes due to publication bias finally systematically reviewing all the models on information seeking behavior was beyond the scope of this review but we reviewed and discussed the most common models with a specialized expert librarian directions for future research most studies on information seeking behavior do not explore how the information is used by proxy seekers and what happens next 88 while this review explores the outcomes of ohi proxy seeking few studies report outcomes for the seekers themselves as such future empirical studies can focus on these outcomes from the seekers perspectives furthermore little is known about which contextual factors or seeker characteristics are associated with positive and negative ohi outcomes future studies can test our framework in different contexts revise it and propose researchbased solutions to help the proxy seekers use ohi with others conclusion the outcomes of proxy ohi seeking constitute an important topic for both information specialists and health care practitioners members of a persons social circle may help them overcome informationseeking barriers and illness challenges 15 people are sometimes more likely to turn to members of their social circle to make sense of ohi they find rather than discuss it with a health care professional 11 by better understanding how affected people and their social circle use ohi together ohi providers can better adapt their platforms and information to meet both their needs and health care practitioners can target patients social circles with information for dissemination and use 16 potential public health intervention strategies can focus improving proxy ohi seeking and ohi use to promote positive outcomes for proxy seekers and the people they seek for through strategies that help proxy ohi seekers find relevant ohi evaluate it and use it appropriately strategies can also include extending social support networks for people without an effective social circle by identifying social support interventions from previous work that may be applicable in the context of proxy ohi seeking conflicts of interest none declared ©reem el sherif pierre pluye fidelia ibekwe originally published in the journal of medical internet research 24062022 this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in the journal of medical internet research is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included multimedia appendix 1

background highquality online health information ohi can reduce unnecessary visits to health professionals and improve health one of the ways that people use ohi is to support others with health conditions through proxy ohi seeking members of a persons social circle may help them overcome informationseeking barriers and illness challenges there are several models on proxy information seeking yet we know little about the use and outcomes of ohi on behalf of someone elsethe objectives of this paper are to explore and revise a framework on the context and outcomes of proxy ohi seeking methods we conducted a mixed studies literature review integrating qualitative and quantitative evidence with thematic analysis of the findings of 28 studies followed by framework synthesis incorporating the derived themeswe explored 4 main themes 1 characteristics of proxy seekers 2 context of proxy ohi seeking 3 use of ohi to provide social support and 4 outcomes of proxy ohi seeking our conceptual framework incorporates these themes and builds on previous workby better understanding how people use information together information providers can adapt the information to meet all users needs

in 1903 women owned a quarter of all rental properties in montréal a city where 85 of the 270000 residents were tenants a further 1 in 12 rental units were owned by estates where women might well have shared in management decisions from the perspective of the present such a high rate of female ownership appears quite extraordinary but there is a growing body of literature that suggests it might not have always been so unusual this article attempts to answer a simple question did the ownership of rental properties by women matter or did this formal ownership and control of almost a third of all rental units in canadas largest city count for little as their husbands sons or other male relatives aided by the occasional professional property manager or notary would have managed these womens properties 1 there is much to suggest in the laws and customary practices in turn of the century quebec that a subordinate role for women particularly but not exclusively married women would have been the norm while the default marriage regime was community of property the husband was legally empowered to assume all management responsibilities of the community under the provincial civil code women could own property as their propre but all revenues accrued to the community managed by their husbands any sales of real property did require the wifes consent but in a society increasingly marred by domestic violence any exercise of that veto would have come at an undoubted risk 2 notarized marriage contracts establishing a separation of property between future couples were possible but they were frequent only among bourgeois protestants furthermore they were often used to restrict the wifes dower rights to a prefixed amount while establishing by contract a legal regime that mimicked the english common laws subsuming of the wife in the legal personage of her husband thus while women legally owned in whole or in part from a quarter to a third of all rental properties in the city it is not selfevident that they controlled these properties if the question is clear how best to address it is not here i have opted for an analysis of a particular subset of the rental units owned by women using the historical gis research infrastructure known as montréal l avenir du passé 3 i selected all the immigrant households from the 1901 census and then analyzed in some detail nine differing immigrant populations my choice to focus on immigrants reflects the importance of differing forms of segregation in the city over the last half of the nineteenth century montréal had become a city marked by strong spatial segregation along both religious and linguistic lines by 1880 the city had become spatially divided into three ethnocultural groups frenchcanadian catholics englishspeaking irish catholics and englishspeaking protestants an immigrant familys choice of where to live would have been circumscribed by these already existing and powerful forms of discrimination i examine literacy levels relationships to the job market and incomes of immigrant household heads as well as their household incomes each of the immigrant groups examined exhibits substantial internal differentiation for those with cultural ethnic or historic ties to one of the three major groups in the city their own histories appear to have deepened the citys internal divisions however four of the groups examined did not have such ties and for this reason these chinese italian syrian and ashkenazi households are selected out for closer examination the spatial distribution of each of these four groups is quite distinct i examine how the gender of the proprietor might have influenced these patterns i pay special attention to the vexed question of overcrowding which i argue was a gendered issue before examining if the proprietors gender had any affect on those who chose to live at some distance from the main concentrations for their particular group although the diversity of these tenant households provides richly textured test cases to see how landlords and landladies4 acted this paper does not allow for an historical explanation this important limitation to the present study is due to the nature of the sources i use neither census returns nor tax rolls are eloquent on motivation the evidence in these sources is best used for description not explanation understanding these limitations is fundamental to the larger question this study raises and so i start with a discussion of how these century old sources have been transformed by their integration into an historical geographic information system before outlining the conundrum their usage poses i return to this epistemological challenge in my concluding reflections i argue that we really do need to understand how and why knowledge of such widespread participation by women in the formal economy could have been lost from both popular and scholarly memory before we can properly answer the larger questions of causality and motivation sources this study uses parts of the fourth of six layers in maps historical gis of the city of montréal those parts draw on two sources initially created respectively by the federal government in 1901 and the municipal council in 1903 but both have undergone very substantial transformations by map the 1901 decennial census of canada is one of the most studied censuses in modern history and as montréal was then the economic capital and largest city of the dominion its returns have received a disproportionate share of historical attention 5 realizing this was the case map approached all the researchers we knew who had sampled this census and asked for copies of their databases they all cooperated and the result after a considerable editing job to address duplicate entries and completion of missing fields is a combined sample of 16111 of the citys 51297 households at 31 our sample is more than six times the size of the largest previously available public dataset 6 we complement this sample with a much more limited database that provides basic information on the entire islands population 70076 households in which 370242 people resided in 1901 the enumerators asked a complex series of questions most of which were only partially answered three series of questions relating to ethnicity income and literacy and language are of particular importance for this paper i selected the 4300 individuals who were described as being a head of household and who also provided a year when they immigrated to canada i then culled household size and data on earnings for these tenants they were not coresident with lodgers or managers of boarding houses for a discussion of these quite different but also highly gendered contexts see the special issue on lodgers in rural and urban europe in the past edited by moring 5 most notably by the canadian families project for a methodological overview see sager while for the major findings see baskerville and sager 6 all but one of the contributing samples were initially designed to answer specific research questions and so this is not a random sample for present purposes the most important difference is that some samples took individual households but others took all the households on a property or all on a particular page thus the relationship between households within the larger sample varies a great deal which is why to examine one such relationship overcrowding i used the full index of all households in the census immigrantheaded households from the larger sample finally using locational information i linked these households to all those sharing the same lot in the complete census the second major source is a 1340 page publication of the city council which listed in considerable detail the proprietors of every lot in the city along with the cadastral and subdivision numbers the dimensions the area a standardized value per square foot of land the resultant value of the land the associated civic addresses an appraised value of all buildings on the property the religion of the proprietor for purposes of the confessional school tax and if the property was exempt from tax the detailed personal information provided on each owner allows them to be uniquely identified despite the frequency of common surnames council stated that the purpose of this exceptional publication was to encourage speculation in real estate 7 in 2006 and 2007 working with the historical demographer patricia thornton map scanned and ocr ed the document page by page patricia stitched the adjoining two page tables back together in a spread sheet for initial editing i then exported the resultant table to a relational database for final editing and proof reading this database became the basis for a number of my presentations to national and international conferences then starting in 2011 i undertook the creation of a georeferenced layer to map this database the spatial dynamics revealed so far has proven the value of this particular piece of research infrastructure 8 this georeferenced map is the primary source used in this paper and by this i do not mean just that the map is my preferred way of presenting data but that it is through the map that data coming from our two datasets described earlier both based on the same census are linked to date we have linked 87 of all households in the city to the map i was able for this paper to raise that level to 98 for the 4300 household heads in our sample who provided a year of immigration thus this paper focuses on the 4201 immigrantheaded households i have successfully linked to the map 9 the analytical priority i accord to the spatial reference of the lot is conceptually important i am not analyzing immigrantheaded households in the abstract but rather those households i have been able literally to ground on a particular lot this permits a contextual analysis of this subset of the sample that as we shall see goes well beyond the limitations of the sample itself an epistemological conundrum influenced by social science many historians would think of these sources as routinely generated nominal series furthermore again inspired by our sister disciplines social and economic historians would then apply statistical methods to identify not just patterns in the data but to deduce causal relationships for reasons i have detailed elsewhere i do not practice this social science history rather i think that when developing discourses of proof in history we should distinguish between phenomenal and epiphenomenal evidence is the source the product of the historical changes we seek to explain or not if so then its internal historical logic might well allow the evidence to be used in a test of our hypothesis of causality if not then the evidence is best used for description rather than explanation now the question that is at the heart of this study is did the gendered ownership of urban rental units matter neither of the sources i am using can be argued to have the direct product of this gendered relationship however the internal organization of both does speak to the centrality of gender relations in how these governments understood and attempted to bring order to their incoherent worlds we should not mistake their constructions for historical reality rather we need to recognize how gendered inequalities shaped the very evidence we have to work with as curtis observed governments do not take censuses they make them up the fictional character of both sources used here is important for us to remember lest we fall into the sort of ahistorical explanations that have so marred my generations economic history if we need care in drawing conclusions about patterns apparent in either source we need to exercise even greater caution when drawing connections between the two for none should be thought of as the product of turn of the century montréal all such linkages have been created in and through twentyfirst century historical theory and method in short we need to add a considerable dose of selfreflectiveness on our own constructions to the critical awareness that we bring to the constructions of past governments such an explicit recognition of our own historicity is vital to any successful resolution of this epistemological conundrum as these cautionary words suggest the motivations for any gendered differences revealed in the following analysis is currently beyond my ken minimally it would require the analysis of quite different sources and a much greater contextualization of the social cultural religious and gendered tensions within this society than i am presently capable of providing immigrantheaded households by 1901 montréal had for the previous 70 years been the largest city in the most important settler colony of the british empire according to the census this 258yearold city was entirely populated by immigrants and their offspring even if this says more about how racist conceptions of indians shaped government recordkeeping than it does about the actual population more than 90 of the listed residents were identified as canadianborn and over 95 of those could trace their origins back to either france or the british isles but things were changing the number of immigrant heads of household from one of the two founding peoples10 had dropped below 75 for the first time in the almost 300year history of this settler colony table 1 profiles the principal immigrant groups retained for analysis here they account for 94 of all immigrantheaded households in the 1901 census they include the seven largest groups by country of origin as well as two more diverse groups 11 under ashkenazi i have regrouped the jewish population drawn from eastern and central europe there was a wellestablished jewish community in the city dating back to the 1760s but it was sephardic i have also chosen to include the newest and ninth largest group by place of birth the syrians the first of whom arrived in 1890 a forerunner of the estimated 600000 syrians who would immigrate to the americas prior to the great war while threequarters of all selected heads had immigrated by 1891 the majority of all nonfounding peoples arrived in the 1890s both the youth and the small size of the syrian and chinese households hint at the qualitatively differing dynamics within these the most recent immigrant groups complexity characterized the syrian families while the chinese lived in households not families 12 by contrast the early date by which so many of the irish had arrived means many would have immigrated as children and so might well be considered as the secondgeneration immigrants the combination of a relatively early arrival and a considerably older median age of the scottishborn heads also should be kept in mind when viewing my results the enumerators asked four different questions about ethnicity what is your place of birth what is your race what is your nationality what is your religion people born in canada were asked a supplementary question about whether they were born in a rural or an urban setting whereas people born elsewhere were asked their year of immigration and their year of naturalization if any in answer to the first question people generally provided either a province within canada or a country the entries for race reflected essentialist understandings of the day so what we with the nationalist discourse of honoré mercier in the wake of the suppression of the second métis uprising and execution of louis riel in 1885 this became a widely accepted concept among federal liberals until the late 1960s by this interpretation indigenous peoples as well as immigrant groups conceived as ethnic minorities had no real role in the making of canada 11 the presence of newfoundland might surprise some but it was a separate british settler colony until 1949 immigration to quebec from newfoundland dates from the 1840s and early 1850s when a significant number of families began moving to the north shore of the st lawrence and to the gaspé peninsula as the french shore agreement blocked settlement of the west coast of the island until 1904 12 the 36 syrian households included 24 wives 34 lodgers 15 cousins and 14 brothers while the chinese included only 4 women but 430 lodgers 40 servants 11 cousins and 5 brothers might now think of as an ethnicity or a nationality was what was most often listed 13 a separate column queried peoples color but under race african was entered for blacks in the montréal returns nationality was listed as being canadian if the person was born in the country a naturalized british citizen or born in the british isles almost all other entries save for the jews were left blank the detailed answers to the religion question spoke to the complexity of the various forms of protestantism practiced in the city only a handful of household heads studied here refused to state a religion although there were two agnostics and an atheist the variety of questions asked does permit the construction of ethnic identities that build on a combination of variables while i have retained the diverse responses for use in subsequent analysis i chose to limit my initial definition of the groups to place of birth i did so in the hope i could avoid presenting the governments essentialist reasoning as an accurate reflection of reality the exception is the ashkenazi jews where i have constructed an identity that is not in the source what is in the source is ample evidence that jews from eastern and central europe were considered differently from all other immigrants by the enumerators for example despite knowing their specific country of birth the enumerators inscribed 412 of them as hebrews jews or jewish under race the only major exception was the 34 people who gave their religion as jewish and were born in germany twothirds had german entered as their race the enumerators asked the heads of household to identify their social relations and those of the household members using four options living on their own means employee employer or by their own account these were not mutually exclusive categories and there were within every group employers who said they also worked on their own account the graph of heads declared social relations not only shows how people said they earned their living but also illustrates how varied the response rates were within the various groups for a number of them the rates are so low that we should not place too much emphasis on any apparent patterns14 nonetheless one can clearly see the importance of peddling and other forms of selfemployment among the jews and the syrians the enumerators also asked if the heads practiced a trade other than their stated occupation they were then asked what their annual earnings were in 1900 from their principal occupation as well as from any other occupations people who lived on their own means or worked on their own account normally did not provide any information about their earnings nor did many employers thus one needs to exercise considerable caution with these figures they represent as accurate a picture of wages as we are likely to have for the period but they do not constitute a basis for an analysis of income inequalities my graph of earnings by household head reveals remarkably broad variations across the differing immigrant groups i present them in the order of their median earnings from 600 for the scottish and chinese to a mere 200 a year for the syrians however this relative success of the chinese may be more apparent than real for note that both their median and their 75th percentile are exactly the same a third of all chinese household heads stated 600 was what they earned in 1900 this contrasts sharply with the wide spread between this median and the 25th percentile of chinese the largest such range for any of the nine groups of the new immigrant groups the jews reported the best overall earning profile with their 25th percentile second only to the scottish and their 95th percentile ranking third quite unexpectedly they report doing as well as the englishborn heads the irish present a quite different profile than other immigrants from the british isles and this despite the fact that many of them would have been secondgeneration canadians 15 perhaps the relatively large number of people living on their own means as with the scottish a reflection of their older age profiles meant an apparently worse situation than was in fact the case on the other hand the situation for italians syrians and somewhat surprisingly the newfoundlanders was unambiguous and qualitatively different much narrower ranges characterize all three groups but with their 75th percentiles well below the median for all immigrant heads the italians and syrians faced particularly hard times earning less than a dollar a day in 1900 was to live in dire poverty all of the italians and the newfoundlanders declared earnings for 1900 they were the only groups to do so this contrasts sharply with their under reporting on social relations and is probably a more accurate representation of the significance of waged labor for these two groups male breadwinner ideology notwithstanding these largely workingclass households did not depend solely on their head for earnings as the graph of midquartile ranges shows when the earnings of all household members are included the situation changes significantly median income for all save the syrians rises by more than 120 while a quarter of the households of all groups save the italians and newfoundlanders declared annual earnings of 1000 or more this dramatic improvement was in part the result of more households reporting relatively affluent households where the head had not declared earnings often were home to other family members who earned good incomes homes where the head was effectively retired also would see major gains in earnings by including the wages or salaries of other household members even relatively poor workingclass homes could see a major improvement simply by the fact that if they took in a lodger their income was often declared indeed in a number of the syrian households the head declared little or no earnings and so the earnings posted here were those of their lodgers thus a complex set of relationships are subsumed in this graph and that is why i did not include any data on the upper and lower quartiles wealthy families would have been considerably wealthier than the declared earnings would indicate while many of the apparently lowest income households would be because the only household member declaring any earnings was a domestic servant the exceptional results for the chinese households do call for an explanation here almost every member of the household declared earnings for 1900 generally 300 dollars for most lodgers and from 500 to 600 for the head almost all of these men worked as laundrymen often they lived in hostels the largest of which had 102 residents with combined earnings of 31600 only an englishborn hotel manager who listed the earnings of his staff and a number of his resident guests managed to top that with a declared household earning of 40628 as we shall see this was not the most surprising difference shown by the chinese the admittedly exceptional situation of the chinese underscores an important fact of life that was true for the majority of immigrantheaded households and for even larger numbers in the recently arrived groups it took the efforts of an entire household to achieve a reasonable standard of living despite their labors many would not achieve even this particularly it would appear among the syrians italians and newfoundlanders however most would through this collective effort achieve something similar to the norms prevailing among canadianborn families 16 this raises the question of integration and the census returns does have some things to say about if and how these immigrant households fit into their new host societies people were asked if they could read or write although the language was not specified they were also asked if they spoke english or french and what their mother tongue was turn of the century montréal was a majority frenchspeaking city but the wealth and superior social services of its englishspeaking protestant minority had begun to act as a powerful agent of assimilation for immigrants as they would continue to do until the charter of the french language was adopted in 1976 with the exception of the newfoundlanders the response rate to the questions on literacy and language paralleled those on social relations italians and chinese largely ignored the questions save for the one on their mother tongue with only a little better than one in eight reporting on their ability to speak either english or french it is difficult to say if the fact that half the italians heads responding said they spoke french and only one chinese head did is significant or not among the other groups literacy rates are uniformly high all groups reported that twothirds or more could read and write while given the subsequent history of the language question in montréal there is a surprisingly large opening to french by both native english speakers and those with other mother tongues better than two out of the five of the jewish and syrian heads said they could speak french while one in five of the native english speakers said they could ranging from a quarter of the irish to only a tenth of the newfoundlanders from households to communities over the course of the last half of the nineteenth century montréal had become highly segregated along both linguistic and religious lines while exhibiting less segregation along lines of social class than had characterized the preindustrial town 17 two of my recent papers have shown how in the closing decades of the nineteenth century protestant landlords played a much more active role in promoting discrimination than did catholic landlords and that their active exclusion of difference was in greatest evidence among small proprietors and in those city wards that bordered on strongly divergent wards it was thus into a sharply and recently etched ethnic and religious landscape that the heads of households from central eastern and southern europe moved they were complemented by smaller immigration streams from greater syria and southeastern china where did members of these new ethnic religious and linguistic communities find a home 18 in order to properly contextualize their choices i start with the immigrants who could claim to be members of one of the founding peoples as is starkly evident in these four maps englishspeaking immigrantheads settled overwhelmingly in the west 19 but not anywhere in that half of the city already existing cultural and religious patterns of segregation within englishspeaking montréal constrained the choices people made what is also evident with four of the five groups mapped here is that preexisting cultural and religious divisions from their places of 17 my recent monograph demonstrated the importance of multiclass structures to the new industrial neighbourhoods we have long mistakenly considered working class 18 i used the opensource software qgis for this project and i would like to acknowledge the collegial support i received to my queries from more experienced users within this community raphael fernandez brent wood alex m of wildintellect com and uwe fisher 19 in montréal the cardinal points do not define direction rather east and west are defined in relation to the st lawrence river conceived as flowing in an easterly direction although here it flows north by northeast when i refer to north west or east in the text it means at the top to the left and to the right of the maps are displayed here they have all been rotated 75° clockwise origin were grafted onto these local patterns to reinforce sharply delineated lines of segregation among the englishborn there was an exceptional concentration adjacent to the pointe stcharles yards of the grand trunk railway note however the clear vertical line to the west marking the former boundary of a now absorbed municipality of stgabriel which did not obtain either drinking water or proper sewage until after amalgamation decades after the pointe these largely skilled workers did include some anglicans and methodists but attendees of both church and chapel tended to live elsewhere indeed the majority of methodists households and three in eight anglican households lived on the same property as another immigrant member of their congregation or parish among the anglicans this communal solidarity is most in evidence in their small islands in the heavily frenchspeaking sea of eastern montréal overall the english do appear to be relatively affluent with one in six living in the golden square mile area south and west of mcgill although only slightly more than a quarter of all retained households they account for a third of those living in this the wealthiest neighborhood in the country after the pointe however their preferred neighborhood was a recent pettybourgeois development of largely single family row housing to the east of mcgill now known as miltonpark the latenineteenth century saw a flourishing of the orange order throughout british north america with deadly riots in newfoundland and new brunswick and a fullfledged assault on the roman catholic cathedral in toronto montréal was spared the worst of this violence perhaps because protestants were always a distinct minority nevertheless the housing choices of the irishborn immigrants show how significant the catholic protestant divide had become the line of green dots midway down the map in the west marks the base of the escarpment above which rose the golden square mile where irish protestant households outnumbered irish catholics two to one to the south st anne parish was the historic center of irish catholicism in montréal which by the turn of the century had crossed over the lachine canal to include adjacent parts of pointe stcharles while some had moved further west into the former municipality of stgabriel the early year of immigration for so many of the irish must have meant that many arrived as children with their parents and should be considered second generation three in 10 irishborn immigrant heads migrated when they were 14 years or younger almost a quarter 72 of the 280 were irish protestants and they account for the majority who made it up into the golden square mile among the secondgeneration catholics we see a different type of mobility they account for almost half of irishborn heads residing in the frenchspeaking eastern and northern wards of the city a quite disproportionate number of the scots a third lived in the golden square mile where they accounted for a quarter of all immigrantheaded households it was here that the uniquely canadian architectural form known as scottish baronial was born only a quarter of these residents were among the 67 scots who immigrated as children but here too generational mobility was clearly in evidence threequarters of the secondgeneration scottishcanadians lived above the escarpment mostly in the largely pettybourgeois neighborhoods east of mcgill and north of sherbrooke in contrast only a handful of the much smaller population of newfoundlanders made it out of the city below the hill but here too the generationold divisions between west country english protestants and irish catholics from the waterford region clearly made itself felt on the streets of popular class montréal the americans show how significant language was for the choices that people made a third of the americanborn immigrants were descendants of either canadien or acadien settlers it had been their parents who migrated to work in the textile mills of new england starting in the 1850s now they were starting to trickle back and not surprisingly they alone among those who could claim founding people status took up residence in the heart of the citys majority culture in stjacques and stemarie in the east and to a lesser extent in stgabriel and stjoseph in the west each of the more recent groups had their own distinct settlement patterns the italians were located well below the escarpment in the mixed popular class wards of stlouis and stjacques over the past 20 years stlouis had been the subject of a turf war between englishspeaking protestant and frenchcanadian proprietors which by 1901 the latter had won this was the only part of the emerging central business district where french was the language of business it was here 2 km east of the three major english language department stores that dupuis et frères would build the largest retail business in french canada stjacques was a hardscrabble workingclass neighborhood with not very many large factories but hundreds of jobbers workshops and small manufacturers it was here in the 1860s that the quintessential workingclass duplex first came to dominate an urban landscape the choice of these italians immigrants to live here in a largely frenchspeaking environment confirms the suggestion in the partial census returns that they were tending to integrate into this linguistic community with whom of course they shared a common religion and a similar language structure at the top of the map one can see the handful of households who were the pioneers of what between the wars would become montréals little italy in northern stdenis ward chinese communities in north america are almost all identified with particular densely used chinatowns these chinese had migrated from very particular places within south china nineteenth and early twentieth century chinese immigrants to canada came almost entirely from a handful of townships in guangzhou 20 it was in this sense the most organized and also the most limited migration stream of any the groups studied here thus one would expect there to be a spatial concentration that reflected the myriad connections which undoubtedly linked members of this group and one can see in the lower center of the map the small cluster of hostels on lagauchetière which corresponds to the citys embryonic chinatown nevertheless it is the remarkable dispersion of chinese households across the entire residential landscape of the city that is most striking only the largely yet to be developed stdenis ward to the north and the heavily industrial hochelaga ward in the east were without their chinese laundries after all everyone regardless of class religion or language has dirty laundry 20 where presbyterian missionaries from canada had been active for decades indeed our sample includes grace eaton a 53yearold artist born in china to pioneering missionaries a clear majority 86 of the 164 heads in the 1901 census for montréal listed their religion as presbyterian for a recent review of the literature and a fine case study see connors the greatest contrast to this exceptional dispersion was the housing arrangements of the syrians unique among the groups studied all of them were located in or very close to the old city center a short distance on foot from st james street the financial hub of the dominion and even closer to the spanking new cpr station serving eastern parts of the country no fewer than 23 of the households lived in the venerable rascos hotel on st paul conveniently this aleppo central was located opposite bonsecours the citys largest market the majority of jewish immigrant heads were also heavily concentrated in fewer than a dozen city blocks east of st lawrence blvd and south of the escarpment this was 2 km east of the citys principal synagogues both located in the square mile where only 3 of these heads lived the immigrantheaded households were near an older temple on chenneville which would be enlarged and rededicated as bnai jacob in 1902 reflective of the distance between these newcomers and the established largely sephardic jewish community was when the latter received funding from baron de hirsch to build a community center dedicated to the secular education of eastern european jewry they erected it where no jewish families lived on bleury midway between the two in the blank space on the map in my earlier work on the history of this wave of jewish migration to montréal i argued that the people experienced a change in identity with their migration to canada i based myself on the heavily national character of the synagogues that the immigrants had created by the early 1920s whereas in their country of origin they would have been a jew in canada they became a romanian jew or a russian jew or a polish jew ironically i argued the very national identity that would have been denied them in their country of origin was in their new home what distinguished their particular rites and customs and so served to define their judaism a closer examination of where and with whom these immigrant heads chose to live in 1901 does not lend much support to this earlier interpretation as can be seen clearly on figure 14 of the areas where most had settled cohabitation with fellow jews was common enough but this frequently involved jewish households from other countries overall slightly more than half of all jewish households 261 of the 498 i can plot on the map shared their lot with at least one other jewish household i think this speaks to questions of agency and of community and not just among the jewish households although we have seen each of the groups had both distinct settlement patterns and its own internal cleavages speaking to complex contradictory histories stretching back well before these people immigrated to canada living in close proximity to others who shared aspects of ones own culture was how these immigrants adapted to life in their new country and in so doing created new communities admittedly the jewish households were at the high end for those actually living on the same lot as another household from their community only the syrians had a higher percentage nevertheless from a low of 1 in 9 with the americanborn to 1 in 6 for the scots through 3 in 10 for the english and 4 in 10 for the italians this practice was certainly not exceptional it might of course be argued that the widely dispersed chinese shows this not to have been the case but i would argue it is precisely their dispersal that speaks to shared strategies of adaptation and accommodation that were rooted in a sense of community both the existence of the hostels for the recently arrived and the subsequent dispersion in a rational manner that ensured households would not be undercutting each other speak to a strategic coherence that befits the most closely knit of all the groups studied on the gender of property owners although much more work remains to be done on these households enough context i hope has been provided to allow for an understanding of both the significance of the agency and the seriousness of the constraints facing these immigrantheaded households this varying context is important for understanding the nature of the choices that their landlords and landladies were making in deciding to lease to an immigrant household as the tenants varied so too did the decisions of the proprietors one would not expect there to be a great variance in leasing practices by gender after all these men women and the helped to create dynastic lineages of rentier capital but as this suggests property was very much a family affair 21 differing familial practices did informally work to enforce differing inheritance practices but there were strong cultural 21 here i am summarizing key findings of my paper social and spatial dynamics of rentier capital institutions they controlled shared important characteristics by the simple fact of their being owners of rental property by 1903 they came overwhelmingly from the bourgeoisie petty middling and big indeed for many it was thanks to a multigenerational rentier strategy that they were so affluent to be sure the most successful had benefited from highly gendered practices whereby disciplining the marriage choices particularly of daughters had and historical forces encouraging equity between legitimate offspring i do not mean by this that inheritance was genderblind quite the contrary propertyowning mothers and fathers carefully considered gendered social expectations for their sons and daughters when designing their wills and as a result women tended to inherit properties that were more equally distributed in the city and less commercially oriented than their male siblings should disputes arise the civil code foresaw family councils to handle any property disputes furthermore as we have seen the default marriage regime gave disproportionate power to the men finally since much of the property owned by women was inherited frequently from a deceased husband their portfolios were rarely entirely of their own making many a landladys tenants would have signed their first lease on that property with a landlord thus for these myriad reasons we should not expect to see significant differences between the leasing practices of men and women and on first glance the density of immigrant households by the gender of the proprietor shows remarkable similarities between landlords and landladies owners of 23 of the rental units in the city women were the owners of 266 of properties where an immigrantheaded household in our sample resided as is clear from the map they owned properties in all of the principal areas where these households chose to live all three of the most concentrated areas of immigrant housing are clearly visible west of the grand trunk railway yards in the pointe for the english the parish of st anne for the irish and just east of the main below ontario for the jews and here women did own properties but as with the landlords the clearest impression created by this mapping is one of spatial breadth this is largely because in almost four out of the five cases there was only a single immigrant tenant on the property so even the eastern wards of the city which as we have seen were largely shunned by the heavily englishspeaking immigrants appear represented only the city center home to the syrians and fewer than a dozen other immigrantheaded households 22 is almost blank somewhat surprisingly properties with heavy concentrations appear in the citys most bourgeois area the golden square mile here in all but three cases these are the mansions of some of the wealthiest people in the empire 23 clearly a number of immigrantheaded households may have made it up into the square mile without making it up the stairs into their own home the exceptions are the three caretakers and the porters households on mcgill campus one of the earliest apartment buildings in the city on stanley owned by roswell corse fisher in whose sherbrooke street mansion worked two immigrantheaded families and five contiguous lots owned by jean françois blanchet on buckingham that were treated as a single property on the roll as these anomalies suggest caution is required in interpreting this map nonetheless a distinct gender imbalance is evident with the most densely occupied properties while 7 landladies have from 5 to 7 immigrantheaded households on 8 properties 34 properties owned by men do and a further 11 have from 8 to 23 none of the properties owned by landladies exhibit this type of concentration these 41 men are landlords to 311 immigrantheaded households on 45 properties while the 7 landladies have 22 including the household of wah hong wing laundryman who told the enumerator that his religion was judaisme 23 these include the four distinct immigrantheaded households who serve jane cassils the three who continue to work in the homes of the late andrew allan and john redpath as well as the two in each of the homes of richard angus and louisa frothingham only 45 immigrantheaded households as tenants on their 8 properties this suggests the possibility that the vexed question of overcrowding may well be gendered overcrowding has a long and troubled history in montréal the two pioneering sociological investigations of the nineteenth century jacques viger in the 1820s and herbert ames in the 1890s were both primarily concerned with this question in the 1970s poor housing was key to terry copp revisiting ames study in his anatomy of poverty while chronic overcrowding for the working class was also a major conclusion of michael katzs ambitious experiment in social science history team members michael doucet and john weaver went as far as suggesting that perhaps a third of workingclass families in montréal were forced to share their personal living space with another unrelated family 24 unfortunately with an oftread article in the 1980s and a major prizewinning work in the 1990s this misèrabliste image was reinforced by bettina bradburys work on latenineteenth century familial strategies despite the publication of a substantive challenge by the architecthistorian gilles lauzon during the intervening years 25 over the last half of the nineteenth century housing in the city became dominated by triplexes and duplexes by 1903 they accounted for twothirds of residential properties as a result it was not at all uncommon to have two three or four tenants on a single property doubled duplexes as shown in figure 16 would normally house four families each with their own door on the street triplexes generally did as well as shown in figure 17 but it was not infrequent for either a ground floor or a first floor entranceway to open onto a joint interior stairway nineteenth century census enumerators were instructed to consider households that did not have their own entranceway onto the street as being shared housing lauzon convincingly demonstrated that the high levels of doublingup reported by the misèrabilistes were the result of having mistaken this technical classification for an historical reality he found that doublingup did occur in perhaps as many as 3 of households but he suggested this figure a tenth that of weaver et al was itself somewhat misleading as the census was taken in the spring of the year just before the may first moving date thus he suggested families that had recently arrived in the city and were looking for accommodation and perhaps had already found it but would only be able to access it on may 1 would be considered as cohabiting even though their stay with extended kin or acquaintances was at most a temporary measure recently lauzon has returned to this question in his detailed social history of pointe stcharles 26 there he argues we need to go beyond the limitations of ames analysis of how many people per room characterized popular class housing a popular 24 doucet and weavers earlier articles eventually formed the basis for their housing the north american city 25 her 1993 study which won both the innis and macdonald prizes has since been reissued twice without any adequate discussion of the methodological problem lauzon discovered gilles lauzons thesis won the prize in labor history in quebec and was published as lauzon his summary and restatement won the frégault for the best article of the year lauzon 26 for a more ample discussion of this important study see my review of lauzon analytical question as the census returns provide both household size and number of rooms to a more revealing functional analysis how many rooms served primarily as bedrooms and was there a separate kitchen and living room this requires reconstructing the demographic composition of the resident families and paying close attention to the built environment which lauzon has done for a sample population in the pointe and the results he obtained suggests that there was a very significant improvement in housing conditions between 1880 and 1920 it is not possible for this paper to conduct an analysis like lauzon suggests although i certainly hope to utilize maps infrastructure to extend his model to other popular class wards of the city in the near future what i can do here is analyze the evidence from the property roll so as to construct a test for the evidence from the census returns as we saw with the blanchet property the roll frequently listed multiple properties together providing all the information for them in a single entry the highest density housing owned by a landlady was just such a case the seven immigrant tenants in anna mills row of eight contiguous units each with its own civic number on murray street in stanne this like the blanchet property is not proof of overcrowding we need a more rigorous test than a simple linking of census returns to entries on a property roll will allow the strip of red properties facing the grand trunk yards in the pointe illustrates some of the further complexities we need to consider these properties owned by elizabeth schofield were part of sebastopol row pictured here after a recent renovation by the municipal housing authority dating from the late 1850s these were the first purposebuilt tenements in the city the roll indicates that she owned 7 lots with even civic numbers from 30 to 76 which suggests 23 units census returns detail 26 households from this range of addresses and furthermore they were not evenly distributed and so i mapped two lots with five and six tenants respectively while others have three or four and one has only two is this a case of overcrowding or not the roll provides us some guidance in developing an appropriate way of thinking through this problem for it contains 1701 entries where in addition to an integer the address included a letter ie 79a 79b etc these letters indicate that these rental units had already been subdivided but in a way the city found acceptable or was at least hereby recognizing and effectively sanctioning landladies owned 23 of both these properties and units they were however underrepresented in those involving five or more units on a single property where they accounted for only 10 of the 75 cases rents charged for these lettered properties were relatively high owners of properties with five or more such units recuperated the cost of their buildings in short order averaging only six and a half years whereas it took on average 7 years and 8 months for the owners of a single duplex or triplex to recoup the cost of their building while for owners of single family dwellings it took more than 11 years rent to equal the value of their buildings i think best to err on the side of caution here so the test i have developed focuses only on those properties where i have a range of civic numbers for the property and where the reported rent for that property equals the value of the building in 7 years or less requiring a range of civic numbers as a criteria eliminates from consideration the housing conditions below the stairs in the mansions as well as in hotels like rascos or the chinese hostels on lagauchetière and the citys still rare apartment buildings it also recognizes that properties like those of blanchet or mill were not densely occupied in the sense meant here requiring higher than normal rents simply recognizes that these owners would have factored in the increased wear and tear on their buildings resulting from overcrowding what is left after applying these two restrictions is a group of properties that if they are linked to more household census returns in the complete manuscript census than the roll suggested they should be then they can be reasonably considered as probable cases of overcrowding by testing this group against maps complete index of all households in the manuscript census i am taking the issue of overcrowding well beyond the question of the immigrantheaded households that has been the focus to date i can begin to ask how these immigrant households experiences relate to those of the larger host communities applying these two criteria to properties where immigrantheaded households resided reduces considerably the number of properties being examined slightly more than a quarter of landladies properties but almost a third of landlords properties had both a range of addresses and generated a high enough rental income that it equaled the total assessed value of the buildings on the property in 7 years or less this relative underrepresentation of landladies was not due to any marked gender differences in either the average or the median rents charged which suggests it reflects different choices distinct practices for differentiated communities eightysix landladies owned 88 properties where there appears to have been overcrowding when linked to the census returns of all households in the city it appears that there were 191 more households on these properties than suggested by the addresses in the roll for an average of 217 households too many in half of the cases there was 1 more than expected but on 24 properties there were 3 or more and 111 of the households lived there this contrasts with 229 landlords having 666 more households on 268 properties or on average of 249 households too many over a third of the properties had only one more than expected but an almost equal number had three or more and on these 93 properties lived 410 of the probable cases what are we to make of this plethora of figures two general observations landlords owned disproportionately more overcrowded properties and the overcrowding was more severe than with was the case for landladies the number of proprietors also matters whereas only 2 landladies owned more than one such property 17 landlords owned 2 or more nine of these landlords owned two probable cases of overcrowding while two owned three four owned four one owned five and james prendergast owned six clearly for some landlords in turn of the century montréal the ethics of proprietorship differed from those practiced by almost all landladies nor should this surprise us after all for the better part of a century bourgeois women had been taught that their place was in the home in the contemporary struggles for both married womens property rights and for the suffrage feminists in canada articulated the reasons why they merited respect in maternalist terms given this history and the limited freedoms the law and paternalist cultures permitted them to exercise it would be surprising if these bourgeois women handled their portfolios in a manner that challenged their role as guardians of the home if their home mattered so much why wouldnt those of their tenants this is not an essentialist argument i am not suggesting landladies were more nurturing than landlords what i am saying is that agency is exercised within social cultural and gendered constraints and in the differing discernable patterns their choices have left us we can see the significance of gendered expectations beyond the gendered distribution of ownership this mapping of probable instances of overcrowding demonstrates several important points first of all there really are not all that many we are dealing with a minority of proprietors too few to matter some might argue in light of the historiography on overcrowding however i think these relatively few cases are significant as they no doubt were to the 2048 households living on these properties i started with 4300 rental units where some of the most vulnerable households in the city resided and now admittedly using very conservative methods to make the estimate it appears that 1 in 12 may be a case of overcrowding i think this result broadly supports the point that gilles lauzon has been making lo these many years second the relative absence of the main concentrations of immigrant housing is striking the pointe almost disappears in steanne while numerous properties qualified only a limited number actually appear by this test to be cases of overcrowding in stlouis home to the bulk of the jewish households and many of the italians there are a number of cases of overcrowding particularly in the heart of what we saw to have been the new jewish quarter but these particular concentrations indicate an important historical and i think gendered issue these probable cases appear because of what i have done by linking the immigrantheaded houses through the map to the broader population and then using the returns about the host society to inform the housing situation of these immigrants i have reconstituted something like the process these immigrant heads faced they lived there because these properties were already through the dynamics of the host society characterized as poor housing the notable concentration on cadieux street home to so many of the ashkenazi jews is a case in point here on the 17 properties identified as overcrowded only a minority of the households were headed by an immigrant 46 of the 91 tenants of landlords and 10 of the 26 tenants of landladies overall 70 of the households living in overcrowded properties were born in canada this is why relative to the other maps stjoseph stdenis and the eastern wards of stemarie stjean baptiste lafontaine and papineau all appear more prominently in this analysis of overcrowding than on any of my earlier maps which showed immigrantheaded households in primarily englishspeaking wards if this analysis is correct then the gendered nature of the ownership of these overcrowded properties discussed above refers not to a situation primarily facing immigrantheaded households but to all those households in the city who were facing dire straits one does not have to endorse the misèrabiliste viewpoint to recognize that this would have included a very significant number of people i would estimate a fifth of the citys 51300 households thus it may well be that in a city where one in four rental units was owned by a woman the discernably different practices identified here for lots where immigrantheaded households resided resonated much more widely within the lived experience of the citys broader working class if the gender of proprietors mattered to those at the lower end of the socioeconomic scale can the same be said for those immigrantheaded households who were doing relatively well after all as we have seen none of these groups appeared in my earlier analysis to be an undifferentiated mass there were considerable differences in both opportunity and income within each group for those who were betteroff did the gender of proprietorship matter the answer is a quite resounding yes in all three communities for which meaningful results might be expected the nearest neighbor index shows that the further away you lived from the core concentrations for your specific immigrant community the more likely you had a landlady rather than a landlord 27 does this mean that when immigrants from qualitatively different cultural backgrounds lived outside the main concentrations associated with their community they chose a landlady over a landlord not necessarily for i suspect it was very often the other way around landladies chose to lease to these unusual immigrantheaded households while the landlords in their neighborhoods would not be that as it may these immigrantheaded households were usually the only foreignborn household head on the property thus whatever the motivations of the people involved or the varying combinations of choices that resulted in these households being located where there were we should have no doubt about the effect this greater ethnic and cultural dispersion would necessarily have reduced the extraordinary levels of ethnic religious and cultural segregation in the city lines of segregation that had emerged in midto latenineteenth century montréal in support of the new patriarchal order of industrial capitalism 28 27 syrians lived too close together for this to be a meaningful question nearest neighbour index for the jewish households with landladies was 0623 with a zscore of 8595 versus 0435 and 20586 for landlords for the italians households it was 0700 with a zscore of 4408 versus 0418 and 13871 for landlords while the chinese posted a 0899 with a zscore of 1203 for landladies versus 0685 and 6596 for landlords 28 see the last substantive chapter in sweeny which surveys the industrial city in 1880 a final word of caution the three sources used here provide a wealth of detailed information about turn of the century montréal once transformed into databases and gis maps the analytical possibilities appear if not endless certainly very rich indeed and this is as it should be for the whole idea behind developing the map research infrastructure is to allow people access to a robust yet complex series of spatially and temporally linked datasets so that they may more successfully investigate historical change the power of such a system is not merely analytical it is also indeed at times i think primarily seductive so much information is now at our disposal we think we should be able to answer the questions we pose not any question to be sure but the important ones about causality clear answers to why questions the questions of our time are however only rarely the questions of times past and even when they were their meaning would in almost all cases have been qualitatively different and so it is with the question at the heart of this study what the men and women on the 1903 roll would have thought of my analysis we can never know but beyond being perplexed and perhaps intrigued by the technology they would undoubtedly have wondered why something so normal in their lives could have become a question for historical investigation only a little more than a century later why when we now know so much more about the past experience of women than ever before should the fact that women owned a quarter of all rental units in a large city a century ago need investigating how could we have forgotten this what mechanisms resulted in the memory of these practices by men and women becoming so lost to us as to lead us to question if they had any real meaning since amy louise erickson wrote her pioneering study on gender and property in early modern england we have had numerous studies showing the importance of female proprietorship in a wide variety of cultures and places 29 despite these rich new perspectives all too many scholars continue to assume that it is reasonable to discuss gender and wealth in terms of entrepreneurial versus riskadverse strategies 30 one of the reasons for such presentminded and in this case frankly sexist impositions of our own concerns on the past is an all too frequent and uncritical recourse to social science history using present day methods and analytical techniques first developed by the social sciences to study the past may at times be appropriate certainly this paper has made use of such methods but we must always be critically 29 for an update on her classic work see erickson for an examination of the highly influential practice in london see doolittle it is now clear however that the active ownership role played by women in early modern england was in evidence in a number of differing societies hardwick sjögren and peter and hutton to guard against eurocentric understandings of gender and property see varley and aluko for an early study on syria see doumani for differing views on the situation elsewhere in the ottoman empire see kark and fischel and huffaker 30 this gendered dichotomy is simply assumed to be natural by many of the authors in green et al indeed it is considered to remain valid even when all of the evidence presented calls that assumption into question selfreflective when we do so in part this means ensuring that our categories and tests are developed in a manner that respects the historical logic of our diverse sources for they come from a qualitatively different time and place but that is not enough what i have found most useful in stopping myself from making egregious errors of presentmindedness is to distinguish clearly between description and explanation and so i return to the conundrum i raised at the outset the motivations of landlords landladies and tenants of turn of the century montréal cannot be determined using maps infrastructure epiphenomenal evidence does not allow of phenomenal explanation no amount of statistical wizardry should hide this simple fact when we advance an historical explanation based on this type of descriptive material we need to be clear that is what we are doing we are not presenting a proof based on evidence from the past we are advancing a possible explanation based on our best efforts in the present to understand a past society furthermore until we better understand how forgetting and remembering interact with structures of power in our own very unequal world to talk of proof for any of the really large historical questions is i fear simply a form of professionally sanctioned peerreviewed collective selfdelusion author contributions the author confirms he is the sole author of this work and has approved it for publication while gratefully acknowledging the collegial contributions noted in the footnotes 1 and 18 and in the acknowledgements section acknowledgments throughout the research and writing of this piece i benefitted from the sage advice of elizabethanne malischewski an early draft was substantively improved by the critical comments of valerie burton and the suggestions of tony chadwick i would also like to thank the participants in our session on migration at the economic history societys 90th conference robinson college cambridge april 2016 for their comments my concluding remarks owe much to a thoughtprovoking paper by the leading scholar of gender and property and our host at robinson college amy louise erickson i would also like to thank ian milligan and daniel alves reviewers for frontiers in digital humanities whose comments allowed me to further strengthen the piece conflict of interest statement the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest copyright © 2016 sweeny 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 or licensor 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

women owned a quarter of all rental units in montréal qc canada in 1903 a city where 85 of the population were tenants in no major city in the world today do women control an equivalent area of the formal economy this paper asks did the gender of proprietorship matter it answers this through a series of tests linking a 30 sample of all immigrantheaded households in the 1901 census with a complete historical gis of all properties and their owners in the city for 1903 the paper plays special attention to ashkenazi jews syrians chinese and italians as these relatively recent immigrants constituted a major break with the largely british and french ancestry of the majority of the population in this 300yearold settler colony it then links the patterns in the sample to an index of all households in the census to explore how these immigrant families integrated into the larger host communities the paper shows that landladies and landlords had differing practices with regard to overcrowding and to the enforcement of segregation the paper makes a sustained argument for rethinking how we should approach the relationship between gender and property

introduction there are about 1914 million social media users from the 2734 million population in indonesia are social media users with the proliferation of data dissemination media on social media social media users can quickly get data or information about everything 1 the level of community response in the digital era has proven to be more responsive to events phenomena positive and negative sentiments in the development of social life in the real world or in the virtual world 2 with so many active users of social media in indonesia it is not surprising that many brands are taking advantage of social media platform to disseminate information such as notifying new products conducting promotions to get benefits 3 twitter is one of the popular platforms widely used by indonesians due to its features to provide information in a simple format wide networks with segmented topicsconversations and the ability to receive and forward information at the fingertips furthermore twitter provides benefits for the government private sector community and business actors who are looking for free and simple tools to disseminate general and important information pissn 25281682 eissn 25279165 social network analysis identification of communication and information dissemination umar aditiawarman 1 mega lumbia 2 teddy mantoro 3 adamu abubakar ibrahim 4 20 rapidly 4 businesses launch promotional activities to market their products in many ways by doing advertisements on tv making banners advertising on social media including paying influencers or artists to disseminate information about their products 5 one of the popular restaurants in indonesia namely holywings which has bar facilities with a variety of drinks and food also uses twitter social media for promotions one of the promotions launched by this restaurant is free alcoholic drinks every for customers named muhammad andor maria this advertisement went viral as many users of social media especially in twitter questioned about the motives and the marketing strategy initiated by the team the advertisement was then taken down due to continuous criticism and protestation from various parties accompanied by police reports 6 consequently holywings received notification from the authorities for the immediate closure of all their outlets the rapid information circulated over twitter has made this case viral and sufficient to draw public attention and authorities to take action today conversation in social media has been used as well by the authorities for various purposes such as law enforcement preserving public trust including public awareness with regard to pandemic situation 7 the public health information related to government recovery programs is somehow disrupted due to highly decentralized fragmented and loosely connected conversations around covid19 eva etal applied sentiment and social networks analysis on the dissemination of vaccination information on twitter using the naive bayes method as well as sentiment network analysis resulted that 92 of twitter user sentiment was positive for the covid 19 vaccine and actors who the most important role in disseminating information was identified the president himself 8 in this study the researchers used measurement parameters in social network analysis to measure and map the scope that the researchers studied due to the flexibility and objectives to be achieved from the results of processing and analyzing the data in accordance with the characteristics of the human relationship itself which is translated into words on twitter social media 9 researchers used the intact group comparison experimental method in determining centrality implicity and grouping with six stages namely determining representative samples instrumentation conducting experiments collecting and analyzing data and for experiments using gephi and python to see the level of spread of holywings data 10 therefore this research was conducted to examine and analyze the pattern of delivery of information regarding the promotion of holywings and to identify the dissemination of information through the network using social media network analysis 11 so that this finding shows a visualization of the spread of holywings promotional news that had resulted in harm to holywings from june 22 when the news was uploaded to date as well as identifying the values of centrality influence and clustering method this study is conducted through several stages including data collection intact group method analyzing edges nodes finding centrality influential and grouping data collection the data collection method using the library method is carried out by collecting journals literature papers papers books and internet sites as library resources related to writing material especially in sentiment analysis literature study also means data collection techniques by reviewing books literature notes and various reports related to the problem to be solved 12 the observation technique is one of the data collection techniques used by researchers to systematically observe and record the object under study both in situations that actually occur intact group method a determination of a representative sample researchers determine the technique of collecting samples in accordance with the research twitter data is realtime therefore the researcher uses a nonprobability sampling method which is an accidental sampling technique where the researcher uses the data encountered during the data collection stage and any interested data will be included in the data sample 13 the researcher uses all data that is in accordance with the characteristics of the research sourced from twitter then any tweet data that appears will match the keywords holywing maria and muhammad 14 b instrumentation in the instrumentation stage the researcher used multi nodes in the final result the reason the researchers chose the multinode method is to make the process easier and can also be arranged and divided equally among the nodes involved c collection data collection is used through social media twitter in the form of tweets data collection is done by retrieving data on twitter using python with google collab tools the data drawn there are 516 data obtained about holywings muhammad and maria from the indonesian language 15 d data analysis after getting the data that has been drawn the data is analyzed by distinguishing the data that is considered as nodes or data edges after that the analytical calculations are carried out using python and tested using gephi e experiment experiments were also carried out using the gephie tools to see the accuracy results of the two experiments using python and gephie tools research flow figure 1 social network analysis a sna social network analysis is the process of mapping and analyzing human interactions sna can be used to obtain information such as interactions and friendships between users which are described as graphs sna helps to understand social relationships that represent users with nodes and relationships between users are represented by lines on the online social network 16 b crawling the data this study crawled on twitter through the twitter api using the tweepy module in the python programming language 17 the key data scrawled is holywings muhammad maria after that the raw tweet dataset is stored in the form of xlsx which will be further processed later data crawling took place on june 24 2022 the data was collected from 516 tweets 18 c analysis edges and nodes sna helps to understand the social relationships that symbolize the user with points and the relationship between users is represented by lines in online social network the edges are username tweet edges are twitter account users while nodes are tweets from twitter account users social network analysis using the retweet network connected using various nodes node shows the account associated with the conversation 19 d implementation pissn 25281682 eissn 25279165 social network analysis identification of communication and information dissemination umar aditiawarman 1 mega lumbia 2 teddy mantoro 3 adamu abubakar ibrahim 4 22 implementation of data processing using python to obtain visualization results as well as centrality influential and clustering result and discussion crawling data when crawling data from twitter about holywings with the keywords holywings maria muhammad 516 data related to this data were retrieved implementation here are the results of preprocessing by taking one sample text starting from the raw data from the results of the crawling process then preprocessing nodes edges for automatic labeling is done using python textblob heres a python script to do autolabeling visualization data visualization is the final stage of the public figure sentiment analysis process this stage is the stage for visualizing the data that has been obtained in the form of diagrams graphs charts and so on the results of the visualization will display a graph 20 the graph above describes a visualization in which the knpiharis account is the most influential account in the spread of holywings news and the cnnindonesia account is the first initial centrality account of the news of the holywings case rising as can be seen there are several nodes such as detikcom holywings website and others as the source of the news spread regarding the issue 00051107325383304945 centrality clustering algorithm 1 clustering 0 anies2024indonesia 0 logikasederhana 0 mujahidbetawie 0 bintangtimur 0 gî §þûx86 0 wlabus 0 0 anggara mu 0 antoine varane jkt 0 anisa 0 abang rifqi 0 abdul 0 abdulla emir pramudya hoki 0 abi 0 abu karan 0 adericky yakub 0 adi hans randa 0 adippj02 0 adipati ranggolawe 0 agus 0 agus darmawan 0 agus dimyati 0 ahmad daud m 0 ahmad yani 0 ajo ali bursi 0 alan nugrohadi 0 albertus agung 0 alexhaiwondo 0 alfian 0 alimugusi 0 allen walker 0 amarasjd1 0 ami syakur 0 anang 0 anang susanto 0 andriraflydzaki 0 andril anwar 0 anggreat 0 antidungu2022 0 ari gilbert07 0 arif m iqbal 0 arya 0 athlafuzsc 0 awal02x99 0 awi 0 basegnos 0 bungaja 0 ba9v5 pty 0 badir03 0 bang ron 0 bangkarto 0 baru lagi 0 bekti 0 beruangkutub 0 bobby ibrahim 0 boeng moedji hassan 0 budi sp 0 cnnindonesia 0 cabey 0 cave man 0 cemiti emas golden pin 0 as for the clustering there are 121 groups with a modularity of 0821 that affect the rise or fall of holywings cases from twitter tweets that are incorporated conclusion sentiment network analysis can also be used in the future for new research in identifying the most influential centrality accounts in news cases sna is very useful to identify the centrality of news spread and examine how the information is disseminated across the networks this study has demonstrated how the identification of news viral is done using centrality influential and clustering analysis the centrality account or the first that caused this news to viral was the cnn indonesia news media account then followed by the influential account by the name of knpiharis which caused many twitter users to retweet the text consequently the promotional campaign initiated by the holywings hit twitter trending topic for a couple of weeks and has drawn attention from the authorities due to police reports lodged

social media especially twitter has been used by corporation or organization as an effective tool to interact and communicate with the consumers holywings is one of the popular restaurants in indonesia that use social media as a tool to promote and disseminate information regarding their products and services however one of their promotional items has gone viral and invited public protests which turned into a trending topic on twitter for a couple of weeks holywings allegedly improperly promoted their products by using the most honorable names muhammad and maria social network analysis of twitter data is conducted to identify and examine information circulating among the users which leads to wider public attention and law enforcement in this study we focused on the conversation about holywings on twitter from 24 june to 31 july 2022 the analysis was carried out using python to retrieve data and gephi software to visualize the interactions and the intensity of the network group in viewing the spread of information the findings reveal the centrality account that caused the news to go viral are the cnn indonesia news media account and haris pertama with a centrality of 0161 and 0282 respectively there are also 121 groups involved in the conversation with modularity of 0821

background smoking remains the single greatest cause of preventable illness and premature mortality and it is estimated that the cost of treating smokingrelated illness in the uk is now £27 billion each year 1 smoking is strongly linked to socioeconomic disadvantage in 2008 27 of adults living in households in england headed by someone in a manual occupation smoked compared to 16 in nonmanual households 2 consequently smoking is the largest contributor to health inequalities between the rich and the poor in the uk it is estimated that more than half the difference in survival to 70 years of age between social classes i and v may be due to the higher smoking prevalence in class v 3 whilst smoking prevalence has declined over recent decades this fall has been less marked in the more socioeconomically disadvantaged groups so that the gap between smoking prevalence in higher and lower socioeconomic groups has widened 2 reducing smoking prevalence especially in disadvantaged groups is therefore essential to improving life expectancy cutting health care costs and reducing health inequalities identifying measuring and attempting to explain socioeconomic disparities in tobacco use are important first steps in developing strategies and targeting resources to reduce them it is widely recognised that traditional measures of socioeconomic status have limitations and may underplay the extent of socioeconomic disparities in smoking prevalence the most frequentlyused measures of socioeconomic status for monitoring health in the uk are those based solely on occupation recent data demonstrate a higher smoking prevalence in routine and manual occupational groups than the 21 found in the population overall 2 though this figure falls well short of the prevalence of 75 or more found in studies of select disadvantaged groups 45 areabased measures such as the townsend index of deprivation 6 are often more easily ascertained than individuallevel measures of deprivation and are likely to reflect important arealevel determinants of health and lifestyle however those in common usage combine data on a relatively small range of factors just four census items in the case of the townsend score and are therefore likely to fail to capture important socioeconomic determinants of smoking mosaic is a uk geodemographic classification system developed by experian as a consumer segmentation and marketing tool 7 using data on over 400 variables from multiple sources mosaic classifies postcode areas into 61 types and 11 groups in terms of demographics lifestyle characteristics and behaviours mosaic may provide a novel tool with which to identify new aspects of the socioeconomic differentials in smoking behaviour in the uk we have therefore used mosaic alongside the townsend index to examine smoking prevalence within patients in a large primary care dataset the health improvement network 8 methods the thin dataset thin is a large dataset of electronic medical records from over 400 general practices throughout the uk 8 and contains data for approximately 68 million patients over 2 million of whom are currently alive and can be followed prospectively the dataset is broadly representative of the uk population in terms of patient age and sex though mortality rates 5 lower than national figures suggest the dataset may slightly underrepresent more deprived populations 9 all patients over the age of 16 and registered with a thin practice on 1st january 2008 were identified of these patients who registered with a practice within the previous three months and who were therefore less likely to have had their smoking status recorded were excluded leaving a sample of 2426370 individuals for analysis these patients medical records were searched for the last smokingrelated read code documented in their notes before the index date which was then used to classify patients as current or noncurrent smokers patients with no mention of smoking in their medical records were deemed to be nonsmokers it has been shown previously that this assumption produces smoking prevalence estimates in thin in line with national statistics 11 epic the providers of thin mapped the postcode of each patient in thin to the areas mosaic type and group and townsend score the latter was provided as a categorical variable corresponding to national quintiles of deprivation in order to preserve patient anonymity mosaic mosaic is a tool designed to enable businesses to understand consumers demographic and lifestyle characteristics and ensure they target their products or services at the right people in the right locations the tool is an areabased classification system which allocates individuals to one of the 11 mosaic groups or 61 types based on the nature of the people living within the same postcode area the classification is carried out at the level of the full uk postcode equivalent to approximately 15 households and so all individuals living in these households will be assigned to the same mosaic category according to their average characteristics 7 approximately one third of the variables used to classify people are derived from the uk decennial census and the remainder from a combination of public and experianproprietary datasets these include property valuations house sale prices selfreported lifestyle surveys a survey of adults consumption of products brands and media and intelligence gathered through monitoring internet use 7 detailed algorithms to explain how these variables are combined to assign each uk postcode to a mosaic group and type are not available from experian due to commercial sensitivities mosaic data were provided for each individual in thin according to their postcode categorised into 61 types and their aggregated 11 broader groups table 1 summarises the characteristics of the 11 mosaic groups showing the group name assigned by experian and a brief description of the individuals in that group a fuller description of each type and group was obtained from the mosaic interactive guide 12 an interactive program available from experian which provides for each of the 11 groups and 61 types a photo collage that gives a snapshot of the characteristics of people in that particular category and written descriptions of their main features such as typical housing types income and residents attitudes towards the area they live in in addition the interactive guide describes the distribution of categories throughout the uk and ranks categories according to their relative performance across the variety of measures used to build mosaic analysis initially the proportion of thin patients who were current smokers was estimated by quintiles of the townsend index of deprivation odds ratios unadjusted and adjusted for age and sex were obtained by logistic regression then the prevalence of current smoking within each of the eleven mosaic groups and each of the 61 types was calculated and the magnitude and range of prevalence figures compared with those calculated previously for each townsend quintile again logistic regression was carried out to obtain odds ratios for being a current smoker in each mosaic group and type both unadjusted and adjusted for age and sex all analyses were completed using stata version 110 the interactive guide 12 was used to conduct a qualitative exploration of the common characteristics of people living in the ten mosaic types with the highest smoking prevalence and the ten mosaic types with the lowest smoking prevalence and to attempt to identify any groups with unexpectedly high or low prevalence ethical approval this study was approved by the derbyshire research ethics committee results of the 2426370 patients aged 16 analysed in this study 82 resided in england 8 in scotland 6 in wales and 4 in northern ireland in line with official population estimates 13 the average age of patients was 471 years and 493 were male a read code documenting smoking status was available for 875 of patients the proportion of patients with no record of smoking status in their notes increased from 113 of patients in the least deprived townsend quintile to 136 in the most deprived and ranged from 93 of those in mosaic group i to 152 of those in group e overall 208 of patients were recorded as current smokers in their medical records a townsend score was available for 869 of patients as figure 1 shows smoking prevalence increased across the quintiles of townsend score from 135 in the least deprived quintile to 327 in the most deprived quintile in the logistic regression analysis adjustment for age and sex made little difference to the results and therefore adjusted odds ratios only are presented the odds of being a current smoker was increased almost threefold in those in the most deprived quintile compared to the lowest quintile a mosaic classification was available for 941 of patients 72 more than the percentage of patients for whom a townsend score is available as figure 2 shows prevalence was highest in group g at 368 and lowest in group a at 111 the odds of current smoking was increased over four fold in group g compared to group a a brief description of the ten mosaic types with highest and lowest smoking prevalence is shown in table 2 from the fuller descriptions available in the mosaic guide the 10 types with highest smoking prevalence were characterised by households that are mostly occupied by single residents often single parents types d24 and h47 consist of cohabiting couples with children the typical age of people in these mosaic types is under 34 with the exception of types g43 and f39 almost all of the ten mosaic types with the highest smoking prevalence are described as typically having few qualifications and the majority are either unemployed or have manual occupations the exception to this pattern is type f35 who are a diverse group comprising both disadvantaged young people as well as university graduates a significant number of people have few if any qualifications but the proportion of people with university degrees holding professional positions is well above the national average annual household income is below £7499 for seven of the ten mosaic types with the highest smoking prevalence and below £24999 for the other three the typical property types occupied by mosaic types with high smoking prevalence are a mixture of houses and flats in urban or suburban locations with public rented ownership being most characteristic with the exception of h47 none of the types have access to a car and all types feel that they live in an area where there is little community support of the ten mosaic types nine are receptive to communication channelled through tv eight to telemarketing and seven to the tabloid press of the 10 mosaic types with lowest smoking prevalence almost all are characterised by households that include married couples with j51 as the exception though individuals in this category are often widowed the most typical age is between 45 and 64 and all types are described as having degree level qualifications all types not characterised as retired are within professional employment average annual household income for most types that are not retired is over £50000 apart from types a04 and b10 who have a typical income between £25000 and £49999 the typical property type occupied by those in groups with the lowest smoking prevalence are houses owned outright in suburban semirural or in the case of type j51 seaside locations all types again except for j51 have easy access to a car and every type feels that they live in a good area with support from neighbours these groups are likely to be receptive to communication via broadsheet newspapers and the internet discussion and conclusions the townsend index of material deprivation and mosaic provide two different ways of profiling an individuals social circumstances in terms of the area in which they live amongst patients in the large primary care dataset of thin we have shown clear socioeconomic differences in smoking prevalence according to both of these measures when using the townsend index we found smoking prevalence to be progressively higher in those living in more deprived areas in accordance with previous crosssectional studies carried out in the uk that used the townsend index to indicate deprivation 14 when using mosaic groups the likelihood of being a current smoker is highest in groups f and g groups that are dependent on social benefits compared with group a which encompasses the most affluent members of the population however the range of estimates of smoking prevalence is greater across the 11 mosaic groups and even more so across the 61 mosaic types compared to the difference across townsend quintiles for example the highest prevalence observed in the mosaic types was 427 whilst the townsend quintile with the highest proportion of current smokers had a prevalence of 327 smoking prevalence in the mosaic group with the lowest proportion of current smokers was 86 compared to 135 in the lowest townsend quintile mosaic paints a worse picture of social disparities in smoking prevalence in the uk than previouslyused measures of social class and may be a useful tool for distinguishing the characteristics of groups with a particularly high smoking prevalence a mosaic classification andor townsend quintile was missing for some patients in this analysis though the odds of being a smoker for these are not extreme suggesting that this data was missing at random and a highprevalence group has not been missed it is unclear why this information was missing for some people but it may be that these patients postcodes were not recorded by their general practice and therefore epic was unable to map them to the areabased measures of deprivation an assumption has been made that patients not classified as current smokers are nonsmokers including those with no smokingrelated read codes documented in their medical records this may lead to an underestimation of smoking prevalence however it has been shown that prevalence figures obtained using this assumption are reasonably reflective of those suggested by nationallyrepresentative surveys 11 and the majority of patients with missing smoking records in thin are either exor nonsmokers 15 the differences in the proportion of patients with a smoking record in different categories of each measure of deprivation were small and unlikely to have contributed to any great extent to the socioeconomic differences in smoking prevalence reported the mosaic classification which groups individuals into 61 categories may be quite a cumbersome system to use as a socioeconomic measure in most statistical models and as noted already little information is available from experian about how the classification is derived limiting assessment of the validity of their approach and the potential to replicate it some variables indicating individuals health status which may be related to past or current smoking behaviour are used to derive mosaic this may confound identification of the groups most and least likely to smoke in the interpretation of mosaic it is also important to be aware that the classification is an arealevel measure based on postcode areas of approximately 15 households and that the characteristics of any given type will only apply to the majority of individuals of that type not all of them it is also important to note that the estimated odds ratios presented in this study will overestimate the respective risk ratios across the groups as smoking prevalence is 208 overall not a rare outcome in calculating odds ratios the use of the mosaic group or type with the lowest smoking prevalence as the reference category will have maximised the difference in odds ratios observed across categories though this is an appropriate approach for demonstrating the wider extremes in smoking prevalence that can be identified using mosaic those mosaic types with a higher prevalence of smoking were characterised by minimal levels of education low income and manual occupations these findings are consistent with existing knowledge acquired using individual measures of socioeconomic status such as income education and occupation 14 however mosaic provides further detail the mosaic types with highest prevalence do not have access to a car have little community support are debtridden and tend to spend a lot of time in front of the television some of these factors seem likely to contribute to difficulty in quitting smoking suggesting perhaps difficulty in accessing cessation support and advice these findings provide some insights into how these groups might be targeted such as through mobile smoking cessation services and provision of transport to enable access to existing services or through television campaigns utilising the principles and techniques of social marketing to ensure that smokers are targeted with appropriate cessation interventions 16 there is some evidence that providing cessation services in novel settings such as community pharmacies dental surgeries or workplaces may be effective in engaging large numbers of smokers though more research is needed to determine whether these are successful in reaching disadvantaged groups in particular 17 similarly mass media campaigns may have a valuable role to play in encouraging smoking cessation though again there is limited evidence whether such campaigns are effective in reaching large numbers of the most disadvantaged smokers 1819 given that many mosaic groups with the highest smoking prevalence are in debt offering financial incentives may provide a useful tool to engage these groups in cessation services existing research suggests such incentives may indeed increase the number of disadvantaged smokers who attempt to quit and the number who succeed in doing so though again further studies would be of benefit 17 this study is one of the first to look at the association between mosaic and smoking prevalence and certainly the first to do so on such a large scale in conclusion the mosaic classification system has been found to be a useful tool in examining the disparities in smoking prevalence between different socioeconomic groups within the uk with those in the group with the highest smoking prevalence being over four times as likely to smoke as those in the group with the lowest prevalence mosaic is potentially useful for identifying the characteristics of groups of heavy smokers which can then be used to tailor cessation interventions to ensure these are as successful as possible and make the best use of resources though mosaic only classifies individuals living in the uk a similar approach to the use of market research and consumer segmentation intelligence may provide a means to identify groups of people with high smoking prevalence in other countries and target them with appropriate cessation interventions authors contributions sl and ls conceived the study as performed the statistical analyses and wrote the first draft of the manuscript and all authors contributed to its critical revision and approved the final version competing interests the authors declare that they have no competing interests

background there are wellestablished socioeconomic differences in the prevalence of smoking in the uk but conventional socioeconomic measures may not capture the range and degree of these associations we have used a commercial geodemographic profiling system mosaic to explore associations with smoking prevalence in a large primary care dataset and to establish whether this tool provides new insights into socioeconomic determinants of smoking methods we analysed anonymised data on over 2 million patients from the health improvement network thin database linked via patients postcodes to mosaic classifications 11 groups and 61 types and quintiles of townsend index of multiple deprivation patients current smoking status was identified using read codes and logistic regression was used to explore the associations between the available measures of socioeconomic status and smoking prevalence results as anticipated smoking prevalence increased with increasing deprivation according to the townsend index age and sex adjusted or for highest vs lowest quintile 296 95 ci 292299 there were more marked differences in prevalence across mosaic groups or for group g vs group a 441 95 ci 433449 across the 61 mosaic types smoking prevalence varied from 86 to 427 mosaic types with high smoking prevalence were characterised by relative deprivation but also more specifically by singleparent households living in public rented accommodation in areas with little community support having no access to a car few qualifications and high tv viewing behaviour conclusion conventional socioeconomic measures may underplay social disparities in smoking prevalence newer classification systems such as mosaic encompass a wider range of demographic lifestyle and behaviour data and are valuable in identifying characteristics of groups of heavy smokers which might be used to tailor cessation interventions

introduction large variations in psychiatric morbidity specifically nonaffective psychotic disorders across geographic areas within a country was first recognized in the 19th century 1 later work suggested that this variation was patterned according to the degree of social disorganization in residential areas 2 that is neighborhoods primarily located in densely populated settings 34 with high rates of social fragmentation and deprivation appeared to have the highest rates of psychiatric morbidity 5 6 7 importantly these findings have also been replicated in a number of nationwide studies from scandinavia 8 9 10 11 12 13 14 where socioeconomic differences across neighborhoods are smaller than in other industrialized countries 15 the current understanding of wider environmental influences on schizophrenia such as population density and neighborhood deprivation suggests that the disorder onset either is likely triggered by stressors 16 or results from longterm exposure to these stressors 17 particularly in individuals with genetic liabilities 18 it remains unclear however to what extent these observations reflect social causation processes where an individuals exposure to neighborhood stressors actually causes the illness or selection where highrisk individuals and families with genetic and environmental liabilities are selected into densely populated or socioeconomically deprived areas yet there are problems with drawing causal inferences from epidemiological studies using observational data most notably prior studies usually failed to control adequately for unmeasured genetic and environmental confounding 19 20 21 likely a large problem given nonrandom allocation of families to different residential areas 22 consequently genetically informed designs could help elucidate potential causal mechanisms 5 23 24 25 26 few studies have been conducted to date however and the results are do neighborhoods predict schizophrenia mixed mainly due to relatively small and selected samples combined with heterogeneous outcome definitions 27 28 29 in the largest such study to date we studied the associations between population density and neighborhood deprivation and schizophrenia and depression respectively we used longitudinal swedish total population data and cousin and sibling comparison models with approximately 24 million children born between 1967 and 1989 to assess the relative importance of unobserved familial confounding we combined neighborhood exposures measured at birth childhood and adolescence with familybased research designs to compare total population effects with those from differentially exposed cousins and siblings methods sample we linked data from numerous swedish longitudinal total population registers maintained by statistics sweden data linkage was possible through a unique 10digit civic registration id number assigned to all swedish citizens at birth and to immigrants upon arrival to the country statistics sweden gave us access to deidentified data after approval from the regional research ethics committee at karolinska institutet the following registers were used to generate the database the multigeneration register linked all index persons to their biological parents and enabled interconnecting biological siblings and cousins the small area marketing statistics register contained annual information on residential area characteristics the cause of death register provided mortality data the migration register provided migration dates the population and housing register provided census data on a range of socioeconomic and demographic variables gathered in 1980 1985 and 1990 the integrated database for labor market research provided more comprehensive census data on all individuals 16 years of age and older and registered in sweden as of december 31 each year since 1990 the national patient register supplied data on psychiatric inpatient care since 1973 and specialist outpatient care since 2001 and the national crime register supplied detailed information on all criminal convictions in lower general court in sweden since 1973 we followed 2 530 788 study participants who were swedish residents born 19671989 and possible to link to both their biological parents from their 15th birth date up until december 31 2009 the median followup time was 165 years we used exposure data from the end of the year they turned 15 participants who had died migrated or been diagnosed with schizophrenia or depression before the age of 16 were excluded moreover we removed those who could not be linked to their residential area at the end of the year in which they turned 15 or lived in a neighborhood with fewer than 50 inhabitants at the same time point the final sample included 2361585 individuals 933 of the targeted population from this sample we generated 2 additional datasets that included all biological first cousins and full siblings neighborhood definition following other neighborhood studies in sweden 1114 we defined neighborhoods according to statistics swedens sams classification system that captures small and internally socioeconomically homogenous residential areas there are substantial socioeconomic differences across sams areas it has been reported that between 1990 and 2004 the share of meanstested welfare recipients a common measure of poverty in sweden 30 was approximately 29 times higher in the most compared with the least socioeconomically deprived decile 24 there are about 9200 sams areas with an average population size of approximately 1000 individuals we discarded areas with a population size of less than 50 to avoid statistical model convergence issues the sams register annually links individuals with their sams area of residence at the end of the year as such withinyear residential mobility is not captured in this measure population density and neighborhood deprivation population density was measured as the natural log of the absolute population size per squared kilometer natural log transformations are commonly used to limit the relative influence of the highest exposed observations in a positively skewed distribution other neighborhoodlevel exposure variables were generated by aggregating data obtained through linkage of all individuals aged 2564 years in the sams register to the annual census records prior to 1990 however censuses were conducted every 5 years consequently we linked individuals recorded in the sams register from 1982 to 1989 to the 1980 and 1985 censuses respectively in addition due to the lack of data on the highest attained educational level prior to 1985 we used educational data from 1985 for those recorded in sams between 1982 and 1984 we calculated a standardized omnibus measure of neighborhood deprivation for each sams area and year based on 4 items derived as described above we compared this measure of neighborhood deprivation with a similar measure 24 using the comprehensive annual censuses that also included an additional 6 items median neighborhood income proportion of a sariaslan et al unemployed welfare recipients single personparent households residential mobility and violent crime rates the correlation between these 2 measures was very high study participants were linked to the annual population density and neighborhood deprivation scores associated with the area in which they resided to investigate potential nonlinear associations we studied the impact of these exposures categorized into quartiles observed confounders all statistical models adjusted for sex birth year and birth order identification of individuals with schizophrenia and depression to minimize falsepositive cases 31 we defined study participants diagnosed with schizophrenia on at least 2 separate occasions as having the disorder schizophrenia diagnoses in swedish patient registries have been validated previously 32 and we identified 4952 study participants with schizophrenia their mean age of onset was 263 years depression caseness was defined as having at least 2 hospital discharges of any depressive mood disorder we excluded patients with any comorbid schizophrenia and bipolar disorder diagnosed during the study period to date no swedish validation of depression diagnoses in the hospital discharge register exists but recently a danish study 33 concluded that single depressive episodes in denmarks comparable national registries implied high predictive validity for moderate to severe types of depression while lacking validation studies and attempting to reduce incongruence with the schizophrenia definition we decided to only include patients with at least 2 separate hospital discharges with depression to minimize the risk of falsepositive cases using this restrictive definition we identified 41 372 study participants with depression and a mean age of onset of 272 years statistical analyses cousin and sibling correlations for the exposures were estimated using linear mixedeffects models that allowed for varying intercepts across families the magnitudes of which were expressed as intraclass correlations a measure of similarity between individuals within neighborhoods 34 we specifically studied cousins and siblings who lived in different neighborhoods at age 15 to increase estimate accuracy we assessed general neighborhood influences the extent that they accounted for the variation in schizophrenia and depression by fitting binomial generalized linear mixedeffects models 35 to data to calculate iccs for the binary outcome variables we assumed an underlying normal distribution of liabilities 36 crude models were fitted on the full population while the adjusted models specifically studied the effects between siblings who lived in different neighborhoods at age 15 iccs derived from the crude models will therefore measure the degree of similarity among all individuals who live in the same neighborhoods at age 15 while iccs derived from the adjusted models will measure the degree of similarity among unrelated individuals who live in the same neighborhoods the relative importance of familial selection factors will be observed as a function of the reduction of the icc estimates across these models to accommodate our complex data structure with individuals crossnested within families and neighborhoods the adjusted models used the crossclassified glmm approach 37 to describe the impact of population density and neighborhood deprivation on schizophrenia and depression in the total population we calculated ors with corresponding 95 cis from logistic regression models we subsequently fitted fixedeffects logistic regression models 38 to the cousin and sibling samples and obtained withinfamily estimates of the exposures from comparing differentially exposed cousins and siblings on average cousins and siblings share 125 and 50 respectively of their segregating genes the latter also extensively share childhood environment attenuated withinfamily estimates among cousins and even lower estimates among siblings would consequently be expected if unobserved familial risk factors confounded associations found in the population conversely if total population and withinfamily estimates were similar in magnitude this would suggest that familial risk factors did not influence tested associations developmentally sensitive periods and accumulation effects additionally in a number of subanalyses we tested for potential bias from ignoring exposure timing and accumulation effects to maximize statistical power due to the relatively poor availability of exposure data prior to 1982 we studied the following subsamples exposure at birth mean exposure scores for both population density and neighborhood deprivation between ages additional sensitivity analyses to test the stability of estimates obtained in our analyses and to rule out alternative explanations we conducted various complementary sensitivity analyses and reran models i and iii with alternative model parameterizations on different do neighborhoods predict schizophrenia outcome definitions and subsamples first we adjusted for both time at risk by fitting cox regression models and the clustering of individuals in different combinations of families and neighborhoods by computing multiway clusterrobust ses 39 second we tested different categorizations of the exposures third we studied the impact of the exposures on individuals who had been diagnosed with schizophrenia or depression only once and those who had been diagnosed solely in inpatient care settings last we studied specific subsamples by excluding females those of nonswedish descent and those who did not live with either parent at age 15 or by including only firstborns and singlechild families all models were fitted using stata ic 121 40 and mlwin 229 41 results the 2 361 585 study participants included 1 715 059 first cousins nested within 559 270 extended families and 1 667 894 full siblings nested within 719 666 nuclear families and nested within 7388 neighborhoods a total of 993 820 cousins and 317 535 siblings were living in different neighborhoods at age 15 of these 8752 cousins and 2327 siblings were also discordant for schizophrenia corresponding figures for depression were 82 121 and 18 993 cousin and sibling iccs in population density were estimated to 64 and 89 respectively equivalent estimates for neighborhood deprivation were 052 and 078 suggesting sufficient variability required in the subsequent withinfamily analyses we could only identify 24 287 individuals who were not registered to be living in the same sams area as either one of their parents at age 15 we found substantial differences in outcomes siblings shared 49 of the variance in schizophrenia liability while 21 of the variance in depression liability could be attributed to sibling resemblance the crude general neighborhood effects were small and substantially attenuated when we adjusted for familial factors neighborhoods did not significantly explain any remaining variance in schizophrenia but explained about 2 of the variance in depression table 2 presents descriptive data on observed confounders addressed in this study females experienced lower risks of at least 2 schizophrenia diagnoses but higher risks of depression moreover we observed a nonlinear association between 3 a percentage increase in the population density score was associated with a 10 increase in the odds of schizophrenia in the total population sample when sex birth year and birth order were adjusted for however when we adjusted for unobserved confounders shared by cousins within extended families the population estimate of population density on schizophrenia was decreased by over a third finally when we adjusted for unobserved familial risk factors shared by siblings within nuclear families effects were fully attenuated we observed very similar findings for neighborhood deprivation categorical measures of both exposures and depression as outcome in the youngest cohort of participants born between 1981 and 1989 we observed that 41 lived in the same neighborhoods as their siblings across the full period to account for the mobility across neighborhoods over time we studied accumulation and timing effects of the exposures across ages 15 610 and 1115 years the results did not diverge from our main findings the observed associations in the population were fully attenuated within nuclear families thus supporting the conclusion that unobserved familial risk factors were responsible for the observed associations this pattern of associations was also observed in all of the additional sensitivity tests discussion we performed the largest familybased study to date of the associations between population density and neighborhood deprivation and individual risk of schizophrenia and depression consistent with previous research suggesting low general neighborhood effects in total population samples 13 we found that such effects accounted for merely 2 and 3 of variance in schizophrenia and depression respectively when we subsequently estimated familyadjusted general neighborhood effects that additionally accounted for the strong familial correlations in neighborhood residence we observed that neighborhoods did not account for significant variation in schizophrenia but accounted for about 2 in depression in addition we found that sibling similarities explained half of the variance in schizophrenia and a fifth of the variance in depression in line with systematic reviews and populationbased studies examining associations of neighborhood influences on nonaffective psychotic disorders and depression 36101323 population density and neighborhood deprivation predicted both schizophrenia and depression in the population however in subsequent analyses of the same associations when accounting for unobserved familial risk factors by studying differentially exposed cousins and siblings we found that effects decreased substantially within extended families and were entirely attenuated within nuclear families various sensitivity analyses found that these results were stable across note or odds ratio ci confidence interval model i full sample of unrelated children adjusted for sex birth order and birth year model ii within extended families adjusted for sex birth order and birth year model iii within nuclear families sex birth order and birth year do neighborhoods predict schizophrenia sex ethnicity birth order right censoring nonlinearity exposure timing and accumulation effects as well as alternative definitions of the outcomes overall our findings support a selection hypothesis observed ecological risk increases in psychiatric morbidity in densely populated and socioeconomically deprived areas are primarily explained by unobserved familial risk factors this implies that familial liabilities that explain the onset of schizophrenia and depression in individuals also explain their selection indirectly via their parents into densely populated or socioeconomically deprived areas these findings do not result from insufficient variability in exposures either within families or between neighborhoods prior studies scrutinizing neighborhood influences on mental health problems in the united states using experimental data have yielded mixed findings 27 28 29 likely resulting from the use of relatively small and selected samples and less severe outcome measures some authors emphasize the relative importance of socioeconomic characteristics of neighborhoods in the etiology of psychosis 7 but a recent prediction study excluded neighborhood deprivation measures due to low predictive validity 42 while the extent to which the results presented here are generalizable to other contexts needs clarification in future research it should be noted that all nationwide studies investigating the presented associations were conducted in scandinavia strengths and weaknesses the list of strengths includes the application of a longitudinal familybased research design with 24 million individuals born in sweden from 1967 to 1989 welldefined and socially homogenous neighborhood definitions were employed and neighborhoodlevel characteristics were measured at birth and during childhood and adolescence the longitudinal nature of the exposures minimized the risk of misclassification and facilitated exploration of potential accumulation effects further assessment of confounding was primarily accomplished through the familybased research design studying differentially exposed cousins and siblings and not with observed familylevel confounders correlated with neighborhoodlevel exposures eight methodological limitations should be noted first given that individuals to varying degrees chose their place of residence estimates of neighborhood exposures are inherently biased due to unobserved individual and familial characteristics being correlated with the neighborhood exposure variables we counteracted potential risks of such bias in several important ways neighborhood exposure data were collected only prior to the age of 16 when the individuals choice is limited and we adjusted for unobserved familial factors explaining parental choices of neighborhoods and included a longitudinal neighborhood exposure measure accounting for movements in and out of multiple neighborhood contexts 43 if anything remaining bias after these corrections would drive the estimates away from the null second while we specifically focused on the smallest and largest definitions of residential areas in sweden we cannot exclude however unlikely that other geographical representations of neighborhoods could potentially account for a larger share of the variances in the studied outcomes previous neighborhood studies on schizophrenia in sweden using similar data sets have additionally found negligible effects of both municipalities and primary schools 13 third our strict approach of increasing the diagnostic precision of the outcome variables by only including patients with at least 2 episodes of schizophrenia and depression could potentially minimize the generalizability of our findings especially in the case of depression to 4 despite the lack of evidence for any effects consistent with a causal inference in these analyses it could theoretically be possible that even longer exposure periods could yield different results unfortunately our existing data did not have enough statistical power to adequately assess this possibility while we found no effects that were significantly different from zero the cis were too wide and included realistic alternatives which is why we decided not to present them metaanalyses or pooled studies from different largescale registries may still be warranted to confidently exclude this possibility fifth although our study have shown that familial effects account for a large proportion of the neighborhoods effects our design does not address the question whether these familial effects are genetic or shared environmental in origin genetic confounding could result from the same genes simultaneously influencing residence in deprived neighborhoods in urban settings as well as later psychiatric morbidity while shared environmental confounding could result from cousins spending longer periods in similar residential environments compared with unrelated individuals before the age 15 studies with complex quantitative genetic designs will be needed for such endeavors sixth a common but criticized 21 approach of estimating genetic risk for schizophrenia in nationwide studies has been to adjust for lifetime occurrence in firstdegree relatives of study participants consistent with previous findings associations studied by us were only marginally attenuated when we adjusted for genetic risk using this traditional approach once again this underlines the importance of considering unobserved familial risk factors in epidemiological studies of psychiatric disorders seventh inferences from sibling comparison models are contingent upon numerous important assumptions including that siblings share their environment that exposed siblings do not exert any influence on unexposed siblings and that differentially exposed siblings are generalizable to the total population 264445 as expected we found that differentially exposed siblings were living in more densely populated and deprived neighborhoods than the total population nevertheless the differences between differentially exposed cousins and the total population were negligible and the withinextended family results matched the within nuclear family analyses lastly given that we have reported consistent null findings across a number of different exposure and outcome definitions one potential concern might be that these findings result from our choice of statistical models for the general neighborhood effects we observed a full attenuation in schizophrenia but we only observed a 23 reduction of the effects in depression for the specific neighborhood influences all models including the sensitivity tests adopting a series of different statistical parameterizations reported null findings we would like to emphasize that family fixedeffects models are commonly applied in epidemiology and many related disciplines to investigate whether observed associations are consistent with causal inferences 2545 to summarize our findings suggest that familial selection factors account for the associations between population density neighborhood deprivation and being diagnosed with schizophrenia and that neighborhoods generally account for a very limited share of the phenotypic variance this was also found for depression omission of adequate adjustments for familial confounding may have led previous authors to overemphasize the relative importance of the direct or moderated effects of these wider environmental risk factors epidemiological neighborhood studies that rely solely on observed confounders risk obtaining severely biased estimates and should therefore be cautiously interpreted future research efforts should be directed toward elucidating the underlying genetic and environmental mechanisms through the continued development of complex intergenerational quantitative genetic models supplementary material supplementary material is available at

people living in densely populated and socially disorganized areas have higher rates of psychiatric morbidity but the potential causal status of such factors is uncertain we used nationwide swedish longitudinal registry data to identify all children born 19671989 n 2 361 585 including separate datasets for all cousins n 1 715 059 and siblings n 1 667 894 the nature of the associations between population density and neighborhood deprivation and individual risk for a schizophrenia diagnosis was investigated while adjusting for unobserved familial risk factors through cousin and sibling comparisons and then compared with similar associations for depression we generated familial pedigree structures using the multigeneration registry and identified study participants with schizophrenia and depression using the national patient registry fixedeffects logistic regression models were used to study withinfamily estimates population density measured as ln population sizekm 2 at age 15 predicted subsequent schizophrenia in the population or 110 95 ci 109 111 unobserved familial risk factors shared by cousins within extended families attenuated the association 106 103 110 and the link disappeared entirely within nuclear families 102 097 108 similar results were found for neighborhood deprivation as predictor and for depression as outcome sensitivity tests demonstrated that timing and accumulation effects of the exposures mean scores across birth ages 15 610 and 1115 years did not alter the findings excess risks of psychiatric morbidity particularly schizophrenia in densely populated and socioeconomically deprived swedish neighborhoods appear therefore to result primarily from unobserved familial selection factors previous studies may have overemphasized the etiological importance of these environmental factors

introduction various studies have reported genetic factors for diabetes mellitus 1 2 3 4 warranting its familial aggregation 5 6 7 8 nevertheless few studies have investigated the clustering of diabetes 910 particularly in married couples who were not genetically related a crosssectional study on concordant diseases in couples revealed that the odds of diabetes concordance was significantly high after adjustment for age alone but not after adjustment for age smoking and body mass index 11 the findings regarding the spousal concordance of diabetes are substantially inconclusive moreover age is considered a crucial determinant of diabetes studies have reported that old age is strongly associated with a high risk of diabetes 48912 the risk increases with age thus middleaged and elderly couples are susceptible to diabetes because of slowing metabolism and obesity a common phenomenon across all the studies on the family clustering of metabolic disorders is the lack of nonfamily counterparts who did not share the same environments hence it is imperative to conduct a concordance study that compares the disparity in the risk of diabetes between couples and noncouples to ascertain the effects of a common environment while examining the age vulnerability most studies on family clustering have reported merely univariate statistics or investigated a very limited number of associated factors however familial clustering or concordance pertains to the common experiences of certain morbidities within a family and is conceivably involved with the risk factors in individual family members therefore examining the factors associated with diabetes in each spouse is crucial for obtaining a more comprehensive understanding of diabetes concordance in couples prior research has reported sex differences in the occurrence of diabetes men were more likely to be diagnosed as having hyperglycemia than are women particularly men with an older age and habits of smoking and drinking 91213 a study indicated no significant association between income level and diabetes prevalence 14 however most studies have reported an association between income and diabetes with low household income identified as the risk factor 1516 moreover the risk of diabetes and other metabolic syndromes varied with occupations because of varying workrelated physical activities 1316 although higher levels of urbanization were associated with higher risk of diabetes 15 the association remains inconsistent in addition studies have indicated that diabetes could be associated with certain chronic diseases such as hiv and psychiatric morbidities 17 18 19 the effects of the potential associated factors on the spousal concordance of diabetes require investigation scarce studies have examined a control group and associated factors for diabetes clustering in couples therefore the present study sought to determine the spousal concordance of diabetes by adopting a mathematically matched group of noncouples to compare the risk of diabetes concordance between couples and noncouples by using nationally representative data methods hypothesis and research design this study hypothesized that the risk of spousal concordance of diabetes is associated with the individual and shared characteristics of spouses the individual characteristics of spouses may exert different effects on spousal concordance of diabetes moreover the study hypothesized the existence of a disparity in the risk of concordance between couples and noncouples the two hypotheses were tested in a longitudinal populationbased cohort by using a casecontrol design the study was approved by the research ethics committee of china medical university hospital taiwan data source and study sample the national health insurance program established in 1995 provides comprehensive health care benefits to more than 997 of the residents of taiwan all the medical claims from this universal program are managed by the national health research institutes which releases the populationbased national health insurance research database this retrospective study retrieved longitudinal data from the 20022013 registry of the nhird which contains the reimbursement claims of 1 million randomly sampled beneficiaries the nhri has indicated that this nhird subset can completely represent all the enrollees the claim diagnoses in the nhird were coded using the international classification of diseases ninth revision clinical modification this study used the data fields relation and encrypted individual identifiers to match married spouses from the nhird registry only two individuals having a relationship status of being insured and dependent spouses were identified as a couple by using spouse in the data field relation and the prerequisite of the encrypted identifiers mutually matched between the two spouses furthermore to obtain an initial diagnosis of diabetes throughout the observation period individuals diagnosed as having diabetes mellitus in 2002 were excluded from the study patients younger than 16 years were also excluded initially data of 5680 couples were obtained however 43 patients were excluded because of inadequate or missing data consequently the current study identified a cohort of 5643 married couples comprising 11286 individuals to ascertain the similarity between the case and control groups except for the couple status the case group was matched with the control group in terms of the same single value of sex age and comorbidities through 11 propensity score matching to reduce selection bias 20 this procedure was repeated twice for each member of a couple to obtain two randomly selected noncouple counterparts thus the three matched variables were tested twice for any significant differences between the two groups the results indicated high similarity with no differences in sex age or comorbidities thus confirming that the couples and noncouples qualified for the comparison psm provides an alternative to adjust for covariates at the level of multivariate analysis 21 consequently 5643 couples and 5643 noncouples were included in the subsequent analysis variables the concordance of diabetes was determined using a dichotomous outcome variable concordance was reported if both spouses or counterparts were diagnosed using icd9cm codes for diabetes mellitus otherwise discordance was reported the present study included two categories of independent variables that are possibly associated with diabetes 1 characteristics of the insured spouse comprising sex age premiumbased monthly salary occupation urbanization level region catastrophic illness or injury and comorbidities and 2 characteristics of the dependent spouse comprising age catastrophic illness or injury and comorbidities the urbanization level and region were considered common environmental characteristics of the couples the remaining variable was the characteristics of the individual spouses legally the taiwan government allows only heterosexual marriage thus one sex that of the insured spouse was used to eliminate collinearity age did not pass the normality test including skewness and kurtosis and was therefore classified into five ordinal levels according to the frequency distribution furthermore premiumbased monthly salary occupation region and catastrophic illness or injury were defined on the basis of the official nhi classifications the national health insurance administration issues the catastrophic illness and injury card to patients with severe illness or injury patients with numerous catastrophic illness and injury conditions such as regular dialysis or permanent disability can apply for the card after the severity reaches the official criteria of the nhi program and is verified by a boardcertified physician comorbidities were assessed using the charlson comorbidity index 22 a frequently used measure in clinical research after original scoring from 0 to 6 conducted by weighting icd9cm codes for each spouse this study classified comorbidities into 0 and 13 because of the lowfrequency distribution of cci scores exceeding 3 the urbanization level was graded using a 5point scale with 1 and 5 indicating the highest and lowest urbanization levels respectively all the 11 independent variables were measured on a categorical or an ordinal level all the variables in the casecontrol design were defined at the pair level data analysis in this study data were analyzed through statistical analysis and data mining statistical methods included the chisquared test and logistic regression the chisquared test determined the prevalence rates of diabetes concordance at the bivariate level logistic regression was used mainly for predicting diabetes concordance at the multivariate level with the adjusted odds ratio and corresponding 95 confidence interval because the members of the couples and noncouples were matched for the three variables conditional logistic regression was used to analyze the matched pair data without the matching factors in the regression model 2324 the conditional likelihood was estimated within the same matched set for binary diabetes concordance 25 moreover collinearity diagnostics were computed using indices including variance inflation and tolerance for data mining c rt and apriori two methods under the no hypothesis paradigm were used to explore hidden patterns that statistics might fail to detect 2627 the application of data mining techniques in longitudinal study analysis of a large clinical data source may discover useful information on disease prediction and health care delivery 28 29 30 c rt a decision tree was used for classification 31 the apriori algorithm of association rules was used to mine for potential associations in the extracted research data 32 data mining largely served as a supplement to statistics in contrast to theorybased statistical analysis data mining is substantially more datadriven research that analyzes the individual level factors associated with the couple concordance of diabetes is still lacking therefore this study used statistics and data mining for the optimization of pioneering modeling for the concordance factors the joint findings engendered by the two approaches should increase the strength of evidence on diabetes concordance data were analyzed using sas 94 and ibm spss modeler 13 results the common characteristics of 11286 individual spouses were analyzed and merged in the unit of a couple catastrophic illness or injury and cci 2 were significantly associated with a higher prevalence of spousal concordance insured spouses who were soldiers social security insured veterans and associated with religious groups were more likely to develop spousal concordance of diabetes compared with those involved in other occupations this study did not detect any signs of collinearity table 4 presents the logistic regression results the results of the unadjusted model indicated that 10 independent variables were significantly associated with spousal concordance after all other covariates were held constant nine variables remained significantly associated with spousal concordance of diabetes male insured spouses were more likely to experience spousal concordance than their female counterparts were insured spouses aged 4554 5564 and 65 years were more likely to experience spousal concordance compared with those aged 1644 years moreover insured spouses residing in areas with urbanization levels of 2 and 3 were more likely to experience spousal concordance compared with those in level 1 urbanization areas the odds of spousal concordance were significantly lower in insured spouses residing in the northern region than those residing in taipei regarding health characteristics the odds of spousal concordance were significantly higher in insured spouses with catastrophic illness or injury than in those without these factors the odds of spousal concordance were significantly higher in insured spouses with mediumhigh comorbidity than in those without comorbidities dependent spouses aged 4554 5564 and 65 years were more likely to experience spousal concordance compared with those aged 1644 years moreover dependent spouses with catastrophic illness or injury were more likely to experience spousal concordance compared with those without these factors in addition dependent spouses with mediumhigh comorbidity were more likely to experience spousal concordance compared with those without comorbidities table 5 presents the results of couplelevel analysis following 11 dual psm the chisquared test revealed a significant association of marital status with diabetes concordance couples were significantly associated with a higher prevalence of concordance than were noncouples the percentage of one spouse diagnosed with diabetes in couples was higher than that of one individual with diabetes in noncouples this phenomenon is consistent among both male and female moreover conditional logistic regression indicated that marital status was significantly associated with diabetes concordance the odds of diabetes concordance were significantly higher in couples than in noncouples after feature selection data mining was performed with a reduced set of relevant data the following classification rules were identified for predicting spousal concordance 1 cci 1 fourth fifth and sixth categories of occupation and residence in northern and southern regions for insured spouses and 2 age 55 years and cci 1 for dependent spouses for predicting no spousal concordance the classification rules were a monthly income of us 960 and no comorbidities for insured spouses and age 1654 years and no comorbidities for dependent spouses the prediction accuracy of c rt was 857 909 the apriori algorithm was not sensitive in detecting the association rules for the presence of spousal concordance however the acquired rules for predicting no spousal concordance included the male sex age 1644 years no catastrophic illness or injury and no comorbidities for insured spouses as well as age 1644 years and no catastrophic illness or injury for dependent spouses confidence in apriori is an indication of the probability that the rule is correct in this study the confidence of the apriori algorithm was 953 982 indicating a strong association between the extracted patterns and spousal concordance of diabetes overall the indices of accuracy and confidence demonstrate effective data mining 3334 discussion high concordance in couples versus low concordance in noncouples to our knowledge this study is the first that investigated spousal concordance of diabetes in a matched casecontrol design a contrast of high and low concordance rates of diabetes in couples and noncouples respectively was identified the dual psm analysis revealed this phenomenon in both prevalence rates and ors the determined prevalence rate of spousal concordance was 519 in couples strongly higher than in noncouples the or of 61743 represents the marked effect of a common family environment on the development of diabetes in couples and deserves emphasis both couples and noncouples were matched by sex age and comorbidities therefore the high contrast in the concordance is not attributable to oldage vulnerability and is closely related only to the coupled status assortative mating and similarities between both members of a married couple in a common environment may explain the high concordance of diabetes in couples 35 studies have indicated resemblances between spouses 3637 particularly in longstanding couples notably collectivism in taiwanese culture 38 may reinforce behavioral resemblances in couples furthermore through cohabitation in the same family environment concordant health behaviors including exercise and dietary habits and shared lifestyles in couples can be shaped 39 40 41 42 and might thus lead to a shared exposure such as concordant obesity 43 to diabetes 44 hence familybased intervention for modifiable health behaviors is a priority in clinical practice individuallevel characteristics predicting couplelevel concordances statistical analysis and data mining yielded the combined results regarding factors associated with spousal concordance of diabetes in addition to the couple status nine factors including personal and shared characteristics of spousal concordance warrant attention most insured spouses were men who could have a higher risk of diabetes than their female counterparts 923 the prevalence rate of diabetes was higher in insured spouses thus explicating the finding that insured men were more likely to experience spousal concordance of diabetes than were insured women old age was markedly associated with high risks of concordant diabetes particularly in spouses aged 65 years this observation is in accordance with the findings of previous studies 4546 the urbanization level and region which are the shared geographical characteristics of couples were identified as the determinants of spousal concordance levels 2 and 3 of urbanization were associated with higher odds of spousal concordance whereas residence in the northern region was associated with a lower risk the geographical disparities in concordant diabetes warrant further research and require the attention of health policymakers the findings regarding comorbidities are similar to those previously reported 4748 and indicate that medical conditions of individual spouses contribute to concordant diabetes in couples overall diabetes in a spouse may indicate the risk of diabetes in the partner a previous study indicated that spousal diabetes is associated with a 26 increase in the risk of diabetes in the partner 49 echoing the present findings the phenomenon of spousal concordance of diabetes is evident therefore the clinical prevention of diabetes should target spouses whose married partners were diagnosed as having diabetes by applying the individuallevel and shared geographical risk factors identified in this study including old age midrange urbanization and chronic morbidities coupleoriented health insurance couplitation health insurance schemes might adjust medical payments by sex age and morbidities such as capitation reimbursement 50 a family history of certain chronic and catastrophic illnesses among genetically related family members is considered for determining premiums nevertheless the spouse history of diabetes is typically not involved in the risk rating of individuallevel health insurance plans therefore the present study proposes a novel yet reasonable direction of a coupleoriented insurance scheme couplitation that is aimed at developing comprehensive coverage and reimbursements for spousevulnerable chronic diseases 51 52 53 particularly diabetes couplitation may improve early detection through examination in a manner paralleling capitation this spouserelated risk rating of an insurance scheme requires feasibility analysis in future studies the limitations of the present study are mainly related to the database used first the nhird does not include information on the educational level health behaviors laboratory test results cohabitation duration and other joint characteristics of the couples the absence of these data weakens the statistical strength of this study second the body mass index is a major risk factor for diabetes the absence of this factor may result in residual confounding and thus bias the findings in an unknown direction third high level of awareness or knowledge of symptoms of diabetes may lead to early diagnosis due to the lack of awarenessrelated data in the nhird the current study failed to take this factor into consideration finally all spouses retrieved from the database were limited to the insureddependent relationship the generalization of the study findings to all other relationships requires deliberation conclusions this study involved cohort and casecontrol designs individualand couplelevel analyses and statistical analysis and data mining all of which were aimed at providing strong evidence this study adds to the existing knowledge base by determining the evident effects of a common family environment and individual characteristics on diabetes concordance in couples oldage vulnerability in diabetes cannot explain this high concordance phenomenon in couples diabetes in one spouse indicates the risk of diabetes in the partner therefore this study suggests that familybased diabetes health care and clinical intervention be conducted using the individual risk factors identified in this study future studies may focus on investigating the spousal concordance of a specific type of diabetes all relevant data are within the paper data curation jongyi wang yatun yang formal analysis yatun yang funding acquisition jongyi wang methodology jongyi wang project administration jongyi wang resources jongyi wang software yatun yang validation chiushong liu chihsuan lung writing original draft jongyi wang writing review editing chiushong liu chihsuan lung minghung lin

spousal clustering of diabetes merits attention whether oldage vulnerability or a shared family environment determines the concordance of diabetes is also uncertain this study investigated the spousal concordance of diabetes and compared the risk of diabetes concordance between couples and noncouples by using nationally representative dataa total of 22572 individuals identified from the 20022013 national health insurance research database of taiwan constituted 5643 couples and 5643 noncouples through 11 dual propensity score matching psm factors associated with concordance in both spouses with diabetes were analyzed at the individual level the risk of diabetes concordance between couples and noncouples was compared at the couple level logistic regression was the main statistical method statistical data were analyzed using sas 94 c rt and apriori of data mining conducted in ibm spss modeler 13 served as a supplement to statisticshigh odds of the spousal concordance of diabetes were associated with old age middle levels of urbanization and high comorbidities all p 005 the dual psm analysis revealed that the risk of diabetes concordance was significantly higher in couples 519 than in noncouples 009 or 61743 p 00001 a high concordance rate of diabetes in couples may indicate the influences of assortative mating and shared environment diabetes in a spouse implicates its risk in the partner familybased diabetes care that emphasizes the screening of couples at risk of diabetes by using the identified risk factors is suggested in prospective clinical practice interventions

i introduction the bespoke working conditions of a jockey differentiates them from other athletes in that jockeys primarily have exhausting calendars with no off season and take part in a sport that is exceedingly hazardous and high risk jockeys take part in a sport that is notorious for being challenging both physically and psychologically for example high incidences of injury low weight requirements risky and rapid weight management methods yet there is inadequate research concerning to the psychology of jockeys sports requiring a horsehuman dyad are under researched in the sport psychology and physiology stress literature a jockey is required to perform on demand and boost the performance of the horse on race days jockeys compete on various horses of varying ability throughout their day this unique experience of constantly changing horses provides the jockeys with a specific demand and stress that is not endured by other athletes competing in other nonequestrian sports cullen et al described horse racing to be a physically challenging sport these physical challenges can impact on a jockeys lifestyle which may influence their stressors and coping strategies a study which examined depression generalised anxiety psychological distress and harmful alcohol use found that nearly 80 of jockeys in ireland met the level for at least one of the mental health disorders even though horse racing is often regarded as a dangerous and challenging sport there is a scarcity of research exploring the stressors and coping strategies experienced by jockeys furthermore there is a paucity within the literature examining the unique stressors and coping strategies employed by female jockeys equestrian sports and horse racing offer a rare opportunity for males and females to compete against each other and is recognised as the only olympic sport that allows males and females to compete in the same event female entry into horse racing and securing work in the male dominated sport has been reported as difficult williams and hall reported that family contacts and influential networks are often more facilitative for men in horse racing the usa jockeys guild membership shows that approximately eight percent of jockeys are female and the majority never reach that top level eleven percent of professional uk jockey licenses are held by female jockeys in ireland a total of 235 jockeys holds licenses for national hunt or flat racing and only 24 of those licence holders are female horse racing is one of the only sports in the world where males and females compete alongside each other however female jockeys represent a small minority with the horse racing community high performance sport often highlights masculine principles such as stoicism mental hardiness whereby repression of perceived weaknesses is often imposed athletes have disclosed fear of deselection from coaches and often do not reveal if they have engaged with psychologists the overarching aim of this qualitative study was to offer a rich depiction of the female jockeys experiences of specific stressors and coping strategies awareness of these stressors may be considered by practitioners working with jockeys insight into the unique stressors female jockeys encounter may provide sport science specialists and researchers with a greater awareness of the influencing aspects towards their stressors and specific supports they need feminist sport researchers have identified that research that specifically examines the unique events of female athletes is crucial to promoting womens sport participation and promoting parity in opportunities sport psychologists are often requested to assist athletes with personal performance and transition issues so it is crucial that the field be responsive to the needs of female jockeys ii literature review particularly poignant for jockeys is that injury is a significant competitive stressor for jockeys horse racing is often regarded as a perilous sport that reports a high percentage of falls and injuries athletes who are injured are more prone to describe depressive indicators than those who are not injured the career length of jockeys can be short legg cochrane gee and rogers identified that the average longevity of a jockeys career is three years in comparison jockeys who have had more opportunity to ride in horse races had on average longer careers legg et al discussed that national hunt jockeys in races fall 50100 times more than flat jockeys flat jockeys generally fall once every 1020 races approximately the pressure to perform is also a key stressor for athletes the highprofile side of horse racing is often portrayed however rarely seen are the chronic injuries personal sacrifices and the daily stressors and hassles many jockeys experience within the media jockeys are generally described as low weight lean and mentally strong athletes on the contrary jockeys often may be dehydrated and lacking in calories and experiencing fatigue jockeys may also have doubts be in a performance slump experience high levels of stress pressure to perform on demand and must manage horse owners and trainers expectations making weight strategies which is commonly known as wasting in horse racing for example sauna use starvation and over exercising are all examples of wasting in horse racing can also be stressors king et al identified that the racing industry contributed to jockeys stress via the workload high volume of travel required career uncertainty and lack of career opportunities limited research exists which examines female jockeys opportunities to ride compared to male jockeys however velija and flynn identified that female jockeys are generally accepting of their inferior position within horse racing based on the stereotype of male jockeys being superior to them from an evolutionary perspective velija and flynn also highlighted that even though structural and organisational changes have allowed women to be approved for licenses to ride train and compete along with males this may not have changed the general view of female jockeys female jockeys are still perceived as physical and mentally weaker and less skilled than male jockeys roberts and maclean completed a qualitative study and their results found that women face prejudice in horse racing in relation to three main factors their physical power body shape and the gender tradition of utilising male riders over female riders which is rooted within the horse racing industry sarkar and fletcher define personal stressors as the environmental demands associated primarily and directly with personal nonsporting life events such stressors include life demands dual careers relationship issues and distressing incidents such as chronic injury based on the kessler psychological distress scale king et al and losty et al both reported indicators of distress for jockeys king et al found that flat jockeys reported higher levels of symptoms of distress in contrast with jump jockeys methodologically it is difficult to compare levels of distress in jockeys to other athletes as multiple methods of measuring distress have been utilised the movement towards sports specific measure would combat this another personal stressor is that being a jockey has been described as a lonely profession unver et al highlighted that female athletes experienced higher levels of loneliness than males and that athletes under 20 experienced higher level of loneliness compared to athletes over 20 years of age fry and bloyce interviewed 20 professional golfers in their study and found loneliness and isolation progressed as players were separated from family and friends these feelings combined with unreliable revenue through golf competitions further added to their workrelated anxieties these are similar comparisons with a jockeys lifestyle the metaanalysis by nicholls et al revealed a significant relationship between coping strategies and sports performance masterybased strategies were positively linked with performance whereas internal control and goal withdrawal was negatively linked with performance lazarus and folkman identified that coping strategies centres on two elements focusing on the problem for example solving or modifying the source or the stress or focusing on the emotion such as a jockey controlling their reactions and regulating their emotions to the perceived stressor cosh and tully discussed that athletes specifically benefit from the support of both parents and coaches however they also highlight that athlete would gain from upskilling in time management selfcare and stress management techniques crane et al identified that the specific metacognitive skill for example selfreflection on ones primary stressor reaction is a possible process for fostering resilience nicholls and polmans systematic review identified that female athletes utilise social support to cope with stressful situations however there is little to no research that compares male and female athletes coping strategies to the same stressor rosenfeld et al and kristiansen and roberts also corroborated with these results the main finding in relation to age is that athletes generally cope better as they mature this finding implies that younger jockeys could be trained to cope more successfully by improving their coping strategies to facilitate them to feel better able to manage their stress there is currently no data exploring the bespoke coping strategies implemented by jockeys this limits the development of evidencebased best practice guidelines for any member of an interdisciplinary team working with jockeys in contrast athletes who reported optimised emotional regulation at an olympic games also reported coping effectively and this appeared as a positive predictor of those athletes who performed well in competition therefore interventions which targeted bespoke coping strategies for jockeys may help to prepare jockeys for the stressors and challenges they face and possibly enhance their performances roberts and maclean identified that women faced specific prejudice in horse racing regarding several issues the three central reasons identified within their study were due to a womens physical strength body shape and the institution and history entrenched within the horse racing industry using a database of over a million horse races over three years binder et al analysed the probability for male and female jockeys placing first second or third and the determining factors for an opportunity to race ride their results revealed that the possibility for female jockeys placing in a race was not significantly different from male jockeys however female jockeys received fewer opportunities to race ride binder et al also noted that many female jockeys race under their initials and not their full names to avert stereotypical reactions from those in the industry these findings are also documented by claytonhathway and stumbitz therefore the overarching aim of this study was to explore female jockeys unique stressors and their coping strategies iii methodology a philosophy the philosophical underpinnings of this study were informed by critical realism critical realism strives to collect deep information from the participants and their unique lived experiences braun and clarke described critical realism as combining ontological realism with epistemological relativism to provide a standpoint that retains a perception of truth and reality but identifies those human practices always share how we experience and know thishuman practices can be said to give rise to perspectival and contextual truths critical realism is described as a philosophy but not a methodology it also reflects the methodological realist tenets by wynn and williams critical realism conceptualises different perspectives and acknowledges that language and culture are crucial within critical realism the researcher accesses the participants perception of their reality shaped and embedded within their culture and language therefore the ontological position utilised in this study aligned with realism critical realism and relativism whereas the epistemological approach aligned with constructionism and poststructuralism the epistemological approach situates significance as multiple socially constructed and connected to wider systems of power the following research questions were explored within this study 1 what stressors have the female jockeys experienced or currently experiencing within their careers 2 what coping strategies aided the female jockeys to cope with these stressors b sample and procedure uk and irish female national hunt and flat racing jockeys who are over 18 and hold a racing license for over one year were invited to take part in the research ten jockeys took part in the present study due to the small number of female jockeys who race ride the exact riding background and experience of the jockeys has been withheld to protect identification of the individual participants publicity of the study was via the chief medical officer on the racetracks and through the jockeys general weekly communications from the chef medical officer jockeys were requested to contact the researcher to volunteer for the research participants selfselected and opted to participate due to ongoing covid19 restrictions jockeys were requested to take part in a semi structured interview via zoom the interviews lasted on average 30 minutes interviews were semi structured in nature which gave the female jockeys openness to detail and elaborate their ideas and to accumulate rich data c interview guide development the interview questions were guided by the interview guide an adaptable and flexible style was employed to guarantee conversational flow the interview guide was developed and built on the athlete and jockey stressors literature three key questions were asked to participants initially to establish connection participants were asked to talk about how they became involved in horse racing and their career to date participants were then asked to discuss stressors they have faced or were presently undergoing thirdly participants were asked to discuss how they coped with these stressors and highlight any coping strategies they found useful d data analysis reflexive thematic analysis was employed to deliver a comprehensive evaluation of the qualitative data and investigate the practices meanings and experience of the female jockeys the sixstages of thematic analysis as described by braun and clarke were utilised to scrutinise the data the stages discussed below describe a systematic attempt to analyse the data however the analysis was creative and recursive where different stages often intersected with another stage each transcript was read several times this allowed the researcher to become more familiar with the data semantic coding of the transcripts was conducted by reviewing the transcripts line by line sections of text were highlighted with a marker short word or a line written alongside it and notes were written alongside the text this aided in generating initial codes generated codes were inputted into a file to initiate the search for themes codes were also inputted into an excel spreadsheet exploring and generating themes was ascribed to something important about the data in relation to the research question and represents some level of patterned response or meaning within the data set the themes were reviewed and refined and revised again with some original themes combined into broader themes or deleted themes were reviewed and reread to make sure the theme depicted matched the nature of the coded data the researcher utilised the read aloud function on microsoft word while reviewing the transcripts with the notes and themes at hand an overarching thematic map was designed highlighting higherorder and lowerorder themes this aided the researcher to visualise and interpret the data the researcher then took time for thoughtful reflection and took some time away from the data a reflective journal was also used to promote persistent reflexivity and notes were jotted into this journal and discussed with the research supervisor themes were then defined and reflected on again e ethical considerations ethical approval was obtained from the university research ethics committee all participants were supplied with an informed consent form to sign prior to their involvement in the study a signed consent form was obtained from all participants before any data collection commenced the informed consent form described the justification for the research the voluntary nature of the participants contributions and assured participants that their anonymity was protected and psychological society of ireland guidelines all participants were also informed that they could withdraw with no reason from the research within a specific time frame upon conclusion of the interview the participants were thanked for engaging and were invited to request copies of the research results confidentiality was also safeguarded through data access and storage guidelines all information received was stored in strict confidence and with due respect for legal requirements for data protection anonymity was assured by allocating each participant a distinctive number the data from their interview was connected to this number instead of any personal details this was completed as soon as the interview was finished so that the data investigated could not be linked to any participants personal details the list of participants and their identification numbers were password protected and this information was separate from all other information the researcher and supervisor had access to all the data data access and storage was in line with the standardised procedures at the university iv results and discussion evaluation of the interviews were developed in line with the research questions and were categorised into themes and codes the assortment of stressors described was considerable however most stressors affiliated with stressors experience by other elite athletes and jockeys however only stressors relevant to female jockeys are identified within this research following this categories of stressors and coping were grouped into two main themes unique female jockey stressors unique female coping strategies the findings are principally examined via thick descriptions in the manner of direct quotes the following results are in line with the overarching research questions of this research section a will discuss the unique female jockey stressors section b will explore the unique female jockeys coping strategies a unique female jockey stressors the female jockeys identified that they felt they had limited time to make it as a jockey the following quote highlights this …im riding for 13 years you you would like to have achieved a bit more to be honest in 13 years its a long time and youre kind of feeling isnt it such a waste you know what am i doing it for really yeah and the going forward i dont really want to be i suppose be riding in my 30s mid 30s i dont legg et al reported that jockeys careers were generally short and those jockeys that had less opportunities to race ride had even shorter careers therefore this idea of a limited career time as a female and lack of opportunity as a female jockey may contribute to this theme …i specifically remember prior to turning professional acknowledging that i knew how hard it would be that it would be difficult i knew how hard it was going to be but i had no idea it was going to be this hard ive had some great successes but not on the kind of continuing that i would like king et al and landolt et al revealed regarding unique jockeys stressors where career uncertainty workload and lack of career opportunities particularly for female jockeys are critical these findings are also reflective of arnold and fletchers systematic review of environmental and organisation stressors within high performance sports leka and jain and king et al identified that low social support high psychological demands effortreward imbalance and high job insecurity are acknowledged as strong predictors of mental illhealth jockeys are incredibly selfreliant and selfreliance can also be a barrier to helpseeking among athletes these findings reflect what the concept of fashionable and momentum are described interweavingly by the female jockeys the short career of a jockey also connects to the theme of certain jockeys being perceived as fashionable and getting more opportunities from trainers it is difficult to establish momentum particularly when a jockey has a lack of control over specific career decisions or horses they ride particularly for female jockeys where females are often overlooked these findings are highlighted in the following passages yes its very hard to create momentum and its very hard to keep momentum its not like other sports where you have a particular performance and your kind of on the team the next week because youre playing really well and its just funny… things are in fashion this concept of fashionable jockeys and lack of momentum link specifically to arnold and fletchers systematic review of athlete stressors where the environmental and organisation were highlighted as stressors female jockeys reported careerrelated stressors which related to career insecurity career opportunities and male jockeys being utilised over female jockeys this corresponds to previous research by cosh and tully who discussed that athletes often feel ambiguity and uncertainty during their careers from both a financial and career standpoint adelman and moraes and williams and hall also corroborated that is it more difficult for females to be successful in the racing industry and that males are often chosen over females for race riding horse racing industry has historically been perceived as a more male dominated environment its not the same because i am a woman in the industry and i see myself being deferred from and other lads chosen ahead of me just because im a girl not because of any other reason i know how good i am i think because that the girls in the industry tend to be a little less ambitious and so a little less affected by the extremity of disappointment that comes with it these findings agreed with velija and flynns study that identified that females are often perceived as weaker and are generally less ambitious than their male counterparts due to ingrained stereotypes regarding female jockeys roberts and maclean discussed that female jockeys are often perceived as physically weaker and less capable than male jockeys and the overarching findings within this study also identified that female jockeys feel this bias and prejudice within the environment of horse racing these findings substantiated with velija and flynns study that identified female jockeys are often perceived as weaker male jockeys are preferred and provided with more opportunities to race ride than female jockeys regardless of verification between the female jockeys on some stressors the female jockeys did not describe one stressor consistently this highlights the discrepancies in the jockeys perceptions towards the stressors identified in the study and it is the perception of the stresses which is key this is also identified in the transactional model of stress and coping by lazarus and folkman their transactional model of stress and coping strategies identified that stress occurs when a person perceives that the demands they face exceed the personal and social resources they have within them to meet those demands from an applied perspective understanding the unique stressors of female jockeys will inform best practice strategies and the nuanced nature of the female jockey in horse b unique female jockeys coping strategies social support from family friends and key individuals was identified as the key coping strategy to manage stressors social support from these informal networks encourage motivate and support female jockeys specifically when they are facing challenging times nicholls and polmans systematic review identified that female athletes are more likely to utilise social support to cope which is highlighted in the key quotes below these results have been corroborated by rosenfeld et al and kristiansen and roberts talking to people you need a lot of people good support around you my family is very good to me sometimes i think my family can be biased because your mother and father always say the right thing to you so yeah having good support around you good people there for you and sport psychology as well its nice to talk to somebody that doesnt have i suppose whats the right way to put it you just have a different view on things female jockeys identified specific coping and wellbeing strategies to manage their stressors such as exercising yoga and reflecting on challenging experiences both exercising and reflecting on the stressors link to lazarus and folkmans transactional model of stress and coping strategies that utilise emotion focused approaches such as managing their emotions and responses to the perceived stressor reflection on a stressor allows the jockey to think about their response and modify their coping behaviour to the stressor selfreflection on an initial stressor and reflecting on ones response to a stressor is also a possible mechanism for strengthening resilience as seen in the quotes below and its a constant challenge to keep that tidy to keep your thoughts in order and remember that youre not defined by racing although because we invest everything into it from my perspective ive invested everything everything into it that if its not working you feel like a failure but thats not true because even though it feels that way theres still a lot more to me as a person outside of racing its just one small bit i ride a lot of long shots or whatever and i go away everyday thinking im going to be a winner im like you never know and then of course the horse will run true to form i come home depressed because im sad that it wasnt a winner even though if you look at the form you pretty much know how the whole race is going to pan out so but thats something you cant really avoid i suppose you just have to get on with it and move on to the next one how jockeys manage these stressors can play an active role in their mental health performance and longevity in the sport pensgaard and duda also highlighted that optimising an athletes emotions can have a direct influence on performance there are considerably more dynamic factors and risks in horse racing that are difficult and some uncontrollable such as managing weight injury and other jockeyshorses falling if jockeys were trained and educated on managing their emotions at a minimum to identify unhelpful thoughts and ruminations this may help them to perform enjoy and cope better within their sport the jockeys within this study identified positive active coping strategies such as exercising and yoga to manage their stress levels no jockey identified any maladaptive coping strategy it is worth noting that this may not be representative of the wider jockey community and these results cannot be generalised v conclusions and recommendations a conclusions lazarus and folkmans transtheoretical model of stress and coping was utilised as a guiding framework to explore the stressors and specific coping strategies of female jockeys the participants interviewed identified unique stressors that impacted them both personally and professionally such as a limited time to develop their careers jockeys being labelled as fashionable and how that impacts their career momentum female jockeys also discussed how they felt they had a lack of control over their careers and that male jockeys were being chosen for race riding over females the female jockeys felt they were not being awarded the same opportunities are their male contemporaries this study identified a multitude of stressors however individual jockeys interpretation of stressors may be different for example some jockeys may feel that pressure to perform is facilitative to their performance others may not therefore the results are unique but may not be generalisable to the wider jockey community the coping strategies of female jockeys were also explored in line with lazarus and folkmans transtheoretical model of stress and coping most of the coping strategies identified by the female jockeys related to regulating their emotions to the stressor such as social support and exercising and this is reflective of the gender differences in the coping literature this is an interesting conclusion and is possibly representative of the horse racing environment no female jockeys identified a problem focused coping strategy for example altering the source of stress possibly due to the lack of control a jockey has over variables within their environment and opportunity to alter the stress no single coping strategy was identified and female jockeys reflected using a variety of strategies andor a combination of strategies this finding proposes that female jockeys apply a strategy based on stress appraisal and previous strategies employed this research was completed retrospectively and not an actual experience of a stressor therefore retrospective bias or recall bias may influence responses to the interview questions b recommendations a valuable recommendation of stress and coping research within sport and horseracing should be to interpret new data into applied bespoke best practice guidelines and thus educate jockeys and service providers to enable educate and support female jockeys to cope with performance and environmental stressors there is currently no data related to the bespoke coping strategies adopted by jockeys this limits the development of evidencebased best practice guidelines for any member of an interdisciplinary team working with jockeys and it would be a recommendation for future research in this area research relating to female jockeys is incredibly limited given the recent rise in the profile of specific female jockeys gender specific research is recommended in psychology and sport science within horseracing longitudinal research relating to female jockeys in the industry is needed to investigate career and progression opportunities for women the practical recommendation of sharing examples of positive role models of female jockeys who have successfully balanced their careers would highlight what can be achieved and

purpose horse racing is one of the only sports in the world where males and females complete alongside each other however female jockeys represent a small minority with the horse racing community insight into the unique stressors female jockeys encounter may provide sport science specialists and researchers with a greater awareness of the influencing aspects towards their stressors and specific supports they need the primary aim of this study was to explore the unique stressors and coping strategies of female jockeys design semistructured interviewed were conducted with ten female jockeysthe results found distinctive female stressors such as a perceived limited timeframe for careers lack of momentum lack of control over their career and males being chosen over females to race ride bespoke female coping strategies were also identified such as social support wellbeing strategies and reflection on stressful experiences no single coping strategy was identifieda valuable recommendation should be to interpret new data into applied bespoke best practice guidelines and thus educate jockeys and service providers to enable educate and support female jockeys to cope with performance and environmental stressors originalityvalue this study fills a significant gap in the existing literature research relating to female jockeys is incredibly limited

introduction hispanicserving institutions are among the fastestgrowing types of higher education institutions in the united states hsis are notforprofit degreegranting institutions with an enrollment of undergraduate fulltime equivalent students that is at least 25 percent latinx students and are eligible for federal designation and grant programs such as the title v program 1according to the hispanic association of colleges and universities there were 559 institutions with hsi designation in 2020 enrolling about two thirds of all latinx undergraduate students which is an increase of 248 institutions since 2010 geographically hsis are mostly located in the western and southwestern united states yet 80 of them are located in california florida illinois new mexico new york texas and puerto rico hsis have a growing importance in advancing college access and success for latinx students since the latinx collegegoing population is rapidly increasing that increase in turn has contributed to the growth of eligible hsis 2 many scholars have documented the historical origin of hsis which dates back at least 30 years a large majority of hsis were initially predominantly white institutions that became latinxserving as a result of significant increases in latinx students college enrollment commensurate with demographic changes yet unlike other minorityserving institutions such as historically black colleges and universities or tribal colleges and universities both of which were founded as a result of de jure segregation and with an explicit mission to serve their respective student populations hsis were not founded with a specific mission of serving latinx students rather hsi designation has been largely defined by an enrollment threshold after an intensive period of advocacy and activism that began in the early 1980s from stakeholders concerned with latinx students access to higher and an opaque concept that lacks specific federal guidelines for promoting strategies to serve latinx students spring 2023 volume in this study we used garcia et als framework of servingness to investigate the extent to which hsis serve latinx students in doing so we focused on latinx students 6year graduation rates specifically we longitudinally examined an overall trend in latinx students 6year graduation rates at notforprofit degreegranting institutions by control and hsi designation status we further investigated how various institutional characteristics vary between hsis and nonhsis and how these characteristics facilitate or hinder institutions servingnessthat is the 6year graduation rates of the latinx student population to answer our questions we conducted a panel analysis of multiple years of integrated postsecondary education data system data from 1266 institutions literature review and conceptual framework research on hsis has increased since their formal recognition in 1992 as a distinctive type of institution research has focused on the origins and evolution of hsis on latinx and other minoritized groups of students access to higher education and on hsi students experiences and outcomes while some studies solely examined hsis other studies comparatively studied hsis with nonhsis or emerging hsis that were approaching the 25 enrollment threshold to date existing studies have documented successes and transformative changes opportunities for improvement and capacity building about hsis the findings of the literature however appear inconsistent given the differences in how analytic samples of hsis were constructed variables examined or conceptual frameworks and theories used meanwhile scholars have consistently stressed that hsis have contributed to improving latinx students access to higher education and degree attainment for those who might not otherwise have had an opportunity to enroll in college the ability to articulate what it means for an institution to be or to become latinx serving or minority serving in the absence of a clear mandate or mission remains a perennial challenge for higher education research policy and practice as garcia et al on the other hand racialized experiences such as racism discrimination or microaggressions connote negative experiences within the organization we incorporated the concepts of validating and racialized experiences in this study by accounting for the compositional diversity of students as well as of instructional staff and examined how these types of student experiences are associated with latinx students 6year graduation rates according to garcia et al the organizational structures of hsis not only influence student experiences but also shape hsis capacity to address the needs of latinx students in their framework structures for serving are for instance development of an institutional mission that highlights serving adoption of diversity plans or applying for grants to serve latinx students not all structural constructs are measurable according to garcia et al but they can be observed and studied through case studies or documentation given the significance of structural characteristics with respect to serving the needs of latinx students we investigated various types of organizational structures including the types of student services offered financial aid offers at the institutional level and institutional expenses that could play significant roles in serving latinx students and that could impact their 6year graduation rates garcia et al moreover highlighted that there are external influences on the servingness of hsis including various historical political or social influences for instance these influences might be federal state or local legislation or political advocacy for the latinx community or institutional governing boards or alumni at hsis in a much broader sense garcia et al emphasized that there is a systemic influence of white supremacy on hsis we discuss how we attempt to account for these external influences in the methods section most importantly by adopting garcia et als multidimensional framework for servingness we spring 2023 volume move away from a tendency in prior studies to frame hsis in binary terms as either serving or nonserving we instead seek to illuminate the complexity of hsi identity and the diverse institutional characteristics that can contribute to their performance as marin noted instead of asking whether an institution is latinx serving it may be more appropriate to ask about the extent to which an institution is latinx serving recognizing the ongoing identity development that may be required and the many ways latinx serving can be conveyed in this regard we investigated to what extent organizational and structural traits of higher education institutions serve latinx students success research questions in this study we aim to identify the types of institutional characteristics related to latinx students 6year graduation rates with a particular interest in hsis we address the following three methods data and sample we used multiple ipeds survey components to create a panel data set for this study ipeds data are aggregated institutionlevel data collected by the us department of educations national center for education statistics from institutions that participate in the federal student financial aid programs we also used the digest of education statistics information to gather data about the hsi status of an institution in particular we used data from table 31240 which provided a list of hsis their enrollment and their awarded degree data since data on hsi status were not available for years prior to 2015 we focused our analysis on the years 20152018 the final sample for this study was limited to 4year notforprofit institutions that were title iv eligible we restricted our analysis to doctoral universities masters colleges and universities and baccalaureate colleges we excluded associates colleges and special focus institutions as defined by the carnegie classification of institutions of higher education our aim was to keep the sample of institutions comparable in terms of the student population they serve the final analytic sample included a total of 1266 institutions measures all measures included in this study were aggregated at the institutional level and come from multiple spring 2023 volume survey components of ipeds 12month enrollment admissions finance graduation rates human resources institutional characteristics and student financial aid 3 the outcome variable we examine is the 150 graduation rates for latinx students who enrolled at the institution as fulltime firsttime degreeor certificateseeking students ipeds defines 150 graduation rate as a students completion of their program within one and a half times the normal period of time in our study the outcome represented 6year graduation rates since we focused on 4year institutions that outcome served as an indicator measuring the impact or quality of attending an hsi the key covariate of our interest was an indicator for hsi status of an institution since our analysis included both hsis and nonhsis an institution was defined as an hsi by having an enrollment of undergraduate fulltimeequivalent students that is at least 25 percent latinx who are us citizens or permanent residents since hsi status is subject to adjustment due to yearly changes in latinx student enrollment an institutions hsi designation is considered as a timevarying feature which also varies across institutions furthermore our analysis included various other institutionlevel measures to account for the latinx student experience of an organizational environment as well as for the organizational structures for serving latinx students first to reflect how latinx students may experience the organizational environment we included measures of racial and ethnic composition of the student body and the instructional staff due to the small number of observations we collectively referred to american indian natives and pacific islanders as indigenous we also controlled for six dichotomous measures of student servicessupport financial aid offers and six measures of institutional expenses to address the structures that impact institutions organizational capacity to serve student needs an example would be the percent spent on instruction out of the total institutional expense 4 for financial aid we accounted for the average grant aid per fte undergraduate student and we accounted for the average loan amounts per fte undergraduate student these characteristics are considered timevariant characteristics meaning not only that they are different at each institution but also that they vary across time empirical strategy we first conducted descriptive analyses to examine the trends in latinx students 6year graduation rates by institutional control and hsi status as well as to examine the similarities and differences in institutional characteristics between hsis and nonhsis ttests and chisquared tests were also performed to confirm if the differences across institutions were statistically meaningful by their hsi status to answer our primary research question about the types of institutional characteristics related to latinx students 6year graduation rates we conducted a panel analysis of ipeds data from 2015 to 2018 we considered each of the participating title iv institutions as the unit of analysis measured at different points in time and we identified the panel structure of the data accordingly we estimated a fixed effects model given the result of a hausman test which indicated that it was the preferred model rather than a random effects model in our analysis we used the xtreg command in stata that demeans the variables and we estimated the standard errors correctly accounting for the fact that the cases are not independent of each other given the continuous outcome variable our linear regression panel model with fixed effects can be written as y it β 0 β 1 x it a i λ t ε it y it is the outcome a continuous measure of latinx students 6year graduation rate for each institution at time point β 0 is an intercept term that can vary at different time periods x it is a set of timevarying covariates such as the proportion of latinx students facultystudent ratio institutional selectivity financial aid offers or institutional expenses a i is an institution fixed effect that controls for all timeinvariant unobserved institutionspecific characteristics that might affect the outcome such as institutional climate this means that a i absorbs the impacts of all timeconstant institutional characteristics that have not been included in our model λ t is a timefixed effect that controls for unobservable covariates that vary over time but are fixed across institutions finally ε it is an error term that is different for each institution at each time period and represents the effects of all timevariant variables that have not been included in our model limitations there were some aspects of garcia et als framework that were not observable through our data mainly we were not able to account for some of the structural factors that unlike other outcomes and experiences are not necessarily measurable in traditional ways such as mission and value statements or diversity plans we attempted to mitigate this limitation by accounting for institutional characteristics such as control or institution type since these characteristics reflect institutions orientation or diversity goals to some extent those characteristics do not vary over time in most cases we also could not account for any external influences such as white supremacy discussed by garcia et al yet all institutions we examined were domestic institutions that were potentially being impacted by such external factors to a similar extent and so should not impact our estimates significantly spring 2023 volume findings trends in 6year graduation rates for latinx students table 1 and figure 1 illustrate the trends in 6year graduation rates for latinx students by institutional control and hsi status we found that between 2015 and 2017 the average 6year graduation rates for latinx students were steady without any significant change the rates however suddenly dropped in 2018 with greater changes among private institutions which generally had higher 6year graduation rates for latinx students than public institutions had we also discovered that on average private nonhsis had the highest and public hsis had the lowest 6year graduation rates for latinx students throughout the years differences in institutional characteristics between hsis and nonhsis as shown in table 2 hsis and nonhsis appeared to have meaningful differences in their institutional characteristics in terms of the outcome hsis on average had between 5 to 7 percentage points lower 6year graduation rates for latinx students than nonhsis this trend held for the years 2015 through 2018 hsis and nonhsis we also found several differences between the sector and size of hsis compared to nonhsis hsis were larger on average enrolling about 5000 more students at each campus than the nonhsis in our sample enrolled while the majority of nonhsis in our sample were private colleges and universities fewer than half of hsis were private the level of degree offerings also differed between hsis and nonhsis hsis included fewer baccalaureate degreegranting institutions but more masters degreegranting institutions when compared to nonhsis institutional characteristics and 6year graduation rates for latinx students table 3 presents the findings from the panel analysis of the relationship between institutional characteristics and latinx students 6year graduation rates for all institutions hsis only and nonhsis only the first column reports the estimates for the full population of colleges and universities in our sample we found that hsi status of an institution was not a statistically significant predictor of latinx students 6year graduation rate all else being equal however among the other institutional characteristics student demographic characteristics and institutional services offered were predictive of the latinx graduation rate for each additional percentagepoint increase in the proportion of multiracial students the 6year graduation rates for latinx students decreased by 083 percentage points controlling for all other covariates among the student services offered both remedial classes and academiccareer counseling were predictive of lower latinx graduation rates with the provision of remedial services associated with a 512 percentage points lower latinx students 6year graduation rate holding all else constant and academic counseling associated with a 2273 percentage points lower rate career placement services were predictive of higher latinx students 6year graduation rates with this student service offering associated with 504 percentage points higher rate all else equal we also found that institutional expenditures were predictive of latinx students 6year graduation rates higher 6year graduation rates were marginally associated with higher spending on research and institutional support and on central facilities and space management spending on academic support was associated with higher latinx students 6year graduation rates with each additional percentage point of spending predicting 185 percentage points higher graduation rates holding all else constant discussion and conclusion the primary goals of this study were to better understand the meaning of servingness in the context of hsis and to determine the extent to which hsis serve latinx students in terms of their 6year degree attainment at notforprofit 4year institutions using a multidimensional conceptual framework of servingness proposed by garcia et al we defined our outcome and the key institutionlevel factors that could be associated with the outcome we first examined trends in 6year graduation rates for latinx students from 2015 to 2018 findings showed that public hsis had the lowest 6year graduation rates for latinx students over the years while private nonhsis had the highest rates more broadly public institutions on average had lower 6year graduation rates for latinx students than private institutions by hsidesignation status even after accounting for all other characteristics the average latinx students 6year graduation rates were significantly lower for hsis than for nonhsis moreover latinx students 6year graduation rates were generally lower than 50 at private hsis public hsis and public nonhsi institutions from 2015 to 2017 while private nonhsis had graduation rates slightly higher than 50 our overall findings were consistent with previously reported rates intriguingly we also observed that 6year graduation rates for latinx students suddenly we further delved into understanding the similarities and differences between hsis and nonhsis regarding the organizational environment that impacts student experiences and moreover how these institutional characteristics were associated with latinx students 6year graduation rates our results demonstrated that hsis had significantly larger proportions of asian and latinx students and lower proportions of white and black students than did nonhsis in particular the percentage of latinx students at hsis was nearly 54 times higher than at nonhsis however all else being equal the spring 2023 volume ratio of latinx students had a marginally significant and negative impact on latinx students 6year graduation rates at hsis although previous scholars have emphasized the importance of student experiences with samerace or sameethnicity peers our result suggests that peer effects might not apply in the same way for this outcome although we did not examine other academic outcomes such as grades or retention the data in our analysis do not show a statistically meaningful relationship between the proportion of latinx students and their 6year graduation rates at nonhsis this might be attributable to the fact that nonhsis have a much lower proportion of latinx students which limits the impact of latinx student body on latinx student outcomes hsis had a significantly higher percentage of latinx instructional staff than nonhsis however contrary to expectations the proportion of latinx instructional staff did not have a significant association with latinx students 6year graduation rates either among students at hsis or in the full sample while prior studies showed that a representative faculty could have positive effects on latinx student outcomes our findings suggest that at hsis with a large proportion of latinx peers a larger proportion of latinx instructional staff might have a limited contribution to latinx students 6year graduation rate this result could show the nuances of validating experiences for latinx students latinx students at hsis may find more profound validating experiences through peer interactions than through staff interaction because the former interactions occur more frequently using garcia et als framework of servingness this study also focused on the impact of institutions structural capacity to serve latinx students we investigated student services offerings financial aid and institutional expenses at hsis and nonhsis and analyzed how these factors were associated with latinx students 6year graduation rates we discovered that a greater proportion of hsis offered remedial education employment services and oncampus day care than did nonhsis and that the average cost of attendance was covered by higher percentages of pell grants and loans at hsis than at nonhsis the offering of remedial services was a significant and substantively large predictor of lower latinx graduation rates in both the hsi institutions and in the full sample however this was not a causal effect in which remedial services led to poorer academic outcomes instead this likely reflects the fact that institutions serving students with high levels of need for academic support are both more likely to offer remedial support and more likely to have lower graduation rates for all students among the other student services for the full sample we also found that academiccareer counseling was associated with lower latinx students 6year graduation rates while placement services were associated with higher rates a finding that was consistent for the nonhsi sample career placement services could increase students motivation to complete their degrees given the promise of gainful employment awaiting them after graduation hsis expenses on instruction research student services and institutional support also accounted for significantly lower percentages of the total institutional expense than nonhsis our findings demonstrated that hsis were distinguishable from nonhsis in various aspects such as the types of student support or institutional spending emphasized by institutions in addition our findings highlighted that it is inappropriate to compare the two types of institutions without context in terms of the predictive capacity of institutional spending measures we found that additional spending on research and academic support was associated with higher latinx students 6year graduation rates at hsi institutions that was not the case in the overall sample overall we conclude that these structural features are generally associated with institutional selectivity as well as with the financial capacity to provide an academic environment and support for student success these features have an important impact on latinx students 6year graduation rates at 4year institutions in summary framing servingness at hsis as an organizational and structural issue allows for focus on institutions as the unit of analysis to identify needs for strengthening their capacity to serve latinx students to that end leaders decision makers and policymakers must be clear in their words and actions about what it means to serve latinx students and to identify the types of resources needed for their success for instance securing financial resources such as federal or state funding to support latinx students should continue to be a key focus for institutional leaders moreover such support should result in greater capacity for serving latinx students to improve and sustain positive academic and nonacademic student outcomes namely hsis must recognize that these students are the reason why institutions are designated as such and why they are eligible for targeted federal funding

this study builds on the body of research on hispanicserving institutions hsis and latinx student outcomes and uses garcia et als 2019 conceptual framework of servingness using multiple years of data from the integrated postsecondary education data system ipeds we examined the extent to which hsis serve latinx students in terms of 6year graduation rates at notforprofit 4year institutions key findings suggest that the average 6year graduation rates for latinx students are lower at hsis than at nonhsis

human status criteria sex differences and similarities across 14 nations we come into this world with a nervous system that worries about rank robert frank from choosing the right pond the human social landscape is not flat variable degrees of hierarchical organization and differential access to resources characterize every known human group hierarchical rank applies at all levels of human populations pertaining to all individuals and groups within a populationto men to women to kingroups within the larger group to coalitions and collectives within populations and to larger groups within the human population social status is the subcategory of hierarchical rank in human social groups based on respect admiration and reputational regard a persons status is inherently a judgment by others containing both evaluative and descriptive inferences derived from a range of events actions possessions communications characteristics alliances allegiances grievances and rivalrieseach charged with positive or negative valence that increases or decreases status relative rank is central to many scientific disciplines among sociologists class and socioeconomic status are among the most important structural variables status differentials loom large in the ethnographies of anthropologists and articles address topics such as the big man and the prestige functions of potlaches among economists status striving is regarded as a universal human motive that drives much observed economic behavior and for evolutionary scientists access to key reproductive resourcessuch as desirable mates formidable allies abundant food privileged territory highquality tools and social influencehas been linked historically and crossculturally to rank within the group providing a selective rationale for the evolution of statusstriving and statusevaluating mechanisms for psychologists the processes and criteria by which status is assessed accorded and tracked must be based in psychological mechanisms unknowns of human status despite the centrality of hierarchy and status to many scientific disciplines relatively little is known about the precise criteria by which humans assess and allocate status respect admiration and reputational regard most theories of human status tend to focus on the broad dimensions along which humans allocate and attain status such as dominance power benefit generation competence prosociality expertise and prestige although crucial for building a theory of status these broad dimensions provide little guidance to the specific and diverse array of inputs that regulate human status assessment and allocation given the range of adaptive challenges faced across the environments in which humans evolved a complete understanding of human social status requires the additional examination of the more substantive contentsaturated status criteriathe specific acts characteristics interactions and eventsthat humans use to evaluate and allocate status and to track status trajectories over time research has not yet documented which if any status criteria are speciestypical and culturally universal whether some criteria are reliably sexdifferentiated across cultures nor whether and how status criteria shift according to culture ecology group composition life stage relationship or other contextual factors the goal of this article is to provide an initial framework for detailing the criteria that humans use to evaluate and accord status the ways in which these criteria differentially affect men and women and to provide empirical tests in 14 cultures status in evolutionary perspective status is a product of universal evaluative mechanisms that rank individuals within groups hierarchically and groups within populations hierarchically according to subjective perceptions of value which create patterns of deference over resources the criteria of human statusthe events actions communications and associations that lead to increases and decreases in respect admiration reputation prestige deference and influenceare evaluated by evolved psychological mechanisms that are adaptivelypatterned speciestypical numerous and specific reflecting the different adaptive problems that ancestral humans had to solve when interacting with others from an evolutionary perspective hierarchies exist in part because individuals within groups benefited from avoiding costly conflict over resources by recognizing asymmetries in abilities circumstances and motivations that lead to differential success in conflict in nonhuman animals an individuals rank within hierarchies tends to be heavily dependent on success in agonistic encounters with the expansion of the human lineage into a greater number of niches and the development of language and complex symbol systems the dimensions along which status were accorded became commensurately more numerous and complex no longer was status based primarily on patterns deference to aggressively dominant individuals but on patterns of deference across a broad and complex range of social interactions dedicated and complex psychological machinery would need to have evolved in humans to monitor and accord status to others and to the self and to track changes in status and status trajectories over time the psychological mechanisms that interpret and evaluate status criteria would have imposed a powerful selection pressure over evolutionary history on the behavioral strategies of humans consequently behavioral strategies should have evolved that function to embody the status criteria imposed by the evaluative mechanisms of other humans much as mating strategies have evolved in part to embody the qualities desired in potential mates that individuals are motivated to attract these strategies may be regulated by systems that compare ones traits and abilities in evolutionarilyrelevant domains to a cognitive map of socially valuable traits to compute feelings of selfesteem proportional to the degree one should be held in esteem by others such as the hierometer or sociometer hypotheses suggest the evolution of status criteria the criteria by which individuals are accorded status are deeply rooted in human evolutionary history and highly nonarbitrary just as edible objects differ in food value and places differ in habitat value people within a group differ in a myriad of fitnessrelevant ways such as mate value and coalitional value these differences result in systematic differences in perceptions of relational value and ultimately respect reputation prestige and status the psychological mechanisms that evaluate and determine status criteria are designed by the forces of natural selection operating over thousands or millions of years therefore the criteria that humans use to allocate and evaluate status will ultimately be determined by factors that would have influenced the survival and reproductive success of our ancestors just as humans evolved separate taste preferences for sugar fat salt and protein to solve different nutritional requirements we expect that humans have evolved mechanisms to evaluate status criteria that correspond to the different adaptive challenges and fitness consequences posed by interacting with others because of the multitude of ways in which other individuals can affect our survival and reproductive success the psychological mechanisms that have evolved to evaluate and accord status to others are likely to be numerous and specific hypotheses about the evolution of specific status criteria in humans require consideration of the selection pressures recurring across human ancestral environments although creating a plausible model of the human environment of evolutionary adaptedness is fraught with difficulties researchers and theoreticians have converged on several basic points of reasonable consensus through converging information from the paleontological record the archaeological record our knowledge of ancient habitats our knowledge of patterns of primate homology the characteristics present in contemporary smallscale societies and characteristics present in modern humans we can piece together a plausible scenario of some key aspects of human ancestral conditions ancestral environments throughout human evolution males had lower obligatory parental investment than females females bore the energetic and time costs of gestation and months or years of breastfeeding whereas a males minimum investment was only the contribution of sperm required for successful fertilization over evolutionary time this asymmetry would have driven women to be more selective about whom to mate with relative to men at least in some mating contexts men would have had to compete comparatively more for sexual access evidence overwhelmingly suggests that hunting and gathering were major human activities across human evolutionary history ancient humans ate a variety of foods but calories from meat tend to be more nutrientdense than calories from plants so meat would have been valuable food the time constraints of breastfeeding combined with the impracticality of caring for an infant throughout protracted hunting expeditions suggests that ancestral women probably spent more time gathering and processing sessile foods than chasing game hunting especially largegame hunting was practiced primarily by coalitions of men hunting makes it possible to obtain large caloricallydense packets of meatmore than the amount any one hunter needed or could reasonably consume but hunting returns are highly variable across cultures the interaction between large payoffs and high variability created conditions that elevated levels of foodsharing to a degree not seen in other primate species and promoted the evolution of psychological mechanisms for social exchange early cultural norms likely arose from these mechanisms the benefits of living in larger groupsand the increasing costs of ostracism would have created additional selection pressures honing adaptations for group living huntingespecially largegame huntingalso required higher levels of cooperation among males creating selection pressures to form coalitions and psychological mechanisms attendant to coalitions the existence of coalitions created further opportunities for acquiring resources through intercoalitional aggression which created selection pressures for coalitional defense there is compelling evidence for the hypothesis that men formed cooperative coalitions for the purposes of largegame hunting coalitional aggression and coalitional defense against aggressive male coalitions there is no evidence that women in ancestral environments formed coalitions with other women to raid neighboring tribes to capture husbands or to hunt largegame animals although women likely formed alloparenting networks intergroup conflict and warfare likely exerted strong selection pressures on men across human evolutionary history calorically dense food packets from hunting created the possibility for heightened average levels of male parental investment exceeding that of other primates women who could reliably access highcalorie nourishment for themselves and their offspring would have had higher reproductive success than women who could not thus the genes of women who secured investing mates as well as those of men who invested would have been better represented in subsequent generationsleading to higher male investment over time the combination of higher male parental investment and relatively concealed ovulation in women selected for men who placed greater importance on assuring their paternity in offspring of longterm mates the interaction between longterm mating strategies and relatively high male parental investment created selection pressures on men to select mates of high longterm reproductive value tradeoffs between shortterm and longterm mating led to the evolution of shortterm and longterm sexual strategies sketches of some of the important and relatively invariant features of ancestral environments provide a crudely formulated context for advancing general hypotheses about the status criteria that humans use to evaluate each other sex differences in reproductive biology and investment selected for sex differences in psychology and behavior which led to sexual divisions of subsistence labor in our huntergatherer ancestors these ancestral divisions of labor fostered sexually asymmetric cultural values and expectations whereby different traits and affordances became differentially valuable in and to men and women creating a feedback loop between culture and our evolved psychology culture and evolved psychology coevolved sex differences in value that emerged across a range of relationship domainsfrom mate value to kin valuewould have been maintained by individual expectations and cultural norms ultimately manifesting in differences in the criteria of status a diagrammatic depiction of our model of the evolution of human status criteria is shown in figure 1 figure 1 model of the evolution of human status criteria from ultimate to proximal causes of manifest criteria general hypotheses about status criteria the status criteria linked with each of the different major forms of human relationships shown in table 1 are expected to be partially overlapping and partially distinctive the mate value of a woman for example can be an asset to potential mates as well as to her kin groupparticularly in cultures in which marriage is arranged by kin and women are exchanged between groups the higher a womans mate value the higher her value to kin in forming political alliances and in obtaining desirable wives and other resources in exchange analogously a mans athletic prowess and hunting ability can increase his value as a coalition member as a kin member as a reciprocal ally and as a mate table 1 abstract classes of relational value and conceptual definitions classes of relational value conceptual definition kin value value to immediate and extended family coalitional value value to specific coalitions collective action hunting and war parties mate value value to ones mate and prospective mates reciprocal exchange value value as partner across oneshot and repeated dyadic interactions the utility of differentiating the different classes of value is not that these classes are entirely independent but rather that some criteria differentially affect ones value within each of these major forms of human relationships we may tolerate lack of reciprocation from kin for example but refuse to tolerate it in a nonkin dyadic alliance we may value strength or bravery more strongly in a coalitional partner than a reciprocal exchange partner or value agreeableness more in an exchange partner than coalition member to take another example a substantial cost may be incurred if ones mate has an extramarital affair but not if a friend has an extramarital affair costs and benefits differ depending on the nature of the relationships it is plausible to hypothesize that distinct psychological mechanisms have evolved for each of these relationships to the degree that the constituents of value differ for each the costs carried by relationship violations differ for each and hence the adaptive problems one must solve to extract the relevant value differ for each thus we expect some degree of overlap in the status criteria between relationship domains we delineate hypotheses and predictions that apply equally to women and men and those that differ between the sexes status criteria central to both sexes given the multitude of adaptive problems that are the same for men and women we expect that many of the criteria that humans use to assess and allocate social status will not be sexdifferentiated health would have been central to the social value of men and women across all fitnessrelevant domains thus we hypothesize that overall health will be equally important for both women and men we also hypothesize that many components of kinsupport as well as general aspects of group value and social exchange value will not be sexdifferentiated because many aspects of value in each domain are not sexdifferentiated specifically we predict that criteria related to kinalliances will be central to both men and women because kin would have tended to be the strongest allies and would have provided a consistent pool of shared resources to draw from having highstatus and supportive kin members would have been beneficial for both men and women for raising socialexchange value being a valuable member across domains should be central to both mens and womens status because others would be more willing to reciprocate or initiate fitnessenhancing social exchanges thus we expect that many aspects of group and social value would not be sexdifferentiated we also do not expect direct reproductive output such as having children to have different impacts on the status of men and women sexdifferentiated status criteria sex differences are only expected to occur within the delimited domains in which women and men have recurrently faced different adaptive problems over human evolutionary history in contrast where they have faced similar adaptive problems psychological similarity is expected we hypothesize that status criteria will differentially impact men and women in domains where there are sex differences in the perceived components of relational value examples of cues that are hypothesized to impact the relational value and consequent status of men and women differently shown in figures 3 and4 respectively status criteria central to men given that men participated in coalitional hunting and raiding at higher rates than women throughout human evolution we hypothesize that components of value relevant to the success of hunting and warfare coalitions will be more central to the status of men than women the success of male coalitions would have depended in part on their ability to coordinate actions in the pursuit of collective goals thus we expect that leadership qualities will be more central to mens status than womens this is not the same as claiming that leadership abilities will not enhance womens status but rather that leadership abilities will be more crucial for mens status than womens on average another major component of coalitional success is the ability and willingness of its members to achieve shared goals this would depend heavily on mens athleticism physical formidability bravery and likelihood of defection so we expect mens status to hinge more heavily on these criteria than womens status many of these traits would also have been relevant to a mans ability and willingness to protect their mates and offspring which strengthens our expectation that these components of status criteria will be more central to men than women because resource acquisition ability would have been a critical component of mens mate value we also expect that components of the ability to provide resources will be more central to mens status than womens status this does not imply that ability to acquire resources will not be important to womens status but rather that it will be more important to mens than to womens status status criteria central to women for reasons outlined previously ancestral women would have been responsible for most domestic duties thus we hypothesize that womens status will depend more on domestic skills than will mens status this prediction may obtain more strongly in traditional societies cultural shifts toward egalitarian domestic duty sharing in many western cultures may diminish or even eliminate these sex differences in more modern countries we also hypothesize that physical attractiveness will be more central to womens status than mens due to the greater weight physical attractiveness has played in womens mate value over evolutionary time particularly in longterm mating contexts a womans attractiveness would have impacted her ability to access highresource mates and consequently her relational value to kin and social partners mating strategy and status criteria high statusobtained by embodying the criteria imposed by othersenables an individual to carry out his or her preferred sexual strategy whereas low status inhibits an individuals ability to carry out his or her preferred sexual strategy for men this tends to mean better odds of obtainingor failing to obtainlongterm mates of high desirability as well as access to multiple mates or shortterm opportunistic copulations for women this tends to mean better odds of obtainingor failing to obtaina longterm mate or marriage partner who invests heavily a marriage partner of high mate desirability and under some circumstances being able to attract shortterm sexual liaisons and access the resources and possibly genes of high status men here we test the prediction that carrying out ones preferred sextypical sexual strategy will be associated with higher status whereas being unable to carry out the preferred sexual strategy will be associated with lower status thus we hypothesize that criteria central to mens sexual strategy will have greater impacts on the status of men than women and that criteria central to womens sexual strategy will impact womens status more than mens status the current study no systematic analysis has detailed the relative impacts that various personal characteristics have on status and reputational regard across cultures no studies explicitly test which actions events qualities and associations reliably affect the status of men and women differently across cultures there remains a gap in the scientific understanding of statusthe precise qualities actions and events that humans use to evaluate the status of other individuals to fill this lacuna we employ ratings of the status impacts of 240 specific events characteristics and behaviors and from 14 countries from brazil to zimbabwe to explore and document human status criteria and we test basic predictions based on hypotheses drawn from evolutionary metatheory about sex differences and sex similarities in human status criteria to summarize we hypothesize that mens and womens status criteria will depend equally on skills and characteristics that increased their relational value equally across domains throughout our evolutionary history and that that there will be sex differences in status criteria where ancestral relational value differed between the sexes regarding status criteria central to both men and women we predict that health characteristics related to general group and social exchange value having children and kin alliances will not have sexdifferentiated status impacts regarding sex differences we predict that mens status will be more dependent on characteristics relating to willingness and ability to protect athleticism leadership qualities and resource acquisition abilities whereas womens status will be more dependent on characteristics relating to reproductive value and domestic skills importantly we predict that sexdifferentiated aspects of mens and womens sexual strategies will also have sexdifferentiated status impacts method participants a total of 2751 people from 14 countries across five continents participated in this research the sexspecific sample size and average participant age for each country is presented in table 2 materials and procedures generation of statusaffecting items the statusaffecting itemsthe acts characteristics and events that raise or lower statuswere generated through a mix of actnomination procedures and expert input early in the item generation process one sample of american undergraduates nominated actions characteristics and events that could increase status and reputation while a second sample nominated actions characteristics and events that could decrease status and reputation we culled the nominations eliminating redundancies grammatical errors and vague statements but erred on the side of overinclusion retaining all acts and events that had even partial distinctiveness this process resulted in 175 statusaffecting items additional items were added stochastically over time as a result of discussions with anthropologists and psychologists who had specific knowledge of different cultures for example our chinese collaborator suggested that having a male child may increase status in china more than having a female child so two items were added to reflect this nuance additional items were added to test the specific hypotheses outlined above for example showing bravery in the face of danger was added to test the hypothesis about sexlinked status criteria as a function of the different forms of male and female coalitions researchers who collected crossnational data added additional items over time in total this generation process resulted in 240 statusaffecting actions characteristics and events we make no claims that this list is exhaustive in principle thousands of acts events characteristics and interactions have consequences for increasing or decreasing an individuals status moreover some status criteria will be specific to novel forms of modern culture which change constantly for example skill at computer coding or data visualization could not have been status criteria among human ancestors but among some modern subcultures these skills are highly valued consequently no list of status criteria will be exhaustive or complete rather this study provides an initial foray into the large gap in understanding what causes peoples status to rise or fall it also provides initial crosscultural tests of hypotheses about universal and sexdifferentiated status criteria statusimpact ratings respondents across the 14 countries rated the distinct impact of the full list items available at the time of data collection1 according to the prompt in this study we are interested in the effects of certain events and behaviors on the status and reputation of the persons who perform these acts or experience these events some will be likely to increase a persons status and reputation in the eyes of their peer group others will be likely to decrease their status and reputation in the eyes of their peer group please use the scale below to rate the likely effects of each act or event on status and reputation for males and for females for some events and behaviors the effects on status and reputation may be the same for men and women for others the effects on status and reputation may be different for men and women respondents rated each item twiceonce in reference to the impact on men and once in reference to the impact on women researchers who collected data within each country translated the prompt and items into the language most relevant to their culture or country using a threestep process first a bilingual speaker translated the items into the relevant language then a second bilingual speaker translated the items back into english finally a third bilingual speaker resolved any discrepancies between the original wording and the backtranslation the full instructions sent to crossnational collaborators are provided in the online supplemental materials astute readers may notice that the rating prompt is somewhat doublebarreled because it asked raters to think about the effect on status and reputation theoretically these constructs are expected to overlap to a large degree but they are partially distinct it is possible that this conflation could qualitatively affect our results given that this archival dataset was collected over a decade ago we could not directly address this issue we did however attempt to investigate the likelihood that the doublebarreled prompt led to qualitatively different results than ratings of only status or only reputation we asked separate groups of american raters to rate all 240 statusaffecting items using the same prompt as in the international data collection but we altered to prompt throughout to say either only effects on status or only effects on reputation these more specific ratings exhibited high interrater agreement moreover they were very highly intercorrelated for both male and female targets as well as with the ratings from every country based on the original prompt the full correlation matrix between statusonly ratings reputationonly ratings and international ratings based on the original prompt is provided in the online supplementary materials the high correlations between ratings based on different prompts suggest that results based on ratings from the original prompt are unlikely to be qualitativelyor even statisticallydifferent had it specified only status or only reputation item clustering we directed four trained research assistants to group the statusaffecting items according to shared content which we labelled accordingly we then further grouped these contentclusters into theoreticallyrelevant domains according to our hypotheses groupings were set before analyses were conducted some of the statusaffecting items did not fit neatly into our hypotheses so we grouped them separately for use in exploratory analyses in cases in which the items potentially overlapped across domain or content clusters we opted to keep categories separate rather than to merge them to preserve unique information discrepancies in grouping decisions were resolved through discussion a table showing the placement of all 240 items within clusters and domains is presented in the supplemental materials analytic strategy we examined the magnitudes of sex differences in status criteria across three levels of analysis item level content level and domain level the item level assessed sex differences at the level of specific items the content level metaanalyzed the itemlevel sex differences within content clusters finally the domainlevel analyses metaanalyzed the itemlevel sex differences according to domain clusters we describe the details of how we sought to maximize power in our analytic strategy below item level analyses to examine the overall effect of referentsex on the status impacts on each of the 240 acts events or characteristics across the 14 countries we used the lme4 package in r to conduct multilevel regression analyses that accounted for the nested structure of the data by allowing random intercepts for both participants and countries and random slopes for countries while controlling for raters reported gender in addition to bonferronicorrecting each pvalue for alpha inflation from 240 tests we also adopted a critical alpha level of 005 after adopting this extremely conservative significance threshold we still had 80 power to detect statistically significant effects for even practically trivial differences because of our large sample size and withinsubjects design we therefore computed classical cohens d for each effectwhich is desirable because it is designblind and comparable across designs and relied on conventional cutoffs to evaluate the practical significance of effects content and domain level metaanalyses after computing itemlevel effects we metaanalyzed sex differences across the prespecified content and domain clusters to do so we grouped effects according to content and theoretical domain we then reversecoded effects where warranted so that effects within a contentcluster were directionally consistent we subsequently weighted each effect by its respective sample size and number of countries sampled and averaged the sex differences within each content and domain cluster these aggregated content and domain clusters provide more powerful robust and reliable tests of our hypotheses because they assess differences across the broader conceptual and theoretical domain that each item samples and the observed sex differences are less dependent on the specifics of item phrasing and itemspecific sample sizes results itemlevel overview of the 240 items rated by participants across the 14 nations 123 were judged to increase a persons status among their peers and 117 were judged to decrease status figure 5 presents an overview of the itemlevel tests of sex differences in status criteria most were expected a priori and fell within the small to medium effect size range most of the items that exhibited trivial differences were either expected not to differ a priori or were exploratory the means and standard deviations of the 15 most beneficial and detrimental statusaffecting items for men and women combined are presented in table 3 the darkshaded circles represent items that were hypothesized be sexdifferentiated and the lightshaded squares represent items that were not hypothesized to differ or were exploratory dotted lines represent conventional cutoffs for small medium and large effects cohens d values greater than zero favor women and values less than zero favor men table 3 the 15 most statusincreasing and 15 most statusdecreasing criteria for men and women combined across countries in the interest of efficiency and economy of presentation we now focus on the content and domain levels of analysis for primary tests of our hypotheses highlighting interesting nuances in the itemlevel results where relevant the complete results and plots of the 240 itemlevel analyses are provided in the supplemental materials statusaffecting item status status criteria central to both men and women domain level we hypothesized that the domains of health general group and social value having children and kin alliances would be equally important to the status of both men and women these hypotheses were supported the metaanalyzed sex differences are trivial across the domain clusters health general group and social value having children and kin alliances figure 6 metaanalyzed sex differences within domain clusters that were hypothesized to be central to the status of both men and women dotted lines represent conventional effect size cutoffs error bars represent 95 confidence intervals content level even at the contentcluster level nearly all sex differences across the domains of having children group and social value health and kin alliances were trivial the two exceptions were small malefavoring sex differences in the insult retaliation cluster containing items addressing retaliation for public insults and the relationship differential cluster containing items related to standing within interpersonal relationships figure 7 plot of universal status criteria organized by domaincluster depicting the average relative status impact of a given contentspecific act characteristic or event on mens and womens status as well as the absolute magnitude of the sex difference in summary many status criteria are not sexdifferentiated and appear to have similar effects across nations sampled in our study suggesting possible universality acts characteristics and events that are associated with general value to the group and to individuals within the group value to ones kin and physical health are three candidates for universal status criteria status criteria more central to men domain level we predicted that clusters relevant to the domains of leadership ability and willingness to protect others resource acquisition athleticism and mens sexual strategy would be more important to mens status than womens status we found support for small but reliable sex differences across all these domains except for resource acquisition ability figure 8 metaanalyzed sex differences within domain clusters that were hypothesized to be more central mens status than womens status dotted lines represent conventional effect size cutoffs error bars represent 95 confidence intervals content level analysis at the content level revealed additional interesting nuances the overall sex difference of mens sexual strategy on status appears to be driven by mediumsized sex differences in having younger mates which has a negative association with womens status but a positive association with mens status additionally although the overall domain of resource acquisition ability is not sexdifferentiated closer examination at the content level revealed that hunting ability increases mens status more than it does womens the domain of leadership also warrants further examination leadership qualities appear more central to mens than womens status at the domain level but the influence contentcluster increases womens status about as much as it increases mens status the difference at the domain level appears to be driven by conformity which lowers mens status more than womens and holding a leadership position which increases mens status more than womens plot of status criteria central to men depicting the average relative status impacts on men and women as well as the absolute magnitude of the sex difference status criteria more central to women domain level we found support for the domainlevel predictions that domestic skills attractiveness and aspects of womens sexual strategy would be more central to womens status than mens status figure 10 metaanalyzed sex differences within domain clusters that were hypothesized to be more central womens status than mens dotted lines represent conventional effect size cutoffs content level as shown in figure 11 the contentlevel analyses further confirmed that all components of attractiveness and domestic skills are more central to womens status than mens status across the countries sampled sex differences in the effects of womens sexual strategy on status are especially clear at the content level infidelity chastitypurity and longterm mating success increase womens status more than mens sexual promiscuity lowers the status of both sexes but lowers it more dramatically for women than for men figure 11 plot of status criteria central to women organized by domaincluster depicting the average relative status impacts on men and women as well as the absolute magnitude of the sex difference some additional itemlevel findings are noteworthy the overall sex difference in hypergamy that favors women seems to be driven by itemlevel differences in having a spouse who is more intelligent than oneself and having a spouse who earns more money than oneself which both raise womens status but lower mens status additionally securing a wealthy mate is equally beneficial for the status of both men and women at the content level but itemlevel analyses suggest that womens status is more damaged than mens by marrying someone who is poor at the item level being a virgin is harmful to mens status but beneficial to womens status and losing ones virginity before marriage is detrimental to womens status but has essentially no effect on mens finally the sex difference in the impact of longterm mating success appears to be driven by the larger decrease in status that women experience upon failing to secure a mate or after being divorceditems that address simply finding a longterm mate tend to be equally beneficial to the status of both men and women exploratory analyses finally we explored the impacts of contentclusters and items about which we did not make a priori predictions as shown in figure 12 some interesting sex differences exist at the level of content clusters that were not predicted first drug use and delinquency seems to harm mens status much less than womens these differences are even more pronounced at the item level for example being able to drink more alcohol than ones peers increases mens status slightly but decreases womens status severely second at the contentlevel most of the effects of personality are not sexdifferentiated but there does appear to be a small bias in extraversion that favors men figure 12 plot of exploratory status criteria depicting the average relative status impacts on men and women as well as the absolute magnitude of the sex difference for the most part these exploratory effects do not appreciably differ at the itemlevel but there are some notable exceptions first crying in front of ones friends is much more damaging to mens status than womens second the sex difference in the effect of genderprototypically on status is trivial at the contentlevel of analysis but the items within that clusteracting masculine and acting feminineare the most sexdifferentiated items in our data with respective cohens d values of 180 and 220 results summary an overview of our metaanalytic results at the domain level according to our hypotheses is shown in figure 13 the domainlevel results largely support our hypotheses we found only trivial sex differences in domains that were hypothesized to be equally important to both men and women we also found sex differences in all but one of domains that were hypothesized to be sexdifferentiated the sole exception centered on resource acquisition ability for which there was a sex difference in the predicted direction but with a trivial effect size mostly driven by the effect of hunting skills discussion this 14nation study provides the first systematic examination of the detailed criteria used by humans to assess and allocate status and the impacts that specific acts characteristics and events have on the status of men and women drawing on evolutionary metatheory we hypothesized that human status criteria reflect numerous and specific evolved preferences values and expectations across the full range of evolutionarily recurrent relationships such as mating relationships coalitional relationships familial relationships and social exchange partnerships we therefore expected the criteria by which men and women are evaluated to be similar across many domains and that sex differences in status criteria would exist in domains where components of relationship value differed for men and women across our evolutionary history data from 14 countries on the statusimpacts of a multitude of acts characteristics and events provide preliminary support for our theory of human status criteria status criteria shared by men and women at the core of human status criteria is a set of traits that would have been valuable in both men and women across the ancestral social landscape being healthy having strong kin alliances and embodying characteristics generally valuable across relationship domainssuch as trustworthiness willingness to share resources with others and having a wide range of knowledgeare central to the status of both men and women among their peers these qualities render both men and women valuable as mates as dyadic allies as kin members and as coalition membersand apparently do so for men and women equally the only nontrivial sex difference we observed across the set of content clusters that we predicted to be the same for men and women was retaliating after an insult results showed that this act is not as beneficial to womens status as mens in hindsight this difference makes sense on nisbetts theory of the role of violence in honor he hypothesized that men who failed to respond with strong retaliation after public insult would suffer large blows to their status particularly among men living in ecological conditions in which reputation for retaliation deterred other men from encroaching on critical and purloinable resources future work could test predictions from this hypothesis by studying the status impacts of retaliation in cultures that vary in these ecological conditions such as contrasting herding cultures with agrarian cultures cultures with weak versus strong systems of law enforcement and so on aside from this sole sex difference that we failed to predict a priori the numerous status criteria that are not sexdifferentiated reflect the broad array of adaptive problems and components of social value largely shared by men and women sexdifferentiated status criteria we now turn to domains in which we hypothesized that adaptive challenges and components of social value would have differed somewhat for men and women across our evolutionary history therefore leading to sexdifferentiated status criteria consistent with our hypotheses womens status differentially hinged on both physical attractiveness and domestic skills although our results show that physical attractiveness is important to the status of both men and women physical attractiveness had a greater effect on womens status in accordance with the hypothesis that ancestral womens value across relationships would have been somewhat more dependent on physical attractiveness than that of mens in contrast mens status centered on specific components of coalitional value such as athleticism bravery physical formidability and aspects of leadership which by hypothesis was relatively less central to ancestral womens relationship value we also predicted that mens status would be more dependent on wealth industriousness education and career success than womens because ancestral mens value across relationship domains would have been at least partially dependent on resource acquisition abilities however we found no sex differences in these domains with the sole exception of hunting skills the reason for this is not immediately clear as it is well established that economic resources are more central to mens than to womens mate valuea finding robust across several largescale crosscultural studies perhaps our reasoning about this domain was flawed and we should not have expected sex differences across such a broad array of resource acquisition abilities after all any person who could reliably access resources would be valuable across many domainsregardless of their sex considering these findings this hypothesis should be revised to expect sex differences only in the specific types of resource acquisition that would have made a larger impact on the value of ancestral men than women such as the robust sex difference in the impact of hunting ability alternatively it is possible that resource acquisition abilities broadly construed have a more significant impact on the relative status of men and women in realworld situations involving mate selection than would be suggested by subjects responses to the items in our study future research will need to test this revised hypothesis more explicitly sexual strategies and status we found support for the prediction that sexual strategies are associated with status for both men and women aspects of mens sexual strategy such as securing shortterm mating opportunities being generous to potential mates and attracting young fertile mates were indeed more central to mens status than womens status contrary to predictions we did not find sex differences in the status impacts of having a faithful mate or forgiving infidelity both were predicted to affect mens status more than womens status based on the stronger selection pressures that cuckoldry has exerted on mens fitness the impacts of sexual strategy on womens status in contrast center on criteria reflecting chastity purity fidelity and lack of promiscuity these differences in the impacts of sexual strategy on the status of men and women closely mirror the sexspecific criteria that are desired in potential mates men and women who embodied these criteria could have used their resulting status to further their preferred sexual strategies which likely upregulates selfesteem and further increases ability to pursue preferred sexual strategies masculinity and femininity the large sex differences in the impacts of acting masculine and feminine found in our exploratory analyses deserve further consideration for three reasonsbecause they were not predicted by our model because they appear to have profound status consequences and because they show the largest sexdifferentiated status consequences in the entire 14nation study prior research has found that masculine traits include assertive forceful has leadership abilities is willing to take risks dominant and has a strong personality and feminine traits include affectionate sympathetic sensitive to the needs of others understanding compassionate warm tender and gentle other research has found that both masculine and feminine traits can have positive groupbeneficial qualities as well as negative groupharmful qualities for example the negative aspects of masculinity include making decisions without consulting others involved in them ridiculing someone in the presence of the group and instructing others to perform menial tasks rather than doing them oneself negative aspects of femininity include walking out of a store knowing one has been shortchanged without saying anything tolerating an insult without retorting and agreeing that i was wrong even though i wasnt it appears that participants folk concepts track more closely the positive aspects of masculinity and femininity than the negative aspects because both are associated with higher sexspecific status theoretical implications and future directions taken together these findings offer evidence that manifest human status criteria reflect evolved mechanisms designed to assess and order conspecifics according to sexspecific fitness affordances manifest status is a combination of all the numerous acts characteristics and events that we have examined here and undoubtedly many that we have not examined the sex differences in status criteria ranging from small to medium in effect size have substantial practical and theoretical implications that offer many potential directions for future study across psychological research evolutionary implications the differences in the impacts of a given attribute or ability for men and women quickly compound over human evolutionary history these small effects would have had profound fitness consequences for example men who achieved high status by virtue of their value as a coalition member and as a potential mate would have been preferentially sought out by desirable coalitions and desirable matessomething known to occur in many cultures for example among ache men who attain status from their hunting skills similarly women who achieved high status by virtue of their value in different relationships or alliances would have been preferentially sought would have obtained more valuable mates and would have possessed social capital beneficial to kin and offspring over evolutionary time these differences would have created and sustained selection pressures that further maintained the patterns of behavior values attitudes thoughts feelings and cultural norms and status criteria present in modern human cultures of course we are not denying that culture can either amplify or diminish the magnitude of such sex differences through socialization nor are we denying that various cultures provide distinct kinds of opportunities for the development and expression of these sex differences however by positing that these sex differences are rooted in evolutionary processes can we explain the fact that such differences appear to be culturally universal the available evidence suggests that these phenomena cannot be explained solely in terms of the arbitrary social creation and enforcement norms and values imposed by one dominant group whatever our attitudes may be toward such norms and values evolutionary biological analyses are crucial to a full understanding of their origins mismatches between ancestral and modern environments there exist known mismatches between ancestral and modern environments the underlying mechanisms that evaluate social value and drive status criteria therefore do not necessarily reflect reliable differences in social value in the modern world for example physical formidability may have been critical to ancestral male coalitions that required feats of strength and psychological bravery to prevail in smallgroup warfare or largegame hunting the fact that we found that these qualities continue to contribute to mens status may reflect one such mismatch in the modern environment aside from delimited athletic contests there is no evidence that physical formidability directly contributes to the success of coalitions in business settings university settings or among teams of computer programmers on the other hand formidability and bravery may continue to be relevant social assets in protecting kin mates and friends from physical assault or sexual assault for example as implied by the bodyguard hypothesis future research is needed to identify which status criteria continue to contribute to social value and which are archaic vestiges of adaptive problems no longer relevant in modern environments another interesting direction would be to study whether and how certain behaviors that were statusenhancing in our ancestral past are now maladaptive for example mens participation in violent coalitional contests may have been adaptive in the ancestral past as way to display bravery and physical prowess and ultimately increase their statusselecting for motivations in young men to pursue those activities in many modern cultures these motivations might lead young men to engage in activities that have negative social consequences no longer increase status reduce the chances of attracting a mate or are otherwise detrimental to fitness for instance the growing body of research suggesting that the disproportionate amount of time young men invest in violent multiplayer video games lowers their physical fitness economic prospects and attractiveness to women provides some evidence of a potential mismatch between evolved status criteria and the modern world levels of abstraction the current conceptual framework and limited empirical research partially elides a key issue levels of abstraction in status criteria looking across cultures one culture might value hunting ability another a medical degree and a third entrepreneurial achievement at a higher level of abstraction however these seemingly diverse status criteria may simply embody traits or skills relevant to the generation or acquisition of socially valued benefits within a specific cultural context similarly those in canada might esteem hockey ability those in europe soccer skill and indigenous amazonians success in chestpounding duals but at a higher level of abstraction all are components of athletic prowess or formidability what appears at lowerorder levels to be culturally variable status criteria may in fact be universal status criteria at a higher level of abstraction deciding the appropriate level of abstraction will therefore be critical in accurately understanding cultural variability in status criteria future theoretical and empirical work will need to address this complicated and perhaps only somewhat tractable issue of mapping culturally specific status criteria at the correct level of abstraction conceptualizations of status there are several conceptualizations of hierarchical rank in the literature for example theoretical distinctions are made between power rank dominancebased status prestigebased status reputational regard and status broadly conceptualized these distinctions are actively debated in this preliminary investigation we adopted a relatively broad conceptualization of status as a component of hierarchical rank based on respect and reputational regard interesting differences in the centrality of certain criteria may arise using alternative conceptualizations of status a critical direction for future research will be to empirically examine differences in the weight given to different criteria under different theoretical conceptualizations such investigations may help to distinguish empirically between overlapping status constructs and address definitional issues perspectival shifts in status criteria status criteria exist in the eyes of the beholder or perhaps more precisely in the adaptations of the beholder just as individuals value changes depending on who they are being evaluated by and the purpose for which the evaluation is made so too should the criteria used to allocate and assess status therefore status criteria should predictably shift according to characteristics of the individual doing the evaluating such as their age their relationship to the referent their own physical characteristics and abilities and their own status family members for instance might place greater weight on a womans fertility and reproductive success when evaluating her status than will a potential samesex friend who is evaluating her as a reciprocal exchange partner because reproductive potential is more closely tied to kin value than to a reciprocal exchange partner similarly a mans coalitional allies may place greater weight on his bravery and willingness to take risks for the group than does his mate for whom those risks may imperil the survivorship of her partner and coparent ecological shifts future research should examine ecological shifts in status criteria where ecology includes both the physical and cultural environment different physical and cultural environments select for different skills and traits to be valued status criteria should shift accordingly in environments with high parasite loads for instance attractiveness health and caretaking skills may be especially valued and should consequently be weighted more heavily in status assessments likewise hunting ability should be weighted more heavily in environments in which largegame cooperative hunting is common or in which hunting returns are extremely variable than in environments characterized by smallgame hunting fishing or greater dependence on horticulture other important ecological factors will need to be examined such as extant sex ratio which could lead to status criteria being more important for the sex that is overrepresented in the mating market gender egalitarianism of the culture under investigation which could reduce sex differences in status criteria for some domains such as domestic skills and history of warfare which might influence the weight placed on characteristics relevant to mens coalition value in assessing status a critical future direction will be to explicitly examine the ecological variables that predict shifts in specific status criteria which will require a larger and more diverse sampling from cultures than we secured for this initial investigation although our 14nation study covers a diverse range of countries and cultures there are many interesting and diverse populations that remain understudied future research should sample even more countries and cultures to afford a more holistic assessment of the nuances in status criteria across ecologies and cultures for example comparisons could be made between broad cultural characteristics such as individualistic and collectivistic cultures weirdness and between dignity and honor cultures as well as more comparisons of status criteria between racial groups within countries and between rural and nonrural populations the ontogeny of status criteria status criteria undoubtedly have sextypical ontogeny curves adolescents males for example are generally regarded as lower in status than mature malesat least by women seeking longterm mates adolescent females in contrast accrue status in many cultures for their value as potential mates the status accorded to older people varies across cultures depending on their culturespecific value to kin and coalitions in cultures in which older people command valuable political resources or valuable information such as among the tiwi of northern australia they would be predicted to be highly valued the status ontogeny curves for men and women are also predicted to be different in part because of age differences in the components of sexdifferentiated social value and because of the variance linked with these components a womans mate valuewhich we have shown is central to her statusis highly influenced by her reproductive value which declines sharply with age a mans mate value on the other hand is more influenced by hunting skills which typically peak somewhere between the midto late30s in western societies financial income peaks between the mid30s and mid50s thus our theory predicts sexspecific ontogeny curves for status with mens generally peaking later than womens mens resource accrual trajectories are also more variable than womens reproductive value trajectories consequently chronological age should be a stronger predictor of womens status than mens status the ratings of status impacts in the current study were provided by relatively young samples of convenience consequently our findings may generalize better to populations of similarly aged individuals than to older populations future research should sample a broader range of ages and examine agerelated shifts in status criteria explicitly conclusion the current investigation is the first to examine the specific criteria by which humans evaluate and accord status crossnationally our theoretical model suggests that human status criteria reflect a complex mixture of evolutionary environmental and cultural forces our findings highlight the myriad criteria central to both men and women as well as those that are sexdifferentiated future research is needed to further examine the complicated array of factors that led to the evolution and maintenance of numerous and specific human status criteria and the multitudes of adaptations that have evolved to navigate the complexities of status hierarchies

social status is a central and universal feature of our highly social species reproductively relevant resources including food territory mating opportunities powerful coalitional alliances and groupprovided health care flow to those high in status and trickle only slowly to those low in status despite its importance and centrality to human social group living the scientific understanding of status contains a large gap in knowledgethe precise criteria by which individuals are accorded high or low status in the eyes of their group members it is not known whether there exist universal status criteria nor the degree to which status criteria vary across cultures also unknown is whether status criteria are sex differentiated and the degree of crosscultural variability and consistency of sexdifferentiated status criteria the current paper investigates status criteria across 14 countries n 2751 results provide the first systematic documentation of potentially universal and sexdifferentiated status criteria discussion outlines important next steps in understanding the psychology of status

focus on daughters rather than sons because women tend to form their first families at earlier ages and report higher quality retrospective data on family formation events our analysis incorporates the following familyoforigin types continuously married parents with nondistressed relationships continuously married parents with distressed relationships single divorced parents remarried parents with nondistressed relationships and remarried parents with distressed relationships combining information on relationship distress and family structure makes it possible to parse the estimated effects of distress from those of divorce and remarriage we also assess the mediating roles of several theoretically relevant factors parents economic resources parental warmth the perceived quality of the family environment adolescents attitudes adolescents school success and adolescents psychological wellbeing previous studies many studies indicate that childhood family structure has implications for young adults family formation transitions youth with divorced single parents are more likely than those with continuously married parents to engage in nonmarital cohabitation and to have nonmarital births these studies provide consistent evidence that parental divorce is linked with an increased likelihood that youth will adopt nontraditional family behaviors research on offspring marriage is mixed some studies suggest that parental divorce increases the odds of marriage other studies suggest that parental divorce decreases the odds of marriage and yet other studies find no association between parental divorce and marriage these discrepancies may exist because most studies in this literature have not distinguished between early marriages and later marriages wolfinger directly addressed the timing issue and found that parental divorce was associated with an increased likelihood of marriage among teenagers in contrast youth with divorced parents who remained single beyond age 20 were disproportionately likely to avoid wedlock few studies have considered whether parental divorce is related to marital births although cherlin kiernan and chaselandale found no evidence for this notion although parental divorce appears to increase the likelihood of forming nontraditional families the evidence is less clear that childhood family structure has implications for forming traditional families only a few studies have considered how parental remarriage might affect young adults family formation transitions some research suggests that living with a stepparent has few implications for cohabitation and nonmarital births beyond the estimated effects of divorce in contrast other studies suggest that parental remarriage increases the likelihood that youth will form cohabiting relationships and early marriages these latter findings suggest a modeling interpretation that is parents who remarry convey the belief that marriage is a desirable status despite a previously unsuccessful union nevertheless the number of existing studies is too small to reach clear conclusions few studies of family formation transitions have focused on parents marital quality one exception is a study by amato and booth which found that parents divorce proneness was associated with nonmarital cohabitation among offspring even in the absence of parental divorce another study by musick and meier found that marital conflict predicted offsprings likelihood of having a nonmarital birth the general lack of attention to this issue is probably due to the fact that most data sets do not contain information on parents marital quality when children were living at home conceptual perspectives three broad perspectives underlie our thinking about how childhood family structure might be related to daughters traditional or nontraditional family transitions although these explanatory perspectives are not mutually exclusive they emphasize different variables and social processes an economic deprivation perspective focuses on the fact that most single mothers have a low level of financial resources due to the loss of economies of scale associated with splitting one household into two and the lower earnings of mothers compared with fathers a lack of economic resources makes it difficult for single parents to afford goods and services that facilitate childrens school successsuch as computers travel and special lessonsand to provide financial support for higher education because many daughters from disadvantaged families have low expectations for higher education they tend to begin their families at relatively early ages in contrast daughters from economically advantaged families tend to delay family formation until they have completed college although most young women from lowincome families of origin want to marry many believe that attaining economic security is a prerequisite to marriage disadvantaged youth also may believe that the economic returns to marriage are minimal if most available partners in their social networks also are disadvantaged because an economically secure marriage seems out of reach daughters from lowincome families tend to form cohabiting unions and bear children outside of marriage as an alternative parental remarriage however generally improves the financial situations of mothers and their children substantially for this reason young women with remarried parents may be more likely than those with single parents to obtain education beyond high school and avoid early family transitions a focus on economic resources suggests the following hypotheses daughters with divorced single parents are especially likely to form nontraditional families early in the life course and correspondingly less likely to form traditional families daughters with remarried parents exhibit patterns of family formation comparable to daughters with continuously married parents the associations between living with single parents and forming nontraditional families are mediated by parents household income parents perceived economic stress and adolescents school success a modeling perspective assumes that girls living in nontraditional households adopt nontraditional views about family life their parents have demonstrated that union dissolution is an acceptable solution to an unsatisfying relationship moreover most children in singleparent families have opportunities to observe their parents engage in dating and perhaps covert sexual behavior through observational learning and identification with parents daughters are likely to adopt many of their parents attitudes and behaviors consistent with this assumption studies show that young adults with single parents tend to hold nontraditional attitudes about nonmarital sex cohabitation nonmarital births and divorce attitudes about sex and family life in turn are good predictors of early sexual activity cohabitation and nonmarital births this perspective suggests the following hypotheses young women with single or remarried parents are more likely than other young women to form nontraditional families early in the life course and correspondingly less likely to form traditional families these associations are mediated by daughters nontraditional attitudes an escape from stress perspective focuses on the level of stress associated with various family arrangements studies show that single parents spend less time with their children are less emotionally supportive dispense harsher discipline and report more conflict with their children than do continuously married parents presumably these deficits in parenting result from the stress of union disruption the strains of solo parenting and trying to make ends meet on a restricted budget other studies show that marital distress in twoparent families is associated with comparable deficits in parenting with respect to stepfamilies tension between children and stepparents is not uncommonespecially during adolescence stepfamily life is especially stressful for children when parents and stepparents have poor marital relationships irrespective of family structure tension in the family of origin is associated with lower ratings of closeness to parents less happiness lower selfesteem and more symptoms of psychological distress among offspring adolescent females living in stressful homes may be motivated to leave their families of origin and establish their own familiestraditional as well as nontraditionalrelatively early in the life course marriage and cohabitation both represent opportunities to escape from unhappy family environments and find emotional support and intimacy else where similarly nonmarital as well as marital births can provide mothers with a sense of meaning and purpose in life the decision to embark on a traditional or nontraditional pathway may depend on a variety of contingencies including whether suitable marriage partners are available consistent with this assumption amato et al found that adolescent females with weak emotional ties to parents or low levels of psychological wellbeing were especially likely to cohabit have nonmarital births marry and have marital births at early ages this perspective suggests the following hypotheses daughters with divorced single parents continuously married parents with distressed relationships and remarried parents are at risk of making early family transitionsnontraditional as well as traditional daughters with remarried parents are especially likely to engage in early family formation given that they have experienced a larger number of familyoforigin transitions living with remarried parents with distressed relationships is the most aversive home environment and hence most strongly associated with early family formation these associations are mediated by adolescents relationships with parents perceptions of the family environment and psychological wellbeing few studies have considered the longterm demographic consequences of growing up with two continuously married parents with a distressed relationship nevertheless compared with children from lowconflict households children from highconflict households tend to have weaker ties to parents more liberal attitudes toward divorce and lower levels of psychological wellbeing these findings raise the possibility that the estimated effects of union disruption on childrens family formation transitions are due to the relationship distress that frequently precedes disruption the current study addresses this commonly proposed selection factor by comparing daughters with continuously married parents with low and high levels of distress methods sample this analysis utilizeddata from the national longitudinal study of adolescent healtha nationally representative longitudinal dataset of over 20000 adolescents and young adults inhome interviews with adolescents were completed in 19945 1996 and 20012 a parent or parent figure also was interviewed in wave i we focus exclusively on young womens family formation transitions for two reasons first women tend to make family formation transitions earlier than do mena trend confirmed in preliminary analyses of these data because the statistical power of event history analysis depends on the number of observed transitions statistical power is lower for men than for women in this data set research also indicates that men underreport nonmarital births and currently single or remarried men underreport marital births that occurred in first marriages consequently the amount of measurement error for parenthood is higher for men than for women several sequential sample selections were made youth were selected if they completed a wave i and wave iii interview and had a parent who completed a wave i interview next the oldest portion of the cohort was selected we took this step because younger adolescents could experience parental divorce or remarriage after the wave i interview but before reaching age 16 which would make our assignment of these cases to family types inaccurate to ensure the correct time ordering of variables we omitted 903 adolescents who reported cohabiting marrying or having a nonmarital birth prior to wave i adolescents had to be living with continuously married biological parents divorced single parents or remarried parents adolescents with cohabiting parents were excluded from the analysis cases also were dropped if they were missing values on the sample weight after dropping sons from the analysis the final analytic sample consisted of 2461 daughters independent variables we relied on a constructed variable available in the add health data set along with information on the interviewed parents marital status to define family structure in wave i at this time 1647 daughters were living with two continuously married parents 402 were living with a divorced or separated single mother 59 were living with a divorced or separated single father 292 were living with a remarried parent with a lowdistress relationship and 61 were living with a remarried parent with a highdistress relationship preliminary analyses found no significant differences between daughters living with single mothers and single fathers so we combined these two groups in subsequent analyses information on relationship distress was obtained from the wave i parent interview most studies of marital quality have focused on positive as well as negative dimensions with the most commonly used measures being marital happiness and marital conflict respectively to incorporate both dimensions we relied on two questions from the parent interview on a scale from 1 to 10 how would you rate your relationship with your spouse and how much do you fight or argue with your spouse the distressed group consisted of parents who provided a rating of 7 or less on the happiness item and 1or 2 on the conflict item that is the distressed group reported a relatively low level of happiness and a relatively high level of conflict this procedure yielded 432parents or 22 of all married parentsa figure that corresponds to other studies for example a taxonomic analysis by beach fincham amir and leonard found that 20 of married couples fell into a high discord category and a latent class analysis by dush taylor and kroeger found that 22 of married individuals fell into a low marital quality category because parents were not interviewed in subsequent waves distress was measured on a single occasion this is not a serious problem however because many dimensions of marital quality are remarkably constant over time for example johnson amaloza and booth found correlations of 57 and 54 for measures of marital happiness and conflict over an eightyear period when they used structural equation methods to account for measurement error the respective correlations were 85 and 77 for most couples relationship quality changes only modestly even over long stretches of time dependent variables family formation transitions were based on detailed relationship history information collected from daughters in wave iii questions asked whether respondents had ever married lived with someone in a marriagelike relationship and had births within or outside of these relationships followup questions addressed the month and year in which these events took place when the respondent reported a union but did not provide information on when it occurred we imputed the date according to the median value for respondents of the same age imputation was necessary for only a small number of cases when information on births was missing we relied on syntax created by schoen landale and daniels to impute dates overall first unions involved 1078 cohabitations and 396marriages and first births involved477 nonmarital and 256marital events mediating variables during the wave i interview parents provided information on total household income we used a log transformation of this variable to reduce skewness parents also responded to the following question do you have enough money to pay your bills we reverse coded this item to represent perceptions of economic hardship the other mediating variables were constructed from the wave i interviews with adolescents we assessed maternal and paternal warmth with seven questions including how close do you feel to your mother father and how much do you think she he cares about you scores on these variables were based on the first component from a principal components analysis of the items theta is the appropriate reliability coefficient for a scale in which items have been weighted to maximize internal consistency theta reliability coefficients were 86 for mothers and 89 for fathers the two parental warmth variables were weakly correlated a positive family environment was based on five items how much you feel your parents care about you people in your family understand you you want to leave home you and your family have fun together and your family pays attention to you the first component from a principal components analysis served as the scale score two variables were created to assess nontraditional attitudes a measure of nontraditional attitudes towards sex was based on ten items including if you had sex it would upset your momdad and if you had sexual intercourse it would make you more attractive to the opposite sex correspondingly a measure of nontraditional attitudes towards pregnancy was based on seven items including getting pregnant at this time in your life is one of the worst things that could happen to you and it wouldnt be all that bad if you got pregnant at this time in your life theta reliability coefficients were 79 for attitudes toward sex and 64for attitudes toward pregnancy responses for both measures were scored so that high values reflected nontraditional attitudes the two attitude variables were moderately correlated previous researchers have these items to create similar attitude scales school success involved two variables school adjustment included four items dealing with how frequently adolescents had trouble getting along with teachers paying attention in school getting homework done and getting along with other students the second measure was the mean of reported grades in math english historysocial sciences and science which were reverse coded for both measures higher values indicated greater school success the two variables were moderately correlated two measures of psychological wellbeing were available selfesteem was based on four items you have a lot of good qualities you have a lot to be proud of you like yourself just the way you are and you feel like you are doing everything just about right depressive symptomology was based on 19items that dealt with how often during the previous week the adolescent reported feelings depressed too tired to do things sad and so on items were scored so that high scores represented high levels of selfesteem and depression the two wellbeing variables were moderately correlated control variables control variables included offsprings age and race we also included the gender of the interviewed parent whether the interviewed parent was born outside of the united states the age at which the interviewed parent married for the first time the frequency of the interviewed parents attendance at religious services during the previous year and the interviewed parents education we included these variables because they could be correlated with family type during adolescence as well as daughters early family formation transitions analysis we relied on discretetime event history analysis we treated cohabitation and marriage as competing risks so the outcome reflected first union transitions we created a personyear file that included information for each year of age between the wave i and wave iii interviews respondents were censored from the data file after they had cohabited married or reached the wave iii interview without forming any unions the second personyear file treated nonmarital births and marital births as competing risks respondents were censored from the data file after they reported either type of birth or reached the wave iii interview without become parents multinomial logistic regression in stata was utilized to estimate these models all analyses were adjusted for the sample design as well as weighting to produce the correct standard errors for significance testing because the amount of missing data was low we used a single imputation to replace all missing values household income was the one exception with 11 missing data consequently we created an imputation flag for each case and included this variable in all analyses involving income the imputation variable was never significant however and we do not report it in the tables as noted earlier a primary goal was to assess the extent to which multiple explanatory variables mediate the associations between familyoforigin type and demographic outcomes in early adulthood to assess mediation we relied on the classic formulation of baron and kenny that is a mediating variable must be significantly associated with the independent as well as the dependent variable and the b coefficient for the independent variable must decline substantially after including the mediator in the equation instead of b coefficients however we relied on relative risk ratios rrrs are appealing because they involve probabilities and most individuals find probabilities to be easier to understand than logits we assumed that a 20 reduction in rrrs between models is large enough to be substantively significanta criterion often adopted in public health research attrition because some cases dropped out of the sample between waves i and iii we performed an attrition analyses using logistic regression and all variables described earlier although several variables were significant predictors of attrition a logistic regression model successfully predicted less than 5 of excluded cases this result is consistent with studies showing that most sample attrition is random and has relatively modest consequences for estimates of population parameters results descriptives table 1 shows means and standard errors for all control and mediating variables by family type the final column indicates whether the overall differences across groups were significant with respect to the control variables the average age of respondents in wave iii was about 23in all family types the proportion of black adolescents was elevated in the single parent group the proportions in other racial and ethnic categories varied modestly across family types mothers were usually the interviewed parent although the proportion of mothers was somewhat lower in singleparent families because fathers were sometimes the custodial parent the level of parental education was between 5 and 6 in all groups which is equivalent to graduating from high school or obtaining a ged respectively immigrant parents were over represented in families with continuously married parents parental age at first marriage showed little variation across groups parents religious attendance was highest among continuously married parents with lowdistress relationships and lowest among single parents and remarried parents with highdistress relationships because the scale of measurement was arbitrary for most of the explanatory variables these variables were standardized to have means of 0 and standard deviations of 1 to facilitate subsequent interpretation single parents reported the lowest level of household income and the most difficulty paying bills maternal and paternal warmth were highest among adolescents living with continuously married parents with lowdistress relationships paternal warmth in particular was comparatively low among adolescents living with a single parent and a positive family environment was especially low among adolescents living with remarried parents with highdistress relationships adolescents living with continuously married parents had the most conventional attitudes school adjustment and grades were highest among adolescents with continuously married parents finally adolescents had the highest level of selfesteem and the lowest level of depression when they lived with continuously married parents with lowdistress relationships these results are generally consistent with prior research additional ttests revealed that adolescents with continuously married parents with a highdistress relationship compared with adolescents with continuously married parents with a lowdistress relationship reported significantly less maternal warmth less paternal warmth less positive family environments and lower selfesteem given that reports of marital distress came from parents and reports of explanatory variables came from adolescents these findings support the construct validity of our measure of marital distress union formationamong daughters we begin by presenting the results for nonmarital cohabitation and marriage tables 2a and2b show the rrrs from a multinomial discretetime event history model in which nonmarital cohabitation and marriage were treated as competing risks women who did not transition to a coresidential union served as the omitted reference group model 1 in table 2a indicates that the risk of cohabitation was no higher for daughters living with continuously married parents with distressed relationships than for daughters living with continuously married parents with nondistressed relationships in contrast living with a single parent was associated with a 47 increase in the risk of cohabitation between waves i and iii 100 similarly living with a remarried parent was associated with a 104 increase in the risk of cohabitation when the relationship was not distressed and a 212 increase when the relationship was distressed although not shown in the table the risk of cohabitation was significantly higher for daughters with single parents or remarried parents than for daughters with continuously married parents with highdistress relationships the rrr for the single parents was marginally lower than the rrr for lowdistress remarried parents and significantly lower than the rrr for highdistress remarried parents the two remarried groups did not differ from each other these findings indicate that the risk of cohabitation was elevated when offspring lived with a single parent and even higher when offspring lived in a stepfamily models 27 introduce the explanatory variables in model 2 parents income and difficulty paying bills were not associated with cohabitation in model 3 positive family environment was negatively associated with cohabitation although maternal and paternal warmth were not significant model 4shows that positive attitudes toward pregnancy and sexual behavior were positively associated with cohabitation model 5 indicates that school grades and school adjustment were both negatively associated with cohabitation model 6 reveals that selfesteem was negatively associated with cohabitation and depression was positively associated with cohabitation finally model 7 includes all of the mediators taken together these variables reduced the rrr for living with a single parent by 96 for living with a remarried parent with a lowdistress relationship by 35 and for living with a remarried parent with a highdistress relationship by 29 these declines meet our 20 criterion for a substantively important mediation in the final model adolescents ratings of the home environment attitudes and school grades continued to be significant predictors of cohabitation whereas maternal warmth paternal warmth school adjustment selfesteem and depression were no longer significant as noted in table 2 family environment the two attitude variables and school grades were significantly associated with all family types involving union disruption these three variables therefore met all the criteria for mediation table 2b shows the results of the multinomial logistic regression analysis for marriage in model 1 only living with remarried parents with highdistress relationships was a significant predictor of marriage additional analyses indicated the rrr for living with remarried parents with highdistress relationships was significantly different from every other family type with the exception of living with remarried parents with lowdistress relationships in subsequent models parental income and adolescents attitude toward sex were negatively associated with marriage whereas attitude toward pregnancy and school adjustment was positively associated with marriage the rrr for living with a remarried parent with a highdistress relationship declined by only 6 between models 1 and 7 which does not meet our criterion for mediation in other words the explanatory variables cannot account for the association between living with a remarried parent with a highdistress relationship and early marriage among daughters nonmarital and marital birthsamong daughters tables 4a and4b show that the results of the multinomial event history analysis for nonmarital and marital births which were treated as competing risks model 1 in table 3 areveals that the risk of having a nonmarital birth between waves i and iii was not significantly greater for daughters living with two parents in highdistress marriages than for daughters living with two parents in lowdistress marriages in contrast living with a single parent was associated with a 132 increase in the risk of having a nonmarital birth similarly living with a remarried parent with a low distress relationship was associated with a 97 increase in risk and living with a remarried parent with a high distress relationship was associated with a 352 increase in risk rotating the omitted group revealed that the differences between daughters with single parents and those with remarried parents irrespective of distress were not significant the coefficient for remarried parents with distressed relationships however was significantly larger than the coefficient for remarried parents with nondistressed relationships taken together these results indicate that parental union disruption is a better predictor of nonmarital births than is marital distress among continuously married parents irrespective of whether custodial parents remarry these results also indicate however that the risk of having a nonmarital birth is highest among daughters living with a remarried parent with a distressed relationship marital distress appears to make a difference but only in remarriages in model 2 parents income was negatively related to having a nonmarital birth model 3 shows that maternal warmth paternal warmth and family environment were not significant predictors model 4reveals that nontraditional views about having sex and pregnancy were both positively associated with nonmarital births model 5shows that daughters who obtained higher grades were less likely than other daughters to have nonmarital births model 6 indicates that scores on the depression measure were positively associated with nonmarital births finally in model 7 parents income adolescents attitudes toward pregnancy and sex school grades and depression all continued to be significant predictors selfesteem also attained significance in the full model moreover although not shown in the table all of these mediating variables were associated with living with a single parent or a remarried parent comparing model 7 with model 1 reveals that the explanatory variables reduced the rrr for living with a single parent by 62 and the remaining coefficient was only marginally significant correspondingly the rrrs declined by 39 for living with are married parent with a lowdistress relationship but by only 11 for living with a remarried parent with a highdistress relationship overall although parents income adolescents attitudes adolescents school grades and adolescents psychological wellbeing accounted for some of the associations in model 1 these factors were least successful in accounting for associations involving highdistress parental remarriages with respect to marital births model 1 in table 3b shows that daughters living with a remarried parent with a highdistress relationship were more likely than daughters living with continuously married parents with lowdistress relationships to have a marital birth in subsequent models parents income difficulty paying bills the quality of the family environment and school grades were negatively associated with marital births a nontraditional attitude toward pregnancy was positively associated with marital births as was school adjustment in the final model changes in the rrr for daughters from highdistress stepfamilies were modest across all models however with little evidence of mediation discussion the current study replicates previous research showing that parental divorce is positively associated with daughters nonmarital cohabitations and nonmarital births irrespective of whether resident parents remarry as noted earlier studies of early marriage have yielded contradictory results with some suggesting that parental divorce increases the odds of marriage and other studies suggesting the opposite the present study found that parental divorce did not increase the risk of early marriage except when daughters lived with remarried parents with highdistress relationships given the contradictory findings in the literature more studies are necessary to reach a firm conclusion about this issue our results are similar to those of cherlin et al in suggesting that parental divorce does not increase the risk of marital births in general although this does occur among daughters living with remarried parents with highdistress relationships a major goal of the current study was to assess three general conceptual perspectives on the links between family structure and daughters subsequent family formation transitions the economic deprivation perspective assumes that living with single parents increases the likelihood of nontraditional transitions and that these links are mediated primarily by parents household income perceptions of economic hardship and offsprings school success consistent with this perspective parents household income appeared to lower the risk of nonmarital births contrary to this perspective however cohabitation and nonmarital births were elevated among daughters living with remarried parents despite the fact that remarried parents had incomes comparable to those of continuously married parents moreover income mediated little of the estimated effect of parental remarriage on cohabitation and nonmarital births and household income and parents perceptions of hardship were not associated with cohabitation in general our analyses provide little support for the notion that economic deprivation leads daughters with single parents to adopt nontraditional family forms the second conceptual perspective focused on modeling and social learning this perspective assumes that transitions to nontraditional family formation are elevated among youth with single parents and remarried parents given that both groups of parents have modeled disruption as a solution to an unsatisfying relationship moreover this perspective assumes that adolescents attitudes mediate the associations between parental union disruption and offsprings nontraditional transitions the results for cohabitation and nonmarital births generally support this perspective adolescents attitudes were significant predictors of nonmarital cohabitation and childbearing and attitudes partly mediated the associations between parental divorce and offsprings nontraditional transitions presumably daughters with unconventional views toward sex and pregnancy are less concerned about the moral implications or stigma associated with cohabitation and nonmarital births than are more conventional daughters finally the escape from stress perspective assumes that living with continuously married parents with high distress relationships as well as living with single or remarried parents increases the likelihood of nontraditional and traditional transitions that is any kind of transition can represent an escape from an aversive home environment and an opportunity to find emotional support and intimacy in ones own family our analyses were not consistent with a key prediction of this perspective the level of distress among continuously married parents was not related to any family formation outcome nevertheless the current study provides partial support for the notion that remarriage increase the risk of all traditional as well as nontraditional transitions the estimated effects of parental remarriage on daughters marriage and marital births however reached significance only when parents had a highdistress relationship because conflicted stepfamilies are the most likely to be aversive home environments the escape from stress perspective is supported this perspective also assumes parental warmth perceptions of the home environment and psychological wellbeing play key mediating roles we found some support for this notion in that perceptions of the home environment selfesteem and depression played mediating roles with respect to nontraditional transitions these variables did not play mediating roles in the analyses of marriage or marital births however overall the support for this perspective was mixed like all studies the current investigation contains several limitations for example our measure of marital distress was limited to only two items measured at a single point in time a broader measure of this construct might have revealed significant associations in addition the sample was relatively young with a mean age of about 23 at wave iii for this reason we were not able to capture family formation transitions that occur at older ages with respect to selection we incorporated two rarely studied groups as well as a variety of control variables that may represent selection factors nevertheless it is probable that unmeasured selection factors affect parental union disruption and remarriage as well as offsprings family formation transitions we also were not able to consider the length of time that youth spent in various family forms nevertheless research shows that marital happiness and conflict tend to be highly stable over long periods of time so it is likely that youth with distressed parents experienced a troubled home environment for many years moreover some studies show that the length of time in a singleparent family is less important than ever living in a singleparent family youth born outside of marriage however are a heterogeneous group with some born to cohabiting parents and others not including this distinctionwas beyond the reach of the current study although future research will no doubt pay closer attention to the life courses of these individuals despite these limitations the present study makes three contributions to the literature first it replicates previous studies suggesting that divorce and remarriage increase the likelihood that daughters will cohabit or have nonmarital births second we show that living with two continuously married parents appears to protect youth from nonmarital cohabitations and births even when the marital relationship is troubled for young womens early family formation decisions having two married parents is more important than the quality of the parents marital relationship these findings suggest that the relationship distress that often precedes union disruption is unlikely to be the cause of subsequent family formation transitions among offspring third our data provide moderately strong support for a perspective based on modeling adolescents with divorced parents are especially likely to adopt unconventional attitudes and adolescents attitudes in turn are good predictors of their decisions to cohabit or have a child outside of marriage we also find some support for the escape from stress perspective that is daughters living in distressed stepfamilies were especially likely to make nontraditional as well as traditional family formation transitions marital distress appeared to affect daughters subsequent transitions only when it occurred in stepfamilies these findings suggest that future research should pay greater attention to stepfamily dynamics when attempting to understand the family formation behaviors of youth more generally our findings suggest the utility of combining information on family structure and family process in understanding childrens life courses

we used data from the add health study to estimate the effects of parents marital status and relationship distress on daughters early family formation transitions outcomes included traditional transitions marriage and marital births and nontraditional transitions cohabitation and nonmarital births relationship distress among continuously married parents was not related to any outcome offspring with single parents and remarried parents had an elevated risk of nonmarital births and nonmarital cohabitation offspring with remarried parents with a highdistress relationship had an elevated risk of early marriages and marital births these results combined with analyses of mediating variables provide the strongest support for a modeling perspective although some support also was found for a perspective based on escape from stress

background interviewer effects can have consequential impacts on survey data particularly for reporting sensitive attitudes and behaviours such as sexual activity and drug use yet these effects remain understudied in lowand middleincome countries the demographic and health surveys present a unique opportunity to study interviewer effects on the selfreport of sensitive topics in lowand middleincome countries by including interviewer characteristics data this paper aims to narrow the gap in research on interviewer effects by studying the effects that age difference between interviewer and respondent and interviewer survey experience have on the reporting of ever having sexual intercourse methods we used dhs data from 91 066 women and 56 336 men in 21 countries where the standard dhs was implemented among all women of reproductive age and interviewer characteristics were included in the data set using a bayesian crossclassified model with random intercepts for interviewer and cluster we assessed whether the effect of an age difference of 10 years or greater was associated with a difference in selfreport of ever having sexual intercourse adjusting for respondent demographics results there was a meaningful association between an age difference of greater than ten years and reporting of ever having had sexual intercourse in most countries for both genders after adjusting for interviewer age and experience rural or urban cluster and individuallevel characteristics among women the marginal posterior probability of reporting ever having sexual intercourse if the interviewer was ten years or more years older was lower for 17 of 19 countries among men the marginal posterior probability was lower for 16 of 20 countries ranging from 1830 to 1710 percentage points conclusions in most countries women and men were less likely to report ever having sexual activity if the interviewer was ten or more years older than them adjusting for potential confounders these findings have important implications for interpreting numerous sexual health indicators such as unmet family planning needs and human immunodeficiency virus acquired immunodeficiency syndrome risk survey administrators may consider more careful interviewerrespondent characteristic matching or novel approaches like audio computer assisted self interview to minimize interviewerinduced variance countries has often been slower to materialize 56 a growing body of research around survey methods suggests that there are opportunities for novel survey administration techniques 35 7 8 9 nevertheless researchers policy makers and public health practitioners will likely rely heavily on interviewer collected survey data for the foreseeable future to develop and target programming especially in lmics it is therefore vital to develop a deeper understanding of the impact of interviewer effects on response accuracy interviewerinduced bias is more likely to occur for sensitive questions such as sexual behaviour and falls into rolerestricted and roleindependent 1011 rolerestricted interviewer effects refer to the introduction of bias as a result of conscious and unconscious interviewer conduct such as reacting to responses probing sensitive questions differently within or between interviewers or modifying questions to reduce workload 612 roleindependent effects result from respondent bias toward interviewers social characteristics such as gender ethnicity age or lack of trust in interviewer and must be observable by the respondent 1013 even with training participants often detect these characteristics and edit their responses as a result 1 it can be difficult to discern whether interviewer effects are rolerestricted or independent but interviewers age education race gender and more characteristics have been associated with nonresponse to questions about sexual behaviour 8 the demographic and health surveys program is one of the most widely cited data sets in lmics it is a gold standard data set for many population statistics particularly where few other similar sources of data may be available since 2015 dhs data sets have included surveyor characteristics which creates an opportunity to study interviewer effects at a global scale 14 the dhs has published two reports on interviewer effects their 2018 report focused on data quality issues like nonresponse time to completion and other general indicators of quality 12 a recent report extended this and found that more sensitive and complicated questions were associated with larger interviewerinduced variance when models considered the crossclassified structure of interviews within communities and interviewers 15 there are few peerreviewed studies of interviewer effects in the dhs leone et al found that variance attributable to interviewers was usually larger than variance attributed to clusters 16 though they called for more research into the specific interviewer characteristics that caused this variance metheny and stephenson found that most interviewer characteristics except for interviewer experience did not significantly affect reporting of intimate partner violence 17 each of these studies were important milestones in studying the dhs and this paper seeks to extend these efforts still further as the first study to investigate specific interviewer characteristics across all dhs countries with available data interviewer effects on the reporting of sexual activity from the dhs does not yet appear in the literature despite calls for research into it 12 because premarital sexual activity is stigmatized in many contexts 18 19 20 it is especially vulnerable to interviewerinduced social desirability bias 2122 it is likely that some interviewer characteristics and how they interact with respondent characteristics may exacerbate the risk of bias for example there is robust evidence in higher income countries and some low income countries that responses about sexual activity can be modified by interviewer and respondent gender 2324 age has also been long identified as a potential source of interviewer effects though age difference is less thoroughly studied 2425 accurate reporting of sexual behaviour is valuable both on its own as an important public health indicator and as a gateway question for other questions and indicators about contraception use and sexual health 26 bias in respondents reporting sexual activity may propagate to other items that are important for assessing other domains of sexual and reproductive health this study aims to determine associations between interviewer characteristics and respondents reporting of ever having sexual intercourse in the dhs using data from 91 066 respondents to the womens and 56 336 respondents to the mens questionnaires across 21 countries all countries respondents and interviewers are gendermatched women are interviewed by female interviewers and men by male interviewers we used dhs survey search tool to identify all current and future standard surveys that included the interviewer characteristics data set we then included all surveys that a used the standard dhs questionnaire b collected data from all women of reproductive age and c included the requisite data to link interviewer characteristics to respondents additionally we excluded data sets where fewer than three percent of nevermarried neverunion respondents reported ever having sexual activity because at dhs sample sizes models failed to converge when reporting was exceptionally rare twentyone dhs countries met the inclusion criteria all male and female respondents who had never been in a marriage or union with complete data were included we excluded respondents who reported ever being married or in a union because essentially all such respondents reported sexual activity although inclusion criteria are nevermarried or in a union we use neverunioned for ease of expression detailed reports of all respondents are available from the dhs program 28 outcome of interest the outcome of interest is whether a neverunioned respondent has reported ever having sexual intercourse this is measured dichotomously with a standard dhs question how old were you when you had sexual intercourse for the very first time one response option of which is never had intercourse explanatory variables we examined all potential interviewerlevel factors to identify those that were a available across all surveys b had any variance between interviewers and c fit theory for factors that could influence reporting of having sexual intercourse ultimately our final model included interviewer age age difference between interviewer and respondent and any previous dhs or other survey experience we hypothesized that the relationship between age difference and probability of reporting sensitive behaviour was not linear and that there is likely a difference at which respondents would perceive an interviewer as older and be more inclined to edit their responses we calculated the difference between interviewer age and respondent age and coded the age difference as fewer than 10 years older and 10 or more years older we also constructed a variable of five or more years older for sensitivity analyses the interviewer characteristics data set also includes information on previous dhs experience and other survey experience collecting data we collapsed this into a single any survey experience variable we also adjusted for several potential confounders respondent age education level wealth index in five quintiles and residence type these variables were included because there is a wellestablished link between these predictors and age at first sexual activity and because of their potential to confound the relationship between the outcome and variables of interest 29 analysis we first performed bayesian simple logistic regression analyses with ever reporting sexual intercourse as the dependent variable for mens and womens questionnaires in each country each model had one independent variable either any previous survey experience wealth index quintiles rural respondent age in years respondent education level interviewer age in years interviewer age difference of 10 or more years interviewer education level and difference in native language between interviewer or respondent native language interviews are nested within interviewers and within sampling clusters thus every cluster has multiple interviewers who also worked across multiple clusters we therefore fit bayesian multilevel crossclassified logistic regression models to analyse the effects of interviewer characteristics on respondent level responses as crossclassified models are conventional for this type of analysis 1115 interviewerspecific intercept was included in the model along with clusterspecific intercepts the inclusion of clusterand interviewerspecific intercepts accounts for potential additional sources of variability induced by the sampling design and controls for a probable scenario where interviewers are assigned to clusters with different latent propensities of reporting ever having sexual activity sampling weights were not used in the present analysis as the research question does not pertain to a population estimate but to the equally weighted interviewerrespondent interaction we also checked for interpenetration of interviewers across clusters to understand the potential for cluster level variance to confound the conclusions prior research suggests that three or more clusters per interviewer would yield sufficient interpenetration for modelling 30 and that interviewer effects often account for more homogenization than sampling or spatial clustering 31 we let y be the probability that respondent i interviewed by interviewer j in cluster k reported ever having intercourse because there is little relevant published literature on our research question in this context we used noninformative priors specifically we placed an improper flat prior over the reals for populationlevel effects for the interviewerand clusterspecific intercepts we placed mean zero normal priors with half studentt3 priors on the standard deviations models for each country and each respondent gender were fitted separately estimates for all models were produced using eight markov chain monte carlo chains with 6000 warmup iterations and 6000 retained posterior samples per chain resulting in 48 000 total posterior samples available for analysis the gelmanrubin potential scale reduction factor was used to assess convergence across chains all covariates across all included models had a potential scale reduction factor sometimes referred to as rhat of 100demonstrating model convergence 32 two key sensitivity analyses were performed first we fitted the models using a halfcauchy distribution for the interviewerand clusterspecific intercept prior standard deviations and results were similar second we changed the interviewerrespondent age difference to five years associations held in most countries with the strength of the association somewhat muted as expected we summarize the results using the median of the posterior samples the middle 95 of the posterior samples and the posterior probability that the difference is greater than zero posterior probabilities close to either zero or one indicate statistical significance 32 because our models estimate odds ratios we also used average marginal effects to convert observed odds ratios into differences in the probability respondents reported sexual activity for interviewers within 10 years and 10 or more years adjusting for potential confounders held at their observed values we did this to reduce the risk that effect sizes would be misinterpreted which is common with odds ratios all bayesian regression analyses were performed using the brms function in r 411 and the posterior package was used for summary statistics of the posterior distributions 33 34 35 we used the brmsmargins command in the brmsmargins package to estimate average marginal effects 3637 results this analysis used data from 21 countries 91 066 women and 56 336 men there were more women 4567 than men included for all countries except ethiopia zambia and zimbabwe where there were more men than women that met inclusion criteria correspondingly there were more unique interviewers for women than for men in all countries except zimbabwe the mean number of womens interviews per interviewer ranged from 2560 in mali to 10640 in rwanda for the mens questionnaire the mean number of interviews per interviewer ranged from 3390 in myanmar to 15360 in haiti among those who were never married there were also intercountry variations in reporting of ever having had sex in most countries more neverunioned men than women reported ever having intercourse among included countries timorleste had the lowest proportion of neverunioned female respondents who reported ever having sexual intercourse followed by the philippines with 15 of neverunioned respondents reporting ever being sexually active liberia had the highest proportion of neverunioned women reporting sexual activity the proportion of neverunioned male respondents who reported ever having intercourse ranged from 1220 in myanmar to 8070 in south africa the majority of included respondents were younger than 25 across contexts in the final model several independent variables are associated with reporting ever having sex among neverunioned respondents in the countries we analysed in all countries respondent age was a critical predictor of reporting ever having sexual intercourse among the covariates that describe interviewer effects an age difference of 10 or more years appears to generally maintain a consistent negative trend † posterior probability that the odds ratio is greater than one constructed as the proportion of posterior samples where the odds are greater than 1 posterior probabilities of exactly 0 or 1 are when no or all samples respectively were above 1 in most countries both women and men are less likely to report ever having sexual intercourse if the interviewer is 10 or more years older than they are adjusting for interviewer age survey experience and respondent age and other demographics we consider a posterior probability of 5 or lower that the coefficient was less than 0 to suggest statistical significance although this is not strictly the same as frequentist statistical significance 32 for female respondents having an interviewer who was 10 or more years older had a significantly negative effect on odds of reporting of ever having sexual activity in benin burundi cameroon ethiopia liberia malawi rwanda sierra leone timorleste uganda south africa and zimbabwe for men the effect was significantly negative in benin cameroon ethiopia the gambia haiti mali malawi myanmar nepal timorleste uganda south africa and zimbabwe in most countries the posterior median for the adjusted odds ratio is lower for men than for women the influence of previous survey experience is less clear similarly rural residency and interviewer age in years do not exhibit a consistent association while living in a rural community does seem to have more influence in some countries than other community and interviewer level variables the direction of the association is inconsistent between countries in seven of 19 womens and nine of 20 mens questionnaires the medians of the posterior adjusted odds suggest a positive relationship between living in a rural community with reporting intercourse all others are negative figure 1 shows the difference in average marginal effect of having an interviewer that is 10 or more years older adjusting for interviewer experience and age respondent characteristics and integrating out interviewerand clusterspecific intercepts the median of the posterior distribution of the average marginal effect contrasts among female respondents ranged from 390 in nigeria to 1250 in zimbabwe excluding zambia an interviewer that is 10 or more years older than the respondent was associated with a difference in the probability of reporting sexual activity from 090 probability in nigeria to 1710 difference probability in south africa the posterior medians of the difference in marginal effects were positive for nigeria and zambia given the vast differences in cultures and settings this is not unexpected and the 95 credible intervals for the male respondents in zambia and female respondents in zambia included zero one outstanding exception is for zambia men where the association is in the opposite direction and has a wide credible interval the coefficient estimate for age difference of 10 or more years is substantially higher when including the random intercept for interviewers discussion to our knowledge this is the first study to leverage the interviewer characteristics across multiple countries across countries and genders included in this analysis respondents are less likely to report ever having had sex when an interviewer is 10 or more years older controlling for respondent characteristics interviewer age experience and cluster level variance the other interviewer characteristic included in this analysis previous survey experience appears to have little association with reporting ever having sexual intercourse in most included countries respondents in nigeria zambia and to the mens questionnaire in guinea were more likely to report ever having sexual activity to people more than 10 years older analyses with future dhs rounds in these and other included countries will shed light on the stability of the observed trends response bias is well established when reporting sexual activity prior to a union in many contexts 5838 where much of the extant literature has focused on nonresponse scholars note that while cooperation is often more likely when interviewers and respondents are alike cooperation does not necessarily imply candor 2512 our findings align with literature from higher income countries that older interviewers elicit more conservative responses to sexual behaviour questions 24 studies have found inconsistencies from even the same respondent across selfreports with differences that vary in directionality and magnitude by gender across contexts 3940 previous research has also identified differences between reporting behaviour of men and women upchurch et al found that both men and women can be inconsistent in their reporting of ever having sexual activity but men were more likely to be inconsistent 41 whereas solerhampejsek et al found that women were more likely to be inconsistent in selfreport 40 mensch et al suggested that boys are more likely to exaggerate their sexual activity 5 the results from the present analysis suggest a more nuanced perspective that this bias is likely to be moderated by external factors including interviewer characteristics particularly age difference between interviewer and respondent these inconsistencies highlight the importance of better understanding interviewer characteristics in relationship to selfreported outcomes validity and reliability the biases we detected from interviewer effects will be transferred across other population metrics which use sexual activity as a numerator or denominator component these include common indicators around use of family planning and human immunodeficiency virus acquired immunodeficiency syndrome prevention behaviour among young or never married segments of the population although we did not examine other outcomes it is plausible that interviewer effects are present in other sensitive outcomes and those who have inconsistent reporting on sexual behaviour are likely to have inconsistent reporting on other measures 4 metheny and stephenson found that previous survey experience influenced reporting of intimate partner violence in zimbabwe 17 and others have detected interviewer effects in the reporting of abortion 1642 this bias may lead to inaccuracies in estimates of the need for interventions among the populations that have the most to gain from such programs population estimates may be improved with protocols that are more sensitive to interviewer effects and with novel collection modes mitigation strategies might include adding age and other characteristics when matching interviewers to respondents where feasible survey administrators may also wish to review interviewer training considering how to minimize rolerestricted bias acasi is another promising tactic to address both roleindependent and rolerestricted interviewer biases acasi has been shown to improve accuracy and reduce interinterviewer variance on sensitive questions in rural and semiliterate settings though it may not be suitable in all contexts 5843 the dhs program may examine how to integrate these modalities in a manner that is accessible across populations there are salient limitations to this analysis although we were able to examine some key background effects there was little information on mediators such as interviewer attitudes beliefs or behaviours this analysis also does not determine what is true for example although underreporting is typically considered to be a greater threat to validity for questions about sexual behaviour 24 it is also plausible that respondents may exaggerate their sexual experience to someone who is within 10 years of age finally key data limitations must be acknowledged several data sets either did not include characteristics for some interviewers or had improperly entered interviewer ids although the proportion of observations in affected data sets was small it is also possible that at the country level models could be improved with the inclusion of variables that we did not include finally upon advice from the dhs team we removed observations where interviewers were misclassified and missingness of individual variables is described in the respondent characteristics finally we note that this research is exploratory in nature while there is sufficient consistency across surveys that the risk of age discrepancyinduced response bias should be taken seriously this research would benefit from replication across contexts in particular because age can be a proxy for other sociodemographic characteristics it would be valuable to extend this analysis with surveys that have more detailed interviewer data than dhs is able to collect we suspect that there may be additional contextual factors that may modify interviewer effects and this is an area rich for future research kianersi et al noted that much of the scholarship on interview effects is now relatively old while attitudes sensitivity and norms are shifting and the public health community should maintain a contemporary understanding of interviewer effects on the reporting of sexual activity 23 future research into the effects of interviewer characteristics on responses to sensitive questions in lmics should be ongoing and focus on improving collection methods better understanding what interviewer characteristics make response editing more likely and reevaluating estimates of indicators that may be vulnerable to interviewer effects the dhs program could facilitate more robust research into interviewerinduced bias by standardizing and expanding interviewer characteristics data sets and matching response categories with the survey questionnaires where relevant this practice would also support replication of these results and analysis of trends in these effects over time conclusions in most countries women and men are less likely to report ever having sex when an interviewer is 10 or more years older when controlling for respondent characteristics this has meaningful implications on the interpretation of this indicator but also makes a strong case that the impact of interviewer effects should be considered more broadly in the dhs and other similar surveys dhs could improve our understanding of these issues by collecting existing interviewer characteristics more consistently and adding several more dimensions survey implementers may consider better matching or careful training or the assistance of technology like acasi to reduce interviewer effects analysts may consider including a random intercept for interviewers when using dhs and similar survey data ethics statement the deidentified secondary data was obtained from the dhs program which makes it publicly available the dhs program secures appropriate ethical approval in each of the countries where it collects data which is detailed in the final reports produced for each country data availability all data used in this analysis is available upon request from the dhs program at funding none authorship contributions all authors contributed to the draft and final manuscript jeffrey w rozelle performed all analysis disclosure of interest the authors completed the icmje disclosure of interest form and disclose no relevant interests additional material online supplementary document

interviewer effects on survey response is welldocumented particularly when seeking to elicit true responses around sensitive behaviour such as sexual activity or substance use 1 2 3 4 researchers widely acknowledge the difficulty and potential data quality problems in collecting survey data about socially undesirable attitudes and behaviour in the united states and europe yet critical examination of survey data from lowand middleincome rozelle et al

introduction in a redistributive health care system the aim of social health insurance is to provide equal access to health care to all insurees in order to reduce or at least to avoid creating more social inequalities yet this objective is not reached in numerous developed countries benefiting from national health insurance evidence has been given to inequalities in health care and documented worldwide especially in france where social inequities are among the highest in europe 12 nowadays cancer is the second cause of death by noncommunicable diseases in the world and the first cause of mortality in france 3 an association has been identified between patients socioeconomic status and different cancer outcomes studies from various countries highlighted a significant impact of the ses on cancer diagnosis 4 5 6 treatment 78 mortality 913 and cancer survivors rehabilitation 14 the lower the ses is the worse the outcome is socioeconomic status has also been demonstrated to be linearly related to cancer screening attendance 15 16 17 18 19 20 but few studies observed this phenomenon in france 21 22 23 furthermore few studies have evaluated the association between ses and the time between symptoms to diagnosis or between diagnosis to first hospital care 2425 and none of them are french yet these indicators have demonstrated to be good surrogates of qualityofcare 26 27 28 the majority of the studies dealing with cancer inequities used an ecological index of social deprivation to estimate patients socioeconomic status in order to identify the relation between ses and cancer outcomes the most used is the townsend index this index is defined as a state of observable and demonstrable disadvantages relative to the local community or more widely to the society to whom the patient family or group belongs 29 in france the use of this index to estimate ses highlighted a low impact of the deprivation on cancer outcomes 30 the limits raised by this study were that this index was too rough to capture individual and community specificities recently a new ecological deprivation index the european deprivation index has been developed 31 this index is a better match to patients cultural and social environment since it is constructed and tailored for each european country but the edi can also be replicated in 24 other european countries and used to perform international comparisons we postulate that edi could be a better estimator of ses than the towsend index we also postulate that since timetotreatment has demonstrated to be associated with quality of care it could be used as a cancer outcome table 1 characteristics of patients surrogate in this study thus the objective of this study is to identify the association between cancer patients deprivation and quality of care in a french comprehensive care centre the principal objective was to measure the influence of patients ses estimated by the edi on the timetodiagnosis in newly diagnosed patients the secondary objectives were to identify associations between deprivation and timetotreatment and other outcomes results in civil year 2013 969 patients were admitted to our institution for a diagnosis of bc pc crc lc or s all of them had histological proved malignancies median age was 65 years 505 patients had breast cancer 169 had prostate cancer 145 had lung cancer 116 had colorectal cancer c and 34 had sarcoma 82 patients had no metastatic disease at diagnosis performance status at baseline was 0 for 612 patients and ≥ 3 for 21 patients median timetodiagnosis was 141 months q1q3 ranging 05 to 35 months for all cancers median timetotreatment was 09 month q1q3 ranging 04 to 14 months for all cancers and 075 months 0411 for bc 202 months 0932 for pc 079 months 0413 for lc 079 months 0314 for crc and 034 months 0table2 timetodiagnosis univariate and multivariate analyses 18 for s surgery was the most frequent first treatment then chemotherapy hormonal therapy and radiotherapy 129 patients were included in the quintile 1 of the edi 201 in the quintile 2 166 in the quintile 3 185 strata analyses did not manage to identify any association between ediquintile and timetodiagnosis for any tumor site explored tstaging at baseline was statistically associated with timetodiagnosis for breast cancer after a multivariate analysis age at diagnosis and tstaging at baseline were statistically associated with timetodiagnosis for prostate cancer after multivariate analysis metastases at baseline and performance status were associated with timetodiagnosis for sarcoma after adjustment no variables were found independently associated to timetodiagnosis for patients with lung cancer or colorectal cancer strata analyses did not manage either to identify association between deprivation and timetotreatment for any of the tumor sites explored for prostate cancer the health condition estimated by performance status was independently associated with a short timetotreatment if it was good similarly the smaller the t staging was the shorter was the timetotreatment for colorectal cancer few factors were identified as influencing the timetotreatment being a man lead to a quicker treatment response as well as having a small t staging neither for sarcoma nor for breast cancer or lung cancer were any factors identified as influencing timetotreatment discussion in this exhaustive monocentric populationbased study the primitive tumor site seems the main predictive factor for timetodiagnostic and timetotreatment the socio economic status estimated with the european district index has not been identified as modifying timetodiagnosis or timetotreatment in this population even for inside strata analyses that removed the strong tumor site effect deprivation does not appear as a factor influencing timetodiagnosis and timetotreatment according to the tumor site times could vary in the ratio of one to 6 for timetodiagnosis 075 month for breast cancer and 469 months for prostate cancer and of one to 3 for timetotreatment 075 month for breast cancer and 202 months for prostate cancer these different observed times illustrate the heterogeneity of evolution and practices according to the tumor site timetodiagnosis is shorter for breast cancer because of the screening practice which shortens symptoms onset and which is the first step into a relatively standardized prompt care path extending from first suspicion to completion of all treatments on the contrary the prostate cancer care path requires more time since elevated prostatic specific antigen generally lead first to a watchful followup rather than to an immediate biopsy within the context of a slow growing tumor timetotreatment has been established as a quality of care indicator worldwide guidelines have been produced to regulate its maximum limit 2728 it has been estimated in this study from 034 month for the sarcomas to 202 months for the prostate cancer which is considered as an indolent cancer the median timetotreatment is 09 months for all cancers in this study which is under the threshold established by guidelines reporting the preferable delays for treatment 2728 28 days in the usa and 31 days in the uk if prostate cancer is excluded all others tumor sites present an adequate speed of treatment response tumor site strata analyses brought some other factors appear to have been taken into account concerning the decision to treat the process so that the best and least harmful care path can be scheduled we found no explanation for the difference in timetotreatment between woman and men for colorectal cancer this needs to be further explored whats more a lack of power into these strata analyses must be considered and does not allow us to conclude firmly this study is the first to explore elapsed times from symptoms to first treatment in 5 cancers and in france its strength resides in the setting of the data collection the sample was an absolute exhaustive collection of patients all patients admitted to the cancer comprehensive center for one year were suffering from the 4 more frequent and one rare cancers with no missing data whats more this sample can be considered as highly representative of a rural french population because of the particular recruitment of this center being the only center in this wide area with both oncologic and radiotherapeutic departments this center is in monopoly in the loire county no selection bias can be here reported this study is also one of the first to use the new french edi to assess socioeconomic deprivation this study didnt identify any association between timetodiagnosis timetotreatment and socioeconomic deprivation in a review of studies examining the association of cancer survival with socioeconomic status woods et al 32 identified 38 articles and mentioned 14 studies having reported no association between socioeconomic status and cancer survival whats more in ecological studies using deprivation index differences were systematically smaller due to the inaccuracy of the estimate even in studies identifying an impact of the socioeconomic status on survival the estimated effect was often moderate more recent studies confirmed this tendency individual deprivation estimates 33 lead to a stronger association than ecological ones 3435 all of the recent studies without any association between socioeconomic deprivation and cancer outcomes used the ecological index either to explore relationships with cancer survival 36 cancer treatment 837 or hpv vaccination 38 these results lead to this assumption an ecological index is not such a good estimate for the individual patient socioeconomic status the deprivation score for an area cannot apply to all its residents people can live in a deprived area without being themselves deprived whats more the french edi is a new index which has not demonstrated its psychometric validity on the long term for now this index has been used in this french area which is mostly a rural county yet bertin et al demonstrated recently that a deprivation index was less valid in rural places 39 the homogeneity for socioeconomic status in each geographical area is less existent another assumption can be that the cancer outcomes chosen were not relevant yet these outcomes have already been identified as qualityofcare indicators as well as proxy for evolution and survival 27284041 saint jacques et al and dalton et al succeeded to identify an association between longer timetotreatment and low educational level for breast cancer 42 and lung cancer 25 berglund underlined an impact of the socioeconomic status on the timetotreatment for lung cancer 43 so these indicators seemed theoretically relevant as cancer end points to explore the last assumption could be that in this particular setting the socioeconomic status did not impact the waiting times but we believe the explanation should be searched for elsewhere in an index that measures socioeconomic deprivation more appropriately probably with individual level data in practice this study underlined the difficulty to assess individual socioeconomic level and by that to assess its impact on cancerrelated health outcomes the only postal address seams not sufficient at least for such a rural area to provide an exact overview of inequalities if health care inequalities are considered by the competent authorities to be mandatory issues to be tackle the hospital routine data collection should require additional characteristics to be gathered for each patient those characteristics could allow a global evaluation of the patient beyond its medical condition what those extra data should be composed of remains to be settle down our study faced several limitations more variables could have been studied but we did not access more in an exhaustive way but even with these few we identified other factors influencing the timetodiagnosis and the timetotreatment we can assume that with even more variables we would have had the same results our study is a monocentric study which shortens the specter of representation yet as we said above the patients admitted to this center are particularly diverse and representative of the whole county population as mentioned previously an ecological geocoded index has been used to estimate patients deprivation this geographical estimation may not be enough relevant either because the patients sample is peculiar or because the edi is a nonindividual estimation labbe et al 44 recently demonstrated how a specific and individual french score may be more reliable to diagnose deprivation however this score requires access to individual data that are usually unavailable in databases while place of residence is systematically collected labbe et al proposed to aggregate this score to perform an ecological index the ecological epices score could then be used to estimate perhaps more precisely french patients deprivation however this score would not address the problem of comparison across countries which is allowed by the edi thus although less accurate edi may provide an opportunity in both assessing deprivation and comparison across settings five tumor sites have been explored in this study it allows the results to give a fair representation of the medical practices of a cancer comprehensive center yet this heterogeneous population led to a lack of power for all subgroup analysis despite all these limits the methodology used remains adequate and allows us to conclude on an absence of a major influence of the patients deprivation estimated with the edi on waiting times but on a major influence of the tumor site on those waiting times in this setting conclusions deprivation estimated by european deprivation index french version does not appear to be related to an extension of the time to diagnosis or time to treatment in our reallife population of cancer patients cancer location and the tumor staging at baseline are much more powerful factors explaining variation in waiting times waiting times estimated in this study are concordant with the maximum delay recommended for the cancer care worldwide and translate good qualityofcare in this setting yet we cannot stop at these rather soothing results further research should be done to clearly identify and measure at an individuallevel more sensitive frailty factors that could be responsible for delays in care developing actions targeting those fragile populations would be the next step patients and methods design a retrospective monocentered cohort study was performed population we included retrospectively all consecutive incoming adult patients diagnosed for breast cancer prostate cancer colorectal cancer lung cancer or sarcoma and admitted to the comprehensive cancer centre of saint etienne between the 1st of january 2013 and the 31st of december 2013 bcs were both ductal carcinoma and adenoma carcinoma crcs were defined as cancer arising from the cecum to the rectum lc includes small cell carcinoma and nonsmall cell carcinoma s included soft tissue sarcoma osteosarcoma and darrierferrand syndrome patients were included only if they had a confirmed histological malignancy patients were excluded if they had tumor relapse hematological malignancies or other tumor site data collection once included data for all patients were collected from two databases demographical data were collected from the administrative database and medical data were collected from the medical information system of the institute missing data were gathered from individual medical files clinical data were gathered clinical condition status at baseline using eastern cooperative oncology group performance status cancer extension according to the tnm staging and grading symptomatology history was reconstructed by the clinician with direct examination during the first consultation onset of symptoms was collected according to the type of cancer date of first clinical signs or date of the first abnormal radiological or biological result for cancer screening consecutive treatments were reported as well as follow up patient sociodemographic characteristics and postal address were also recorded date of diagnosis was defined as the date of the first histological proof of malignancies timetodiagnosis was the time between onset of symptoms and date of diagnosis timetotreatment was the time between the date of diagnosis and the date of the first specific treatment french edi the edi is an adaptable transnational ecological deprivation index it has been developed according to a common definition of deprivationphysical and socialwhile maintaining the specificity of each country this index combines on one hand individual data from a european survey on poverty launched by the european commission 31 and in the other hand data from the population census of each country those characteristics allows this index to be transposable in time and from one country to another and should help in characterize and compare socioeconomic characteristics of a population across settings this ecological deprivation index has been built and used for the first time in france in 2012 3132 the edi can be replicated in 24 other european countries the french edi is divided in 5 quintiles from 1 to 5 the deprivation level for each patient was estimated by assigning him the edi quintile of his place of house deducted from his postal address deprivation was therefore estimated rather than individually assessed the postal address of each patient was geocoded on global positioning system coordinates using google map ® these coordinates were linked to an edi quintile using an areabased measure which was attributed to the patient statistical analysis conflicts of interest the authors declare no conflict of interest author contributions fc ab and nm conceived the project gm collected all the data gm ft and mo did the statistical analyses gm wrote the first draft and revised drafts of the manuscript fc ab jpj pf nm mo ft critically revised the manuscript for important intellectual content the final version of the manuscript was approved by all the authors gm and ab had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis ab is the guarantor for the study references

timetotreatment could be used as a cancer qualityof care surrogate in order to identify the association between cancer patients ses and quality of care in a french comprehensive cancer center methods retrospective monocentered cohort study all consecutive incoming adult patients diagnosed for breast cancer bc prostate cancer pc colorectal cancer crc lung cancer lc or sarcoma s were included between january 2013 and december 2013 the association of edi and timetodiagnosis ttd as well as timetotreatment ttt was analyzed using a cox regression and a strata analysis per tumor site was performed results 969 patients were included primitive tumor site was 505 bc 52 169 pc 17 145 lc 15 116 crc 12 and 34 s 4 median ttd was 141 months q1q3 05 to 35 months median ttt was 09 months 04 14 in a multivariate analysis we identified the tumor site as a predictive factor to influence ttd shorter for bc 075months

background early hospital readmissions are costly to the health care system and considered markers of poor quality up to 20 of hospitalized patients experience readmission within 30 days 1 the center for medicare and medicaid services hospital readmissions reduction program has focused attention on preventing 30day hospital readmissions 2 spurring development of transitional care interventions these studies show mixed results 3 4 5 6 7 particularly in safetynet settings with higher proportions of racialethnic minorities nonenglish speakers and patients with lower socioeconomic status 8 one reason for difficulties reducing readmission rates is appropriate targeting of interventions known clinical risk factors associated with early readmission include history of recent prior hospitalization high burden of comorbid illness and specific diagnoses 9 but using only these factors predicting readmission risk remains challenging 10 according to andersens behavioral model of health services use predisposing factors enabling resources in addition to need influence utilization 11 social support a social networks provision of psychological and material resources to benefit an individuals ability to cope with stress may serve as an enabling resource for health services use 1112 social support may buffer against the medical financial and emotional stresses of hospitalization 1314 while structural factors are proxies for social support assessing ones perceived social support may better reflect health utilization risk 15 16 17 18 but its role in readmission amongst hospitalized safetynet patients is unclear we address this gap by examining the role of a multidimensional measure of perceived social support in predicting 30day readmission rates or death in a cohort of older multiethnic hospitalized adults at a safetynet hospital we hypothesized that individuals with high social support are protected against early readmission or death methods study design and sample the study was part of a randomized controlled trial the support from hospital to home for elders 7 assessing a nurseled hospital discharge intervention in an urban publiclyfunded acute care hospital details about the trial are provided elsewhere 7 briefly the intervention consisted of inperson education by a trained study nurse prior to discharge a patientcentered booklet for postdischarge care and discharge followup telephone calls between july 2010 and august 2012 we enrolled participants admitted to the medicine cardiology or neurology services of san francisco general hospital an urban safetynet hospital 19 participants were eligible for the study if they spoke english spanish or chinese the study was initially restricted to participants aged 60 and older but the eligibility criteria expanded in march 2011 after 239 participants enrolled to include those aged 55 and older we excluded participants who were 1 transferred from an outside hospital 2 admitted as a planned hospitalization 3 likely to be discharged to an institutional setting 4 unable to consent due to lack of understanding cognitive impairment or other reason 5 diagnosed with metastatic cancer and 6 unable to participate in telephone followup the institutional review board of the university of california san francisco approved the above procedures measures data sources we conducted languageconcordant baseline interviews at bedside during hospitalization and a followup telephone interview 30 days after discharge we reviewed administrative and health record data for information on comorbidities and readmissions primary outcome the primary outcome was 30day readmission or death we obtained administrative records at the index hospital and two affiliated university hospitals to ascertain readmissions data for an additional six hospitals we obtained administrative records for any patient who reported any hospitalization at the follow up interview for other hospitals we requested confirmation dates of readmission that patients reported we identified deaths using hospital health department and state vital statistics records for patients who did not complete the 30day follow up interview 7 primary predictor perceived social support we assessed social support using the multidimensional scale of perceived social support 20 the mspss is a validated scale that asks participants 12 questions about their perceived social support from family friends or significant others participants rated each question on a 7 point likert like scale from very strongly disagree to very strongly agree to derive the final score up to 84 we defined social support in categories based on quartiles because the rates of 30day readmission and death were similar amongst the lower three quartiles we collapsed the measure into a binary predictor with scores 74 indicating high social support compared to those with very low low and medium social support other measures at the baseline interview participants reported date of birth sex raceethnicity total household income 21 last completed grade in school and limitations in activities of daily living two weeks prior to admission we asked what language the participant spoke at home and how well the participant spoke english we defined low english proficiency as those participants speaking english not at all or not well 22 we measured substance use using the who assist instrument 23 and participants selfreported any tobacco use and illicit drug use in the prior 3 months we assessed depression at admission using the patient health questionnaire9 24 and health literacy using a selfreported 3item scale 25 we asked participants if they lived alone with a spousepartner or in another situation we asked participants if they were hospitalized in the six months prior to enrollment we administered the telephone interview for cognitive status to evaluate cognitive impairment defined as a tics score less than 20 26 we calculated the charlson comorbidity index using administrative icd9 codes from the index hospitalization 27 analysis we used chisquare tests for categorical variables and ttests for continuous variables to compare participants in the highest quartile of social support versus those in the lower three quartiles we described the rates of high social support across white black asian and latino populations in the cohort we used multiplemultivariable logistic regression to estimate the odds ratios of 30day readmission or death associated with the highest quartile of social support we adjusted for variables chosen a priori based on literature or with significant association with readmission or death in bivariate analyses demographics limited english proficiency low health literacy depression cognitive impairment any baseline adl difficulties 2 weeks prior to admission current smoker hospitalized in prior 6 months and charlson comorbidity category we conducted hosmerlemeshow goodness of fit test to determine model fit in a secondary analysis we restricted the outcome to 30day readmission and excluded patients who died to examine the effect of high social support on readmission alone we repeated this model using each source of social support as the predictor we ran our models with and without our living situation variable to assess whether perceived social support was associated with readmission or death independent of structural support we included treatment group assignment as a variable in the model but removed it from the final model because it was not significant we tested for whether raceethnicity modified the effect high social support had on 30day readmission or death by including a racesocial support interaction term we created a new variable for white and nonwhite race because no latino participants with high social support experienced 30day readmission or death because the interaction was significant we presented stratified results by race we conducted all the analyses using stata version 13 results characteristics of participants there were 674 participants in the cohort with mean age of 662 years 438 were women the cohort was diverse 248 were black 193 were latino and 319 were asian the majority of participants had annual incomes less than 20000 many reported limited english proficiency and had inadequate health literacy the distribution of social support using the mspss was skewed with a median score of 64 and an interquartile range of 5274 compared to participants in the low social support group those in the high social support group were more likely to be latino and less likely to be white participants with high social support were also more likely to be female be nonsmokers and report less illicit drug use within the prior 3 months and were less likely to have depression or live alone relationship between social support and 30day readmission or death among the participants 143 were readmitted within 30 days and 07 dieda combined readmission or death rate of 150 amongst those in the highest quartile of social support 86 experienced readmission or death compared to 169 141 and 181 of participants with very low low and medium social support in unadjusted analyses high social support was associated with decreased odds of 30day readmission or death after adjustment the association was attenuated but suggestive of a protective effect of social support hosmerlemeshow goodness of fit test showed adequate fit our secondary analysis examining 30day readmission rate alone as the outcome excluding patients who died revealed similar results the change in odds ratio and loss of statistical significance was primarily due to adjustment for raceethnicity which subsequent interaction analysis showed to modify the association of social support with our outcome adding living situation to our models did not alter our findings there were differences in the sources of social support and association with 30day readmission or death participants most reported receiving high social support from a spouse followed by family and friends after adjustment those who reported receiving high social support from friends had onethird the odds of experiencing 30day readmission or death compared to those with lower levels of social support from friends participants with high social support from a spouse had lower 30day readmission or death rates but the association was not significant social support from family members was not associated with 30day readmission or death interaction analysis we found evidence that nonwhite vs white raceethnicity modified the effect of high social support on odds of 30day readmission or death amongst nonwhites those with high social support had lower odds of 30day readmission or death compared to those with low levels of social support in contrast whites with high social support had higher odds of 30day readmission or death compared to whites with low levels of social support discussion among ethnically diverse older adults hospitalized at a safetynet hospital we found that those with high perceived social support had lower rates of 30day readmission and death after adjustment for health factors associated with readmission the association was not significant but still suggested a protective effect of social support we also found that while spouses are the most common sources of social support those who perceived high social support from friends were least likely to experience early readmission and death finally we found that race modified the effect of social support on 30day readmission and death to date the role of perceived social support on early readmission has been unclear prior studies of hospitalized heart failure patients show a positive effect of high levels of perceived social support and reduced readmission 28 but several studies of hospitalized copd patients found no association between perceived social support and hospital readmissions at two weeks 3 months or 12 months 29 a study of general hospitalized patients found no association between social support and 30day readmission though in that study social support was assessed with a oneitem question of having someone to help at home 30 our findings support a role for perceived social support in preventing early readmission social support may operate as an enabling resource in andersens model of care utilization in this model utilization is not only based on need for care but also enabling resources perceived social support may prevent early readmission through the ability of patients to access resources necessary for recovery from hospitalization our results also suggest that social support may operate via a threshold effect because participants in the lower three quartiles of social support had similar rates of early readmission or death prior studies found threshold effects of social support in adjustment outcomes for breast cancer survivors 31 and perceived stress in a cohort of firefighters 32 though in contrast to our results they found social support effects diminished at higher levels it may be that preventing readmission requires harnessing additional sources of social support from multiple sources this finding is preliminary and requires additional exploration this study supports assessing perceived social support in addition to structural measures such as living alone structural social support and perceived social support are related but different concepts living alone is often used as a proxy for low social support but can also be a marker for good health and thereby associated with lower hospitalization risk 33 adjusting for living alone in our study did not substantively affect our findings it may be that quality of support matters most in healthcare utilization and this is best measured by evaluating how supported the patient feels social support is a complex concept that may not be well captured by proxy measures our finding of the importance of social support from friends contradicts an early study that found social support provided by family members had stronger association with health outcomes though that study did not assess impact on early readmission 34 cantors model of hierarchical compensation posits that older adults select from a hierarchy of supportive relationships with spouses and family members typically selected first 35 during times of stressful events such as hospitalization the ability to access additional social support from an extended social network may be important postdischarge spousal or familial support may not be sufficient to prevent rehospitalization when unexpected needs arise the importance of support provided by we found that race modifies the effect of perceived social support on readmission with high social support being protective against readmission among minorities and latinos in particular this may reflect how social support varies across race and culture multiple studies show high social support predicts improved health outcomes among hispanics compared to nonhispanics and social support may contribute to the latino health paradox phenomenon 36 37 38 a study of 7374 older lowincome patients discharged to home found that black elders were more likely to report having care support and that white elders experienced greater stress at discharge than their black asian and latino counter parts 39 an observational study of the national health and nutrition examination survey found similar interaction between nonwhite race and high social support and decreased odds of hypertension diagnosis 40 on the other hand in whites the role of social support and readmission is less clear while we found an association between high social support and increased utilization there were few patients with high social support and subsequent wide confidence interval in these patients high social support may indicate higher medical acuity or social vulnerability that are not captured in the data or that these patients social support appropriately directed them to seek out medical care postdischarge alternatively lower levels of institutional trust in health care by nonwhites compared to whites might also explain the differential effects of social support by race 41 social support may help patients disinclined to return to the hospital avoid readmission without adverse health consequences our findings suggest that social support matters in minorities particularly latinos that few white patients reported high levels of social support compared to minorities also bears notingwhite patients in safetynet populations are different medically than those in nonsafetynet settings 42 and our findings may suggest they differ socially as well the influence of perceived social support across racialethnic groups deserves further study our findings have implications for practice a potential reason for the mixed impact of care transitions interventions on readmission is that programs are not targeting the right patients medically complex safetynet patients who have high levels of social support may not need the resources these programs provide to avoid unnecessary care utilization prior transitional care evaluations showing efficacy such as project boost 43 and individualized management for patientcentered targets 44 included interventions that bolster social support of recently discharged patients in minority serving institutions future transitions of care interventions should focus on ways of identifying patients with low social support and then harnessing a patients social support network to avoid early readmission the mspss can be practically administered by discharge planners to tailor transitional care planning limitations there are limitations to this study our cohort was derived from those agreeing to enroll in a randomized controlled trial and may differ from the source population the 30day readmission rate of 143 was lower than anticipated and might reflect patient selection as well as the quality of care delivered during the trial period in addition safetynet populations differ in important ways from the general population limiting generalizability there may be differences in how whites and nonwhites interpreted the social support measure finally this was an observational study susceptible to confounding by unmeasured or incompletely measured variables conclusion this study is one of the first to explore the role that perceived social support and the sources of that support have on early readmission in a cohort of low income hospitalized elders our results suggest that patients particularly those of racialethnic minorities with high levels of perceived social support have lower odds of experiencing 30day readmission or death future studies on how perceived social support functions in readmission might aid in in discharge intervention design authors contributions bc and mk conceived and designed the study lg us jc mk were involved in acquisition of data bc mk dg lg uc jc ss were involved in analysis and interpretation of data bc drafted the manuscript mk ss lg uc dg jc were involved in critical revision bc mk lg us dg ss jc read and approved final manuscript competing interests the authors declare that they have no competing interests

background early readmission amongst older safetynet hospitalized adults is costly interventions to prevent early readmission have had mixed success the role of perceived social support is unclear we examined the association of perceived social support in 30day readmission or death in older adults admitted to a safetynet hospital methods this is an observational cohort study derived from the support from hospital to home for elders shhe trial participants were communitydwelling english spanish and chinese speaking older adults admitted to medicine wards at an urban safetynet hospital in san francisco we assessed perceived social support using the multidimensional scale of perceived social support mspss we defined high social support as the highest quartile of mspss we ascertained 30day readmission and mortality based on a combination of participant selfreport hospital and death records we used multiplemultivariable logistic regression to adjust for patient demographics health status and health behaviors we tested for whether raceethnicity modified the effect high social support had on 30day readmission or death by including a racesocial support interaction term results participants n 674 had mean age of 662 sd 90 with 188 white 248 black 319 asian and 193 latino the 30day readmission or death rate was 150 those with high social support had half the odds of readmission or death than those with low social support or 047 95 ci 026088 interaction analyses revealed race modified this association higher social support was protective against readmission or death among minorities aor 035 95 ci 016076 but increased likelihood of readmission or death among whites aor 37 95 ci 107129 in older safetynet patients nearing discharge high perceived social support may protect against 30day readmission or death among minorities assessing patients social support may aid targeting of transitional care resources and intervention design how perceived social support functions across racialethnic groups in health outcomes warrants further study trial registration nih trials registry number clinicaltrialsgov nct01221532

f ollowing employment trends in other occupational settings 12 the number of female certified athletic trainers in the athletic training profession has grown since the inception of the national athletic trainers association in 1950 the number of female ats has increased since the first woman joined the nata in 1956 with female ats currently constituting 48 of the nata membership 3 in 2006 975 of all national collegiate athletic association institutions employed certified ats yet less than onethird of those institutions had female ats 3 therefore the question of employment equality is raised when we consider the growing numbers of total female ats compared with the consistently low numbers of women working within the collegiate athletic training setting 3 national employment trends have focused on sex as an issue in reduced wages for women which have been attributed to employment absence for caregiving and a consistent theme of family and work conflicts resulting from the need to balance home and work priorities 4 5 6 7 multiple demands on parents related to work and childrearing responsibilities create timeconstraint issues and adversely affect both the quality of work and the attention paid to family 467 work overload and organizational expectations appear to have significant effects on work thus interfering with family 8 according to female parents in other heath care professions 9 a change in work environment that provides more flexibility for family and parenting responsibilities is an important factor in the decision to adjust either occupational setting or work hours although employment in the collegiate athletic training setting often requires increased and irregular work hours these additional workplace demands may in fact increase family interference or general workfamily conflicts 10 female ats are currently underrepresented in the collegiate setting comprising 274 of fulltime staff 3 this skewed representation may be attributed to several issues but clearly balancing professional responsibilities with parenthood is a key factor 1112 considering that 86 of female ats reported greater conflicts between professional and family responsibilities than did their male counterparts 41112 moreover women may perceive a greater conflict between professional and family responsibilities because they typically serve as the family caretaker 13 in addition to experiencing more difficulty when reentering the profession after an absence for family obligations 413 similarly 32 of female ats surveyed perceived that family and personal life lack of opportunities the good old boy network and salary were the greatest obstacles in their profession 5 understanding the degree to which parenting and family obligations influence the limited representation of female ats in the collegiate setting is perhaps an important first step in helping to address this troubling athletic training employment trend therefore the purpose of our study was to investigate collegiate female ats perspectives on parenting and employment methods instrument data regarding female ats experiences and perceptions of parenthood and athletic training employment were collected via an online survey 14 the survey is an original instrument that we created based on a review of the literature 1 2 3 4 5 11 12 13 14 it was evaluated for face validity by 5 female ats with 1 to 15 years of experience in athletic training 14 information regarding the content and style of the survey was assessed to eliminate errors and 1 additional question regarding the respondents current level of employment was changed based on reviewer evaluations the survey was categorized into 5 sections based on previous research and validated instruments regarding the interaction between family decisionmaking processes and the workplace 15 16 17 demographics parents nonparents who do not want to have children nonparents who are interested in having children and general opinions on working mothers in the collegiate setting question formats included multiplechoice fillintheblank and essay responses the demographic section collected information regarding age sex years of experience relationship status and whether the participant was a parent in the section relating to parental status participants with children were asked questions pertaining to employmentsetting selection in addition respondents with children were asked about the number of children they had career changes that occurred after having children the use of child care and how the respondent felt about being a working mother the third and fourth sections of the survey queried all participants three questions were asked regarding employmentsetting selection and perceived changes after becoming a parent or potential parent the final section which involved general opinions from both parents and nonparents on working mothers in the collegiate setting requested that participants discuss past experiences regarding female ats and parenting within the workplace using essaystyle and multiplechoice questions contact information was obtained through the nata using a broadcast system specific to research data were collated through an online survey distribution 11 an initial email was sent to potential participants that included an introductory letter and a direct link to the survey two weeks after the initial email a followup email was distributed requesting participation in the study in order to boost responses one week after the followup email no further surveys were accepted for the study data analysis descriptive statistics were used to analyze demographic information to describe age years of experience as a certified at employment position and parent or nonparent status based on the data collected x 2 and factor analysis could not be conducted as a result of violation of the assumptions therefore we calculated a correlation matrix to determine the perceptions among parents and nonparents regarding motherhood and employmentsetting selection crosstabulation was used to evaluate commonalities between groups in addition a kruskalwallis test was performed to assess differences among ncaa divisions i and ii and national association of intercollegiate athleticsdivision iii and responses to career orientation decision to have children childrens effect on job setting ability to be a female at with children decisions not to have children and feelings regarding children and work as a female at to assess the qualitative aspect of the survey via the openended questions thematic mapping was used answers to each individual essay question were analyzed using a color coding system to mark similar responses and tabulate common themes themes were then reviewed to assess consistency among authors and were appropriately titled results a total of 411 female ats responded to the emailed survey for 11 of the 1000 surveyed female ats automatic replies were generated indicating that the mailbox would not allow acceptance of the survey six responses were incomplete and were not counted thus 405 surveys were usable the mean age of the respondents was 337 6 812 years work settings for the female ats included the secondary school or clinicalsecondary school setting and any collegiate level married and single women represented approximately the same percentages of respondents at 45 and 41 respectively females with children comprised 388 of respondents whereas nonparents accounted for 612 of the population surveyed most of the women who were parents had 1 or 2 children 42 of those female ats had changed job settings because of their children and 65 reported a change in work hours subsequent to childbirth the workingparent arrangement was enjoyable to 41 of female ats with children whereas 50 preferred to spend more time at home yet 87 did not wish to be fulltime parents only 13 revealed an interest in fulltime parenting parents needed more than 21 hours of child care per week in fact most respondents with children used at least 2 different childcare providers to meet the needs of their individual circumstances a majority of nonparents indicated that they wanted to have children the main reason stated for not having children yet was that they were waiting to become financially established undecided nonparents specified that their decision was due to financial resources or marital status interestingly women without children were split as to whether children would be a substantial factor a negligible factor or no factor in affecting their employment setting in addition respondents who did not have children were equally distributed among the possible reasons for nonparent status including the inability to conceive the fact that they were not yet married maintenance of a greater career focus than family orientation and multiple reasons attitudes regarding the ability of a female at to be both an at and a parent indicate that the combination of parenting and working may be a challenge for both parents and nonparents alike although many felt that motherhood and career could be accomplished simultaneously they stated that energy levels tend to be insufficient for accomplishing both tasks the respondents further indicated that both career and family could be adequately attended to with sufficient support responses to openended questions reflected relatively equal positive and negative comments of parents regarding employment challenges other female ats said that family might be neglected because of employment obligations or that the family commitment was too great to handle both sets of responsibilities well according to a limited number of parents and nonparents alike work was usually neglected to ascertain whether differences in parenting employment perceptions existed among collegiate divisions we assessed a number of factors no differences among female ats were noted between collegiate division and career orientation opinion on being a working mother employment factors regarding having children perceptions of the ability to have children and be a female at and attitudes toward mothers working as collegiate female ats in order to obtain a better understanding of female ats feelings regarding children responses to essay questions were solicited to allow for more contextually nuanced responses a total of 270 participants responded to questions on past experiences with female ats and 199 provided final thoughts themes were established based on recurrent comments negative responses to questions on a not all participants answered all questions parenthood and employment experiences with female at mothers revealed several key points 1 many respondents struggled 2 juggling parenthood and work was difficult 3 traditional genderrole issues caused concerns 4 career decisions were based on having children 5 combinations of these issues were cited fiftyseven percent of the total responses indicated mixed feelings regarding the effectiveness and pleasure of work and parenting demands positive responses from nonparents on the topic of their experiences with female at mothers included perceptions of female at mothers parenting support systems or mothers organizational abilities negative openended responses from nonparents reflected a perception that bringing children to the workplace was inappropriate and that the parental focus on work might be lacking reponses to the question about final thoughts indicated that 69 cited organizing the demands of both family and work as the key to success thoughts concerns and outliers comprised the remaining 31 of respondents and included factors regarding intragender and intergender inequities and concerns regarding proper child care discussion the degree to which the smaller numbers of female ats at the collegiate level is predicated on issues relating to employee sex is unclear however the fact remains that female ats constitute only 274 of fulltime staff 3 indeed 262 of our respondents were employed in the collegiate setting a finding consistent with previous research 3 on employment settings of female ats the smaller female at population at the collegiate level could reflect the challenge of a traditional athletic training environment with irregular hours often exceeding 50 hours a week 7 an additional factor may be that employers are reluctant to hire individuals who have been absent from the profession and are therefore perceived to not possess current knowledge regardless of the female ats actual degree of readiness 6 research on other health care providers indicates that flexibility in the occupational setting to allow for parenting is a significant factor in the decision to change work settings and work hours 45 of female ats had made work changes because of their children 69 consistent with previous results 67 changing obligations had prompted the female ats with children that we surveyed to change their career objectives both parent and nonparent female ats stated that a significant factor in maintaining both successful career employment and parenting obligations was the presence of an adequate support system multiple demands were characterized as the greatest obstacles to success for both parent and nonparent respondents and those demands were further cited as the most common employment difficulties in the collegiate setting similarities between parent and nonparent responses were evident when respondents were asked if work was the area of life that was most often neglected perhaps of equal importance family was identified as the portion of life more often neglected by both parents and nonparents our results are comparable with general employment data 8 regarding work and family interference indicating that work overload and organizational expectations had a significant effect on work and thus interfered with family 8 although employment in the collegiate athletic training setting often necessitates increased and irregular work hours 6 these additional work demands may in fact interfere with family or increase general workfamily conflict 8 ultimately workfamily conflict pressures may contribute to female ats decisions to seek employmentsetting changes responses from female at parents indicate that parenting requires great organizational skills is challenging and often results in family neglect yet a majority do not want to be fulltime parents understandably parents had both positive and negative responses to combining work and parenting equal positive and negative responses of parents were indicated on openended questions regarding parental and employment challenges specifically multipledemand concerns of parents which included time constraints or childcare concerns constituted the highest chosen response multiple competing demands between employment and family as illuminated in the research 67 on the general population seem to have the greatest effect on the decisions of female ats with children to alter employment settings or hours although employers may find mitigating the multiple demands of parents difficult perhaps providing flexibility and support can mollify the effect of nonwork factors on the athletic training room environment because athletic training work hours often include evenings and weekends employer flexibility may include alternative staffing strategies modification of travel and assignment of evening and weekend schedules provision of onsite childcare alternatives or possibly allowing children in the work environment of course employers must weigh the appropriateness practicality and liability of implementing a flexible work environment in their institutions but openness to creative solutions may foster a more hospitable and equitable work environment an extenuating factor in an employers willingness to accommodate the needs of parents may be the ready availability of ats desiring employment in the collegiate setting employers will continue to hire qualified ats who can manage the requirements of the job regardless of parenting status consistently parents stated that parenting time commitments similar to the multiple demands within time constraints influenced employment and family parents enjoyed the workingparent situation yet 78 indicated that neither work nor family can be done well in conjunction with the other in another study 4 68 of parents reported difficulty balancing both career and family these results conflict with those of previous research 5 indicating that 863 of female ats felt that females had a greater conflict between work and family and 32 perceived familypersonal life as the greatest conflict with work reasons for the conflicting results could be the many demands placed on an at the difficulty in pinpointing one specific area that causes more conflict than another 17 or familyemployment conflict indirectly related to greater work commitment 8 furthermore these conflicting results regarding family and employment perspectives may contribute to female ats confusion in determining the best environment in which to address their personal and professional needs we noted no differences in perceptions on parenting among collegiate divisions which may indicate that the collegiate setting entails similar female at parent and work issues regardless of collegiate division similarly female ats considering employment in the collegiate setting based on parenting demands may be able to make employment decisions based on the collegiate setting as a whole rather than by division further research may provide additional information that female ats can use with regard to employmentsetting selection comparing the decisions of parents in the present study with results from previous studies 6 7 8 9 1113 yielded similar conclusions and may indicate that changes in work setting and hours after having children are related to the inability of employers to accommodate the needs of parents in their chosen work settings for example 43 of female medical students regarded flexibility as an essential component of the work environment or changing hours and setting based on family responsibilities 9 flexibility was the main reason for female physicians career choices 9 given the responses pertaining to flexibility it was surprising that parental responses to career decision and employmentsetting selection in our investigation conflicted with the flexibility concept most of the parents we surveyed indicated that children were not the major reason for which they changed job setting in addition 68 stated that they changed hours and 45 said they changed their job setting after having children contradictory to previous answers given by our participants parents perceived that energy levels tended to be insufficient with regard to time demands parents indicated that multiple time demands and familyemployment conflict were major contributors or the impetus for changes in employment settings yet they stated that children were not a major issue for the change which may represent a disconnect in comprehending the complex relationship between work and family commitments the lack of candid selfreflection on parenting issues and reasons for a change in employment setting may result in reluctance on the part of both employer and parent to create or request flexibility in dealing with family and employment conflicts other factors involved in career or employmentsetting changes should be evaluated to fully understand why female ats tend to change occupational settings after having children in addition we did not investigate salary gaps and burnout a national concern for women as employees salary gaps may also affect the female at and female at parent burnout is a factor in athletic training as a profession but a direct link to parenting as an additional stressor should be studied to determine if the additional layer of responsibility affects the degree of burnout and subsequent occupational setting changes currently female ats provide conflicting results on the relationship of parenting to employmentsetting selection and change which indicates that an intricate relationship may exist among variables that were not explored in this study nonparental perspectives on working female ats nonparents represented 61 of the total population surveyed with the majority of those individuals categorized as young professionals and the smallest population categorized as female ats with 11 to 15 years of experience the balance of respondents in the younger professional category mirrors nata membership data for female ats in the collegiate setting indicating that most female ats were between 26 and 30 years of age the decrease in female ats in the collegiate setting with age verifies that women are increasingly exiting the collegiate setting after the age of 30 a trend also visible in other employment settings parental issues may be one reason for female ats leaving the collegiate setting yet the departure from employment by female ats in all athletic training employment settings with increasing age may indicate a larger issue in athletic training that deserves further investigation a better understanding of female at demographics and parental choices beyond the age of 30 may provide further information as to why some individuals maintain employment in athletic training and others do not the majority of nonparent females stated that they wanted to have children or were planning a family in the future with most of those responses indicating that they are waiting until they have established a familyfriendly home life or career overall the current study indicates that 81 of female ats either want to have children or have children which is slightly higher than national findings which indicate that 75 to 80 of females will be mothers 616 the high percentage of female ats who plan to have children coupled with the low number of female ats in the typical childbearing and motherhood age range may further validate the suggestion that individuals who have children or are parents may not be present in the collegiate setting nonparents indicated that children would be a negligible factor or not a factor at all in their jobsetting choice again this information conflicts with research 6 indicating that flexibility children and family life were important factors in the choice of occupational setting the difference in perspective from nonparent to parent female at may reflect inadequate awareness of the complex negotiation between professional and family responsibilities for female ats 4 or a lack of mentoring for nonparent female ats regarding career choices because most female ats surveyed plan to become parents it would be prudent to address these important mentorship issues in both the educational setting and with ats employers nonetheless while the need for flexibility was voiced by parent female ats perhaps young professional female ats have created a new paradigm for juggling parent and work expectations that could be incorporated into current and future athletic training employment settings the female at employment environment previous investigators 611 have noted that a negative stereotype still exists for working mothers yet why and how the stereotype is manifested and maintained within society is not clearly understood collegeaged students gave more favorable evaluations to re ´sume ´s from men and women without children than to re ´sume ´s from women with children 11 mothers are still perceived as individuals who should be at home with the children and fathers should be the breadwinners relinquishing control in raising the child 7 the void of female ats within the typical age range of parents may be due to the unfavorable hiring or environment relative to parenting stereotypes issues regarding gender equity and barriers for women have been perceived differently by men and women 7 it is important to understand gender equity in the context of the current employment population in which approximately 50 of the workforce is female and 81 of those individuals desire to parent or participate in parenting 1 many responses from nonparent female ats appeared to indicate negative views of female at mothers perhaps representing a form of intragender inequity which is consistent with the literature 4 negative reactions from coworkers were another cause of increased stress for mothers this was noted by the female ats we surveyed and in the literature 4 as a key reason for leaving a profession both positive and negative essay responses regarding bringing a child to work discussed the necessity of a good timemanagement protocol and communication among all parties regarding the effects on the environment negative responses indicate that children in the collegiate setting are a distraction and a hazard continued investigation into this specific area within athletic training would be beneficial to understanding how athletes and ats perceive children in the workplace in order to better accommodate working parents while maintaining the integrity and standards of a health care facility common positive responses about past female at experiences can be conveyed by the following quote i have a lot of respect for any of the female athletic trainers with children that i have encountered it is a big balancing act between family and work the field of athletic training does not have the typical 95 hours the female ats appeared to understand the struggles and challenges involved in working and parenthood to effectively combine parenting and working research 791819 indicates the need for a good social support system organizational support from work job flexibility and maintained interest within the given setting final thoughts provided by the participants indicated that the most common perspective was explained by the following excerpt it really all depends on the work setup and flexibility at work i believe a mom has to be clear about her priorities and stick to her guns in general athletic trainers have to educate that we are people too and need normalcy in our lives there should be certain guidelines regarding practices and games that have to be followed in terms of scheduling it is not easy to be a working mom and especially not easy to be a working athletic trainer with odd and extensive hours we take care of everyone else and tend to neglect ourselves it leads to burnout the relationships among parents nonparents supervisors and institutions need to be further explored to identify productive working environments for those employed in the collegiate setting different approaches to flexibility scheduling and support should be investigated to aid employees and employers in providing a positive work environment so that athletic training services are optimal conclusions the purpose of this research was to achieve a greater understanding of the experiences and perceptions of female ats with regard to parenting workplace challenges and employment choices in the collegiate setting the limited number of women in collegiate athletic training settings coupled with the lower number of female ats with children is concerning yet predictable based upon national employment data the choices of mothers to change hours or work settings may be based on complex dynamics including irregular and overtime hours inhospitable or inflexible work environments the lack of understanding by nonparents and pernicious societal stereotypes mentorship of female ats may need to include realistic perspectives on combining parenting and work in the collegiate setting in addition to an understanding of individual institutional policies regarding job requirements so that parents or future parents can choose a work setting wisely factors that support athletic training as a familyfriendly career should be further investigated whether parenting has a significant effect on female at career choices especially with regard to the collegiate setting remains unclear understanding female at employmentsetting choices as well as nonparent perspectives may aid in assessing whether perceptual or environmental changes are needed regarding parenting issues among all athletic training employment settings although we have demonstrated only a basic understanding of what the general population of female ats perceives about parenting and athletic training future researchers should identify and clarify the conflicting variables we sought to capture female ats perspectives but more investigation is needed to explore race singleparent versus 2parent households sexual orientation and athleticdivision differences finally male ats viewpoints on the relationships between parenting issues and career obligations should be studied to establish similarities and differences between the sexes

context female athletic trainers ats are currently underrepresented in the collegiate setting parenting and family obligations may play a role in this underrepresentation objective to examine female ats perspectives on parenting and working in the secondary school and collegiate employment settings design crosssectional study setting online survey patients or other participants a total of 1000 nonstudent female certified ats who were currently members of the national athletic trainers association main outcome measure s an original survey was developed to assess perceptions related to motherhood and work responsibilities descriptive statistics were used to assess age years of experience as a certified at employment position and parent or nonparent status a correlation matrix was conducted to determine factors among parent and nonparent status perceptions of motherhood and employmentsetting decisions results of the 1000 surveys sent via email 411 411 female ats responded responses indicated that a majority of the female ats worked in the secondary school setting sixtyone percent of the respondents did not have children past female ats experiences indicated a perception that motherhood created more challenges or struggles or both in the work and family settings whether parents considered children a factor in employmentsetting changes produced conflicting results no significant correlations or differences were found among responses conclusions parenting considerations had influences on both the home and employment settings although parents and nonparents had different views on the implications of parenting in the workplace both groups agreed that parenting could affect the work environment and the choice to change employment settings and careers administrative decisions need to be considered in relation to parenting concerns mentoring that includes employmentsetting choices relative to life goals should be provided to ats regardless of sex

distributed in particular one of the most recurrent results in the literature is that there are significant differences in the levels of political knowledge between men and women not only do women tend to provide fewer correct answers than men to political knowledge questions but they are also more prone than men to respond dont know to these types of questions in fact even if most differences in political knowledge can be explained as a function of resources opportunity and motivation these factors are insufficient to fully account for gender differences in knowledge in this article we aim to explore gender differences in levels of political knowledge with a focus on girls and boys in europe the study of this population is of particular interest since the majority of explanations of the gender gap in knowledge are connected to social economic and psychological processes that mostly take place during transition to adult life in this study we draw on data from european lower secondary school students at a moment in their lives in which these processes have not yet been completed additionally this population has completed exactly the same number of years of education which makes it possible to keep constant one of the main determinants of knowledge for adult citizens as a longitudinal study of the long term effect of education on political knowledge in the us case concludes explaining citizens differences in civic knowledge requires attention to preadult causes we find that there is a gender gap in political knowledge among children even after controlling for different levels of access to resources opportunities and motivations for girls and boys more interestingly this gender gap is dependent on the type of knowledge domain that is considered namely whether it is either more factually or more analytically demanding boys systematically know more than girls when asked about facts but girls display greater knowledge if asked to reason about a particular political matter these findings have implications for the study of political knowledge suggesting that part of the gender gap in political knowledge might be a function of what is defined as knowledge all previous studies on the persistent gender gap in knowledge of adult citizens have used data that strictly measure the factual dimension of politics a type of knowledge that men apparently outperform women on we argue that it is necessary to broaden the conception of political knowledge by including a wider range of topics and cognitive domains as the advantage of men with respect to women might decrease or even disappear the present study makes a significant contribution to the debate over gender differences in political knowledge from both a substantive and an empirical point of view substantively it attempts to bridge the two literatures on young and adult political knowledge that often appear divorced empirically it draws a unique and innovative distinction between factual and analytical domains of knowledge no previous research has incorporated this important dimension in the study of the determinants of political knowledge finally it brings together in the same empirical estimation all different explanations of the gender gap in political knowledge which are not normally considered simultaneously the gender gap in knowledge as confirmed by a growing body of literature the distribution of political knowledge among adult citizens is by no means uniform however surely one of the most perplexing gaps is that between men and women in fact after many attempts to account for gender differences in political knowledge scholars are still struggling to understand this phenomenon the most common explanation of the gender bias in knowledge is based on socialization theories this approach argues that differences in levels of political knowledge between men and women are strongly dependent on the roles they tend to adopt in society traditional social norms define men as being in charge of public life whereas women belong to the domestic or private domain and are more committed than men to childrearing and family life a direct consequence of the socialization process is that women might be less motivated and attracted to the political world than men part of this same argument is that the knowledge gap between men and women is a product of the traditional socioeconomic disadvantages that women have generally suffered as higher cognitive and socioeconomic resources are associated with greater levels of political knowledge since women normally have less cognitive and economic resources than men they are also more likely to know less about politics than men while it is today evident that there is a gender gap in political knowledge among adults there is less certainty with regard to the age in which gender differences in political knowledge become visible greenstein found differences between boys and girls in their ability to provide accurate answers to questions like for example asking the names of incumbent mayor governor president the duties of such officials and of legislative bodies although the level of political knowledge was low in general between children boys significantly outperformed girls additionally boys were more likely than girls to be able to name an interesting news story and to declare an interest in national news a recent study shows also the existence of a relevant gender gap in knowledge of young children in germany small boys systematically outperform small girls in both political awareness and factual questions apart from these very few studies however major research about children has been more focused on political attitudes and childrens levels of political knowledge have seldom been systematically studied in particular from a gender perspective if anything differences in political knowledge between girls and boys are usually described as smaller than that between men and women literature on childrens attitudes towards politics however easily adopts traditional explanations of the gender bias in political knowledge among adults to start with and regarding the socioeconomic explanations parents resources both cognitive and material have been shown to have an impact on childrens political attitudes and on their levels of political knowledge however it is unlikely that eighthgrade boys and girls significantly differ in their economic vulnerability as adults do and that girls are systematically more disadvantaged than boys as such we would expect that the resources of the parents influence equally levels of political knowledge of both girls and boys gender differences in political knowledge among childrenif any should therefore be rooted in other aspects of socialization more related to the transmission of gender roles by the family or the school there is however no definitive answer as to how family socialization on gender roles influences childrens attitudes to politics as well as political knowledge among children previous research presents a fuzzy picture in which both the school and the family seem to counterbalance each other on the one hand jennings and niemi confirmed that mothers have more influence than fathers in shaping childrens attitudes towards politics given the greater amount of time they usually spend with children in comparison to their husbands in addition high homogeneity of the parents or in other words small gender differences between mother and father tends to increase levels of political knowledge both among girls and boys the family therefore seems to have some impact on how children understand politics and how much they learn about it on the other hand jennings and niemi find that levels of political knowledge are highly correlated to performance of the children at school in fact children know more than their parents about some particular topics as a result of socialization in school where children are taught about political issues that have long since been forgotten by their parents despite these contributions it remains unclear to what extent both the school and the family influence levels of political knowledge between girls and boys yet acquisition of political knowledge is shown to be largely agerelated and a function of cognitive development under this assumption one would expect that even if childrens political attitudes are partially shaped at home levels of political knowledge are more dependent on the individual resources of the children the resources of the family and the resources of the school here we analyze data from a sample of students at lower secondary school at this stage the socialization process which transforms girls and boys into women and men is still not definite and the school seems to have a relevant impact on what children know about politics in this context it is of key interest to test whether gender differences in political knowledge become visible at such an early stage of childrens lives how political knowledge is measured a more recent set of explanations of the gender gap in the knowledge of adult citizens focuses on measurement issues and departs precisely from the different positions men and women hold in the public sphere according to this line of research women respond to survey questions differently to men depending on various factors such as the environment in which they are interviewed the sex of the interviewer the motivation to respond to each of the questions or the format of the questions in particular mondak and anderson have demonstrated in the us case that an important part of the gender gap in knowledge is a consequence of the particular format of political knowledge questions which allows a lot of room for guesswork several studies have actually found that gender differences in knowledge are a function of the differing propensity of men and women to guess specifically women are generally more riskaverse and are less willing to guess which creates an advantage in favor of men also related to measurement issues and particularly fruitful in explaining the gender gap is a feminist trend in political knowledge studies which shows that measures of political knowledge used in the above quoted studies are genderbiased as early as in the 1970s gender researchers questioned the traditional picture of women as less knowledgeable and less engaged in particular they argued that gender differences were inflated because conventional research predominantly covered mens interests and fields of knowledge to put it succinctly previous measures of political knowledge appear to contain a gender bias that is tapping at least part of the existing gender gap in fact there is evidence demonstrating that some specific domains of knowledge are more relevant for one sex than the other others have found that women were more likely than men to know the name of the person in charge of their local schools but only recently has it been found that some policy areas and practical information are more directly relevant to women than to men it is precisely when measuring knowledge on diverse political areas when differences between men and women disappear explanations of this trend revert again to the different positions women and men hold in society women are more likely to be beneficiaries of public services and welfare state policies and also to be employed in the public sector moreover womens different situational experiences and positions as wives mothers or public sector employees lead to intrinsic differences in the issues and priorities that mobilize and interest them these differences may in turn affect the kinds of political knowledge that women possess given womens greater reliance on the state and their greater stake in welfare services and programs it seems plausible that women will have more knowledge about government services particularly when these are related to their daily activities and interests until now this type of research has mostly been conducted among adults and it remains almost unexplored with regard to children there are some indices however that conventional indicators which are normally used to measure political knowledge might be equally problematic for children moreover studies show that boys and girls of 13 years old have already different interests which closely correspond to the distinction between women and mens interests while girls tend to prioritize social or environmental issues boys give more importance to foreign policy and war much less explored in relation to how political knowledge is defined is the effect of the type of cognitive domain required to answer a knowledge question both among adults and children to date most surveys aiming at measuring political knowledge have mainly focused on facts this corresponds to what delli carpini and keeter define as factual political knowledge the range of factual information about politics that is stored in the longterm memory in other words adult citizens are asked about politicians specific knowledge about the functioning of institutions and processes etc this is the kind of data which has been used until very recently to conclude that the public is generally ignorant about politics and incompetent in democratic actions and that there are important socioeconomic and gender knowledge gaps among citizens recent research has instead argued that the common analytic definition of political knowledge presents relevant problems of validity something which might produce misleading conclusions about the general publics competence and its unequal distribution experiments on surveybased political knowledge measures have shown that many underappreciated attributes of survey interview contexts are significant determinants of past outcomes hence as a general matter conventional surveybased political knowledge measures appear to be much less valid indicators of what citizens know about politics than many authors have previously claimed in line with this recent literature we take the opportunity in this article to extend the measure of political knowledge to include more than strictly factual questions moreover our study aims at merging the classical explanations of the gender bias in political knowledge with these more innovative trends for an understudied universe the children data and methods the international civic and citizenship education study 2009 is particularly suited to test whether there are gender differences in levels of political knowledge at such an early stage in the socialization process as the average age of the sample is 135 years old in relation to the socialization and socioeconomic explanations the questionnaire has two main advantages first by comparing children of the same grade at school we keep constant one of the main determinants of knowledge among adults education second this approach allows us to simultaneously control for various potential causes of the gender gap related to socialization and socioeconomic disadvantages resources and motivations both at family and school levels with regard to measurement issues several format aspects are controlled for in the iccs first the questionnaire has been selfadministered and thus some of the effects of conventional surveys are avoided such as the interviewee effect or the tendency to risk aversion among women i the iccs questionnaire did not allow for the dk option and children had to leave a blank space if they did not know the answer second the iccs study presents variation in the format of the items including closed ended questions with four or with two options to choose the use of images open ended questions etc this further contributes to minimizing the potential effect of closedended items in the differential propensity of men and women to guess third the questionnaire is meant to cover four different content domains of these some are presumably of more interest to girls while others are normally more associated with boys fourth and especially innovative the iccs framework specifies two types of cognitive domains knowing and reasoning and analyzing which allows for testing levels of political knowledge with another set of items different from the classical factual questions the first cognitive domain knowing outlines the types of civic and citizenship information that students are required to demonstrate knowledge of the second domain reasoning and analyzing details the cognitive processes that students require to reach conclusions figure 1 provides examples of the two types of cognitive domains figure 1 about here in order to better approximate standard factual items of political knowledge and be able to distinguish how these perform as compared to alternative measures of political knowledge we have decided to use the knowledge questions from the european questionnaire together with the released analytical items of the general questionnaire as a consequence this study includes the following twenty four countries austria belgium bulgaria cyprus czech republic denmark estonia finland greece ireland italy latvia lithuania luxembourg malta netherlands norway poland slovakia slovenia spain sweden switzerland and the united kingdom ii the two cognitive domains mentioned above have been operationalized in two dependent variables the first is equivalent to the conventional measures of factual political knowledge as already mentioned most surveys on adults and children that have included indicators on political knowledge have only included questions about the knowing cognitive domain an added value of this study is that it uses questions referred to both cognitive domains factual and analytical our first dependent variable is composed of the twenty items contained in the european questionnaire these all belong to the cognitive domain of knowing according to the iccs classification the latter are in fact equivalent to the conventional measures of political knowledge used in previous studies particularly in europe the first dependent variable factual knowledge hence is a composite index of the number of correct answers to the twenty items included in the european questionnaire a correct answer equals 1 whereas incorrect answers equal 0 and no answer is considered as missing data we do not equate here the options of incorrect and na following recent literature selfadministration of the iccs questionnaire imposes this decision probably because students are used to take written examinations and as there were no penalties in not answering a question na is not equivalent in this case to dont know answers in standard questionnaires this survey mode cancels the gender bias in the propensity not to answer ands boys and girlscontrary to adults present the same propensity to guess these survey items boys do in fact give na slightly more than girls in our survey for this reason na is treated as missing data in this article iii with regard to the second dependent variable that referring to reasoning and analyzing it is intended to gauge students capacity to think critically about political matters this variable incorporates thirteen items included in the general questionnaire which have been classified as reasoning and analyzing by iccs as a composite index of the number of correct answers detailed information about all the topics covered by the items included on each dimension of civic knowledge can be found in the online appendix to test empirically for the potential gender differences in the two cognitive domains of political knowledge analyzed here we perform a threelevel multilevel analysis we have replicated the same estimation for each of the two dependent variables in which a range of variables that control for the standard antecedents of knowledge in the literature on adults has been specified ie individual differences in resources motivation and ability in addition we control for resources and motivation at the family and school levels following previous studies of the determinants of civic knowledge among students results and analysis table 1 shows the differences in the percentages of correct answers between boys and girls for each of the constituent items of the two dependent variables positive percentages in the table indicate that boys outperform girls whereas negative percentages indicate that girls outperform boys several conclusions can be drawn from table 1 first there are significant differences with regard to levels of political knowledge either if we consider factual or analytical questions boys tend to perform better in factual questions to the contrary girls provide more correct answers to analytical questions as compared to boys second and formatwise differences between girls and boys do not seem to be dependent on the format used in each of the questions since we find significant gender differences of relevant magnitudes in questions that use both truefalse and multiplechoice format or both images and words thirdly there are gender differences in relation to the topics covered by each of the questions table 1 confirms that boys tend to outperform girls on the following topics functioning of the eu and eu policies economics and secret policy in contrast girls outperform boys on the following issues group rights media freedom freedom of speech fair trade national symbols these findings echo recent studies of children and adult samples and clearly show that gender differences in terms of political interests arise early in life in short findings from table 1 suggest that there are relevant differences between girls and boys both in terms of the topics and the cognitive domains contained in the knowledge questions this first explorative evidence supports therefore our critique that part of the gender gap might be a function of what is defined as knowledge at least as regards children table 1 about here but do significant differences remain when we control for the different access of girls and boys to resources opportunities and motivations tables 2 and3 presents the results of the estimation of several random intercept multilevel models with students clustered in schools and schools clustered in countries intercepts are allowed to vary both within schools and within countries for each dependent variable we present four equations in which each level is introduced gradually the first column of table 2 indicates the measurement for each of the independent variables descriptive statistics and exact wording of the items are provided in the appendix tables a1 and a2 respectively tables 2 and3 about here as expected and confirming previous studies all individual level factors have a significant impact on levels of political knowledge with the exception of childrens exposure to newspapers for analytical knowledge accordingly the greater the resources in the household and the greater the individual resources of the parents the higher the level of political knowledge of the child furthermore young students exposure to television news also increases their level of political knowledge while exposure to newspaper news only significantly improves factual political knowledge resources and motivation at individuallevel also appear to be related to higher levels of both factual and analytical political knowledge those students speaking the language of the country at home present significantly higher levels of knowledge in addition the more the childs number of expected years of further education the higher their level of political knowledge moving to the school level the compositional effects of individual level explanations reduce variance at the school level to the minimum for the case of analytical knowledge in other words differences in levels of analytical knowledge between schools are mostly due to characteristics of the students which vary greatly across different schools although we also appreciate some compositional effects with regard to factual knowledge these are less clear and variance at the school level remains in fact resources of the school or the community significantly affect childrens factual knowledge additionally children perform increasingly better in political knowledge as the ratio of teachers per student becomes bigger similarly children who live in local communities with more resources and less social conflict know more about politics than children who live in more disadvantaged contexts with regard to the socialization explanations both the family and the school matter in promoting childrens political knowledge the more the resources of the family and of the school the higher are the levels of political knowledge of girls and boys the most important finding however is that the gender gap in political knowledge remains even after controlling for the varying access of girls and boys to resources opportunities and motivations moreover the gender gap varies for each of our two dependent variables girls present higher levels of analytical political knowledge while boys have higher levels of factual political knowledge there are two potential explanations for these results in the light of previous findings from other studies the first relates to the type of abilities required to develop each type of political knowledge as recent evidence from the pisa study suggests pisa 2009shows that girls outperform boys in reading and digital reading while boys outperform girls in mathematics consequently boys are generally more factually oriented whereas girls seem to be better at reasoning about politics also related to this is that the type of ability required to answer a question tends to be somehow linked to the particular domain the question relates to as such factual knowledge can only be asked about facts or specific objects here the european union and its functioning we have previously shown that boys perform much better than girls on domains related to the functioning of the eu and eu policies the economy and secret policy while girls perform better on issues linked to human and social rights both the type of knowledge and the specific domain which is asked about have therefore a significant impact on gender differences in political knowledge among children this further indicates that a gendered socialization has already affected the roles of boys and girls in their early life and accordingly their interest in diverse topics this might happen through the media the school the family and their peers a second possible explanation derives from the line of research which posits that women respond differently to survey questions depending on the survey interview context as recent evidence confirms levels of political knowledge and differences between men and women are partly dependent on the amount of information that is available in the context in which the questionnaire is fulfilled as such informationrich contexts contribute to a reduction of the inequalities in knowledge for example the knowledge gap between adult men and women disappears in information rich environments like a political campaign in line with this argument our findings suggest that differences between boys and girls might be prompted by the different format of factual and analytical questions as shown in the on line appendix the amount of information provided in the analytical knowledge items is usually larger than the amount of information provided in the factual knowledge questions the fact that girls outperform boys in analytical questions might be connected to the amount of information provided in the analytic questions which could raise girls motivations in answering them correctly as argued in a recent study men and women tend to perceive somewhat differently the diverse political spheres in which they operate accordingly the strategy of men and women in recording political information might also be different this all reinforces our claim that boys and girls respond differently to knowledge questions something which we can partially control for once we do not only restrict our measurement of political knowledge to factual questions solely to close results suggest that gender differences in political preferences surface at a very early moment in the socialization process significantly influencing what and how much girls and boys know about politics these findings have many implications for the literature on the determinants of political knowledge among both children and adult citizens these are discussed in the last section discussion and conclusion this article has examined whether the gender gap in political knowledge is only typical among adults or it appears instead at an early age in addition to socialization theories this study has also incorporated a number of measurement issues that are hardly considered in the study of childrens political knowledge we show evidence of a relevant gender gap in knowledge which persist even after controlling for the different access of girls and boys to resources opportunities and motivations the gender gap however is dependent on the type of cognitive domain required to answer the knowledge questions boys perform better on factual knowledge whereas girls are better on analytical knowledge our findings go in the same direction as a few recent studies on adults knowledge which argue that at least part of the gender gap might be a product of the way political knowledge has been conventionally measured which appears to be gender biased in line with studies showing that women and men approach politics differently we find that boys know more about the functioning of the eu eu policies and economics while girls know more about human and social rights however the issue is more complex still differences between boys and girls depend also on the cognitive domain required to answer each particular item these findings have implications for the future of the study of political knowledge firstly differences in how each gender approaches politics seem to appear at an early age before even children have fully adopted a role as women or men in society it is here confirmed that girls know more about areas that are closer to the traditional role of women in society something which has also been found in the case of adults these findings suggest the need adopt a gender perspective when studying childrens political knowledge which until now has been absent in previous studies and viceversa explaining gender differences in knowledge among adults requires attention to preadult causes secondly our findings suggest that gender differences might be a function of the type of items that are conventionally used to measure political knowledge normally limited to the knowledge of facts about the political world boys as men do know more than girls about political facts but girls are better than boys at understanding and analyzing politics in the light of these results a major question needs to be addressed in the future research on political knowledge do these differences endure throughout adulthood unfortunately there is an absence of longitudinal studies in europe which would allow answering such a question still the scarce crosssectional evidence available suggests that differences in cognitive abilities between boys and girls persist throughout life men tend to display an advantage in numeracy and document literacy while women tend to display an advantage in prose literacy our study is based in evidence coming from europe but other countries show similar patterns as well for instance the solely longitudinal evidence we are aware off is of the us case this data indicate that gender differences in the type of cognitive domain children are better at remain until adulthood to this respect longitudinal studies in european countries need to be undertaken in the future all of these suggest that future research in the discipline of political science should adopt innovative ways of measuring political knowledge politics is related not only to governments actions and to how power is distributed but is also related to the distribution of goods services and the relationship between citizens and the government however whereas recent studies argue for the need to include a greater variety in the content of the items used to measure knowledge we also advocate for the need to include items related to both factual and analytical knowledge a persistent debate in relation to the gender gap in political knowledge is whether women are less well represented by the democratic institutions as a consequence of their relative ignorance about the traditional arenas of electoral and legislative political matters an arena that is often perceived as a mens game and primarily understood to be electoral i we elaborate more on this point in note 3 ii all items of analytical knowledge were asked in all 24 countries whereas items of factual knowledge were asked only in 23 countries see the bottom of tables 2 and3 where the number of observations is 23 and 24 respectively iii this decision is also supported by the fact that none of the classical antecedents of political knowledge performs well in explaining the number of na we have replicated the analyses presented in tables 2 and3 for the number of incorrect and na whereas results for the number of incorrect answers correspond exactly to the results of tables 2 and3 except that the coefficients are negative and with the sole exception of the variable at the school level social conflicts the results for the number of na are not conclusive since most of the coefficients turned out to be non statistically different from zero that future research about adults political knowledge adopts a more innovative approach by considering the distinctive psychological orientation to politics of male and female appendix

this article aims at exploring the gender gap in levels of political knowledge with a focus on lower secondary school students in europe using the international civic and citizenship education study 2009 we find that boys outperform girls when asked about facts but girls demonstrate greater knowledge if asked to reason about a particular political matter part of the gender gap in political knowledge among adolescents appears to be a function of what is defined as knowledge we argue for the need to include a greater variety of items to measure political knowledge including both factual and analytical domains of knowledge keywords

introduction the time of pregnancy and having a new baby is often one of great significance in a womans life course the way women are cared for at this time can have profound and lasting effects on their health and wellbeing it is well established that the best maternity care outcomes are achieved by relational care with continuityprovided by the same caregiver over time 12 despite strong evidence of benefit and global policy support 34 models that offer relational continuity are not routinely available in most mainstream maternity care systems across the world most women receive care likened to factory lines of impersonal rushed and standardised care 5 6 7 this is particularly detrimental to women living with socioeconomic disadvantage who more often experience their maternity care as poor distressing or traumatic due to factors such as insufficient information lack of kindness and respect insensitivity and discrimination 8 9 10 11 in response to these inequities communitybased volunteer doula programs have emerged in numerous western countries over the past decade providing nonmedical continuous social emotional and practical support to women experiencing socioeconomic adversity there is abundant evidence of doula support programs improving experiences of care and outcomes for women from disadvantaged sociocultural backgrounds eg 12 13 14 15 16 17 18 19 20 less understood is how when and why these programs work doula support offers relational continuity but detail about relational mechanisms how these are affected by context and their various and differential outcomes are not well understood these questions form the basis of the realist evaluation of a communitybased volunteer doula support program in melbourne australia the program funded by philanthropy and operating since 2014 is the only of its kind in australia volunteer doulas provide free support to women experiencing financial hardship and one or more other indicators of social adversity such as refugee background homelessness or complex trauma the volunteers come from a range of backgrounds including as private doulas midwives and midwifery students and bicultural workers they typically provide two to three visits to women during pregnancy support during labour and birth and two postnatal visits 21 the program has not previously been evaluated realist evaluation is a theory driven logic of inquiry that assumes programs work only insofar as they introduce the appropriate resources and prompt reasoning in groups of people in the appropriate conditions 22 a realist evaluation seeks to find what works when how for whom and in what circumstances it starts with the development of program theories structured in accordance with this realist understandingas contextmechanismoutcome configurations mechanisms are further conceptualised as resources provided by a program and human reasoning in response data are then collected to test and refine the theories resulting refined theories provide plausible explanations for the workings of a program 22 for stage 1 of this study program theories were developed from realist interviews with key informants who designed or were working in the program followed by a rapid realist review of literature seven resulting hypothesised theories covered contexts and mechanisms leading to outcomes at the program implementation level outcomes for women and outcomes in the maternity care system the theories and their development are published elsewhere 23 four theories were prioritised for the evaluation this paper reports the testing and refinement of one of these theories called being by her side comprised of two cmo configurations the theory hypothesised how when and for whom doula support causes a woman to feel dignified and confident the first cmo suggested that when a woman is experiencing socioeconomic disadvantage and is well matched with her doula the doula is by her side gets her gives time attention and respect and believes in her in response the woman sees her own strength and value and this leads to feeling dignified and confident the second cmo hypothesised that when a doula is kind and nonjudgemental she notices a womans small wins and praises the woman as a mother in response the woman feels validated as a mother and then dignified and confident this study aims to test and refine the theory to inform program refinement methods evaluation design the methods were iterative with each stage informing the next data collection mixed methods were used to accumulate knowledge on different parts of the contextmechanismoutcome configurations of theories developed in stage 1 2224 elements of the cmos were put to women in realist interviews and doulas in focus groups for comment with a view to confirming denying and refining them 2225 quantitative data collected by birth for humankind from women about their birth confidence before and after doula support were extracted for analysis to further understanding of program outcomes and outcome patterns client interviews womens cultural backgrounds were considered program contexts to test so sampling aimed for culturally diversity women from the two largest client language groups in the program were included as the project did not have the resources to work with more language groups english speaking women were those who had indicated at program intake that english was their primary language as well as those with other primary languages but indicated no need for an interpreter to communicate in english women were otherwise eligible if they were aged 16 or over and had their babies three to nine months prior to the interview period 2627 women were excluded if known to have a serious mental illness or seriously ill or deceased baby to not increase distress women who identified as aboriginal or torres strait islander and those who would require consent from a guardian were excluded due to low reported numbers and their participation requiring methods not within the study scope englishspeaking women whose babies were aged between three and nine months were immediately eligible to be interviewed and were invited by text message from birth for humankind in early december 2019 invitations were sent weekly to newly eligible women until midjanuary 2020 an initial message and two weekly reminders were sent requesting that interested women contact the researchers eligible arabic speaking women were invited by text message in januaryfebruary 2020 and followed up by telephone call from a bicultural community worker contracted by birth for humankind different cultural positionalities and languages spoken between the anglowestern lead researcher ko and prospective arabic speaking participants were addressed by collaborating with a bicultural researcher 28 the design and facilitation of interview methods for arabic speaking women are detailed further in a separate paper 29 participant information and consent processes for english speaking and arabic speaking participants were provided by telephone email or in person before interviews in accordance with womens preferences and literacy levels the interview schedule was developed from hypothesised theories it was piloted in english with research colleagues and a past doula program client not eligible to participate due to the age of her baby the bicultural researcher reviewed the schedule for cultural appropriateness and translated it into modern standard arabic 30 31 32 three pilot interviews were conducted with arabic speaking new mothers who had no association with the doula program the piloting informed minor adjustments to the interview questions and process to ensure cultural acceptability safety and feasibility of cofacilitationled in english and interpreted 33 34 35 interviews with english speakers were conducted by ko by telephone in january 2020 interviews with arabic speakers were cofacilitated by ko and the bicultural researcher in february 2020 by telephone or facetoface in private rooms of community centres that were easily accessible by the participants the interviews were facilitated like conversations with a realist teacherlearner 22 approach participants were taught bits of theory and in response the participants taught the interviewers how the theory did or did not work for them 36 37 38 for example the hypothesised mechanismoutcome configuration of the doula giving time attention and respect and believing in the woman and the woman seeing her own strength and value leading her to feeling dignified and confident was tested with the questions can you tell me what kinds of support your doula gave you when she was with you what was she doing and how did you feel was there something she did or said that really stands out in your memory if yes can you tell me the story these questions did not assume a particular kind of experiencereasoning or outcome the interview schedule was adapted overtime in response to theory refinements for example the outcome of increased confidence was not initially explored in relation to time but this became important after some participants shared that their increased confidence had lasted beyond the support participants were thanked with gifts at the end of the interview all interviews were audiorecorded and the interviewers took field notes and debriefed the interviews were professionally transcribed and transcriptions were checked against the audio files interview data were considered coconstructions of explanations data from interviews cofacilitated with the bicultural researcher were understood as threeway coconstructions 3940 doula focus groups the focus group schedule was developed from hypothesised program theories and piloted with five research colleagues all current and past doulas were eligible and invited to participate in focus groups invitations by email and text message were sent from birth for humankind the initial invitation and two weekly reminders were sent in december 2019january 2020 requesting interested doulas to contact the researchers participant information was sent by email doulas consented and gave information about their availability via email two focus groups each of two hours duration were conducted in february 2020 after business hours at the birth for humankind office when program staff and management were not present the groups were facilitated by ko and jy in english as all participants were comfortable to participate in english the realist teacherlearner approach was applied the focus groups were audiorecorded and the facilitators debriefed and took field notes the focus groups were professionally transcribed and transcriptions were checked against the audio files routinely collected data data collected by birth for humankind were extracted deidentified and provided to the researchers in september 2021 the dataset contained records of all women referred to the program since its inception in 2014 included was referral information intake information including assessment of womens birth confidence birth information and threetosixmonth followup retrospective assessment including womens birth confidence as felt at the time of giving birth some items had been collected since 2014 while others such as the prepost measures of birth confidence were added in 2019 the pre and post support birth confidence measures used in this study were womens answers to two questions asked by telephone using interpreters where required the first was at the time of program intake by a program coordinator and then followed up at three to six months after birth by a program coordinator contracted bicultural worker or administration assistant both assessments were made on a fivepoint likert scale of extremely confident somewhat confident ok not very confident and not at all confident data analysis qualitative data were analysed first the hypothesised program theory was set up in nvivo 41 with theory title as a code and each context mechanism and outcome as a subcode the interview and then focus group transcripts were coded deductively to the existing subcodes and inductively to newly created subcodes analysis progressed with the creation renaming merging and deletion of subcodes and the coding of interactions between them with the changing structure representing theory refinement sample coding was reviewed and verified by the coauthors the interpretation of data analysis from arabic speaking women was reviewed and verified by the bicultural researcher quantitative pre and post birth confidence data were analysed for change in birth confidence using stata v16 42 the pre and post likert scales were numbered from 5 for extremely confident down to 1 for not at all confident chisquare tests were used to assess representativeness of the respondent sample in relation to all women eligiblecontacted for both pre and post questions the wilcoxon signed rank test was conducted to determine if there was an overall statistically significant difference in the median birth confidence score before and after receiving doula support and the differential directions of change this test was used because the data were ordinal from likert scales comprised two categorical matched pairs 43 further chisquare tests were conducted to determine if there were statistically significant associations between these different birth confidence outcomes and womens sociodemographic maternal socialemotional and program participation factors formal theory found by literature search was introduced to assist and deepen explanatory understanding this involved a process of retroductionthat is the toing and froing between the qualitative data partly refined program theories quantitative outcome data and formal theories 44 this research was conducted with approval from la trobe university human research ethics committee results interview participants fortythree englishspeaking and nine arabicspeaking women were eligible during the study period and invited to participate in an interview eighteen women expressed interest and were provided with participant information thirteen provided consent and were interviewed participant characteristics are detailed in table 1 focus group participants onehundred and nineteen doulas were invited to participate in focus groups half were active volunteers 10 were on leave and 39 were past volunteers seventeen doulas expressed interest and were provided with participant information eight doulas were available during the study period consented and participated in one of two focus groups participant characteristics are shown in table 2 routinely collected data of program participants the program database contained deidentified records of 962 referrals to the program in just over seven years the 962 referrals were for 914 individual women as some women were referred and used the program more than once for different pregnancies the program commenced the routine collection of pre and post birth confidence data from 28 march 2019 only records of referrals received from this date were considered for analysis of these new referrals awaiting intake those referred to another service those who withdrew from the program inappropriate referrals and those for whom support was still active were removed finally 39 records of women who had not yet been eligible for the postsupport follow up questions were removed this left 184 records of women who had been eligiblecontacted for pre and post questions data for pre and post questions were available for 103 records of women chisquare tests found the respondent group to be representative of all women eligiblecontacted for prepost questions no statistically significant differences in sociodemographic maternal socialemotional and program participation characteristics were found between the respondent group and all women routinely eligiblecontacted for prepost questions in the twoandahalfyear period between march 2019 and september 2021 refined theory analysis of all data sources with formal theories of recognition by honneth 4546 and relational reflexivity by donati and archer 47 resulted in significant refinement of the program theory the hypothesised theory was made up of two contextmechanismoutcome configurations hypothesising the generation of womens increased confidence the nature or longevity of confidence was not specified refinements to the theory included changes to these initial cmos and the addition of a further three cmo configurationsmaking a total of five cmos three of the five explain differential outcomes in shortterm confidence and the final two explain longerterm outcomes in confidence and related wellbeing all outcomes are numbered in fig 3 shortterm change outcome 1 represents a shortterm increase in confidence felt during the support period derived from both quantitative and qualitative data it is not specific to but includes an increase in birth confidence outcome 2 represents no change in confidence felt during the support period and was also found in both quantitative and qualitative data outcome 3 found only in the quantitative data is a decline in birth confidence quantitative analysis by wilcoxon signed rank test of 103 records of women showed the three birthconfidence outcomes while the test found a statistically significant change in womens median birth confidence between the preand posttime points the direction of change varied less than a half of women had an 4 potential contextual factors and mechanisms identified in the routinely collected quantitative data were found not to be associated with birth confidence outcomes chisquare tests showed no associations between birth confidence and program participation factors womens reports of whether their doula helped their birth confidence were also found to have no association with the confidence outcomes similarly womens demographic and other social factors were shown to not be associated with birth confidence outcomes therefore these quantitative data did not provide explanatory understanding for differential birth confidence outcomes cmo configurations 13 assert explanations for outcomes 13 each configuration is outlined and evidenced with data where formal theories were drawn on these are also referenced codes have been used for qualitative quotations with d referring to doula and c referring to client followed by participant number cmos 13 are also laid out in table 6 at the end of this section cmo 1 explaining a shortterm increase in confidence the outcome of a shortterm increase in confidence represents findings from interview data about increased confidence felt during the doula support period as well as increased birth confidence from routinely collected quantitative data all interview participants referred to at least a shortterm increase in confidence yet quantitative data showed that under half of women actually reported an increase in birth confidence this cmo asserts that when a woman feels misrecognised in her everyday life and trust has been developed and her story shared with her doula the doula provides recognition of the woman and her life story in response to recognition the woman feels less alone in the world understood and that she can lean on the doula which has the outcome of the woman feeling increased confidence during the support period honneths theory of recognition 45 informed the framing of this cmo recognition of a woman and her story was how the doula support worked recognition is considered a relational resourcea positive and attentive responsiveness to a woman 4546 in this cmo it represents evidence from clients and doulas of a doula giving time attention noticing and working with a womans strengths and existing resources positivity and emotional and physical comfort including touch it confirms the initially hypothesised resource of being by her side getting her and believing in her however recognition is broader than praising or validating a woman as a mother it is about recognising her personhood 4546 recognition works in two contexts first a woman trusting her doula and disclosing personal information about herself and her life enables the doula to recognise her trust and disclosure are outcomes of a preceding program theory from the same evaluation asserting that for a woman to trust her doula the doula needs to show that she is knowledgeable and selfconfident second when a woman lives with misrecognitionthe denial of dignity and selfesteem in family violence homelessness or racism recognition can powerfully offset this 4546 while quantitative data analyses did not provide explanatory understanding for increased birth confidence it did rule out both a doulas attendance for labour and birth and longer even when it seems like an impossible situation for anyone to be okay we see bravery and yeah you find her strengths and skills and acknowledge i was worried about overdoing it with the epidural im worried about overdoing it with any prescribed medication because im a recovering addict and she was just really comforting with that stuff and reminding me that its not heroin its an epidural yeah she was just good with that stuff and she understood we sort of conquered something together yeah i thought my whole birthing experience would just be like anxiety to the top but it wasnt contextmechanismoutcome 2 explaining no shortterm change in confidence quantitative data show that 28 of women had no change in birth confidence but only one interview participant reported no change in confidence cmo 2 asserts that in the context of low trust and disclosure between woman and doula the doula does not or cannot recognise the woman in response the woman reasons that the doula offers little help or benefit and she has no change in confidence the following data illustrate this cmo its easy when i understand the whole story yeah when i dont know then i cant think which way is better to support her one of my clients wasnt very interested to give me the whole information and i couldnt help her a lot if the connection is very strong then you can support a lot we didnt build a relationship she was there but there was not much help she didnt touch me or comfort me or anything she just sat there i really got nothing from her contextmechanismoutcome 3 explaining a shortterm decline in confidence while 28 of women had a decline in birth confidence evident in the quantitative analysis no other data collected in this study or any formal theory contributed explanatory understanding for this or other shortterm decline in confidence the context and mechanism for this outcome are unknown table 6 outlines all known elements of the generative causation of shortterm changes in womens confidence outcomes during the doula support period longerterm change as shown in fig 3 outcomes 4 and 5 stem from outcome 1 a shortterm increase in confidence outcome 4 is a sustained increase in confidence accompanied by increased capacity for agency and psychological wellbeing felt beyond the cessation of doula support a woman may also feel enhanced bonding with her baby outcome 5 is when there is no such longterm change both outcomes are explained by cmos 4 and 5 these are evidenced below and described in table 7 cmo 4 explaining a sustained increase in confidence capacity for agency and psychological wellbeing cmo 4 asserts that when a woman feels confident while being supported and the doula witnesses and affirms the womans confidence the woman sees her own strength and value she may also see other people in a new more positive light this results in lasting increased confidence as well as capacity for agency and psychological wellbeing in addition when support ends the woman reasons that she needs to move on respect the doula and be grateful for what was had rather than what is gone the woman misses her doula but copes well when support ends the following data illustrate the cmo i had questions for the doctormidwife and she doula would say yes you can ask its your right and for birth she was present in the room with me encouraging me and i was doing it if youre happy during your pregnancy and you feel supported and youre getting enough help and youre confident you continue it gives you doula witnesses and affirms womans confidence woman feels support is not enough and is not ready to let go woman does not feel confidence independent of doula or beyond cessation of support additional unknown context and woman may feel great loss and distress when support ends confidence even afterward and you feel so different so as much as it hurts as in like oh she was such a beautiful person and helped me so much understood me and now im not going to see her im going to continue to be confident were validating their personal power the validation the acknowledgment being by her we see her capacity to step up into her own thoughts that which she wants and yeah then that empowers her to take that further in her life as a lived experience of that worked i liked it i can see how i might do this again an additional possible outcome in cmo 4 is a womans enhanced bond with her baby however this may also be accompanied by an unintended negative outcomefeelings of sorrow and guilt for older children with whom she does not have as strong a bond because she was unsupported the following interview excerpt illustrates this but with my son i never had any of this it was just bang bang everything happened no one telling me how miserable i felt and how bad it felt even afterward i was very very depressed and vague it affected everything it affected my relationship with my son because he is notwere not as tight but with my daughter now its so different it is so so different shes fully breastfed and where with my son i felt like its a crack between me and him and yeah but no hes my world and i love him so much but there was nobody to actually help me to continue with the breastfeeding and i was so insecure and i was so swayed that my milk is not enough and im very sorry about myself with him i feel guilty about my son that he missed out on this what im trying to say is that i have two different pregnancies two different experiences one with doula one without and how much it affects even after the pregnancy contextmechanismoutcome 5 explaining no longterm change cmo 5 partially explains an absence of longterm change in confidence agency or wellbeing it stems from cmo 4 but asserts that an additional unknown context results in a woman reasoning differentlythat the support is not enough that she needs more and she is not ready to let go any confidence she has felt while supported falls away when the support ends i really appreciated her walking with me with the baby in the carrier to sort of just step out as wasnt comfortable feeding in public she just helped me pack my bag and she said lets go for a walk im going to walk with you today you can take your baby out and youll know that you can she kept giving me confidence saying its okay shes a baby shes crying its fine but its new but i felt like i needed a little more because i was still not ready to let go a few more times walking would have been something to sort of build a little more confidence around taking care of the baby probably would have helped i wanted her to see me more but unfortunately she couldnt i had to sign a contract i didnt want to message her and get her into trouble but to be honest i felt kind of lost discussion this paper reports a refined program theory that explains how and when doula support leads to confidencerelated outcomes in women initial hypotheses in a theory called being by her side comprised two pathways to a womans increased confidence the first contextmechanismoutcome configuration suggested when and how a doula gives time attention and respect leading the woman to see her own strength and value as a person the second was about giving praise and the woman feeling validated as a mother through testing with women and doulas and routinely collected client data the theory was refined and renamed recognition its five cmo configurations represent alternative relationalreflexive processes between a doula and woman leading to five different outcomes their key distinctions are about the nature longevity and andor absence of a womans confidence the most positive outcome is a womans shortterm increase in confidence felt during the doula support period that is then sustained beyond cessation of the support increased shortterm confidence results from leaning on a doulas confidence the confidence is not the womans own however when a womans increased confidence is sustained it is because the confidence has become her own it is developed in relationship with but becomes independent of the doula the woman is seeing her own strength and value and when this happens confidence extends to an increased capacity for agency and psychological wellbeing the context that prevents some women with increased shortterm confidence from having it sustained and instead feel loss and distress when the support ends is unknown this context affects a womans reasoning so that she feels the support has not been enough and she is not ready to let go it is possible that a womans attachment style could be the explanatory context according to attachment theory by bowlby 48 and its research application by others such as dempsey 49 a woman with an anxious attachment style may crave emotional care from an attachment figure such as a doula and find letting go emotionally challenging refinement of the mechanism leading to sustained increase in confidence was supported by formal theories of recognition by honneth 4546 relational reflexivity by donati and archer 47 and the latter applied to relational care by mann 50 recognition theory asserts that recognition is an attentive responsiveness to a person that is vital for personal integrity and selfrealisation relational reflexivity theory suggests that reflexivityor ones ability to internally balance primary concerns in life with unchosen social circumstances develops in relationship with others these theories helped mechanistic understandingof a doulas care and recognition giving rise to positive changes in the way a woman sees herself her relationships with others mothering andor other future possibilities this mechanism also contributes new knowledge about how support during pregnancy birth and early parenting can stay with a woman longterm authors of a recent systematic review of doula and other birth companion care have called for more research into longterm effects 12 this study contributes that a woman seeing her own strength and value at this time in her life leaves her with more than a positive memory it can change her future and if so her new babys future this finding is consistent with another evidence review findingthat maternity care can be healing for women 51 but also builds on this by evidencing how and when this can happen the main more prevalent negative outcomes in the refined theory are no change in shortterm confidence or a decline in birth confidence experienced by over half of women supported in the program no change is explained by a woman not being able to trust her doula and disclose her concerns and needs in her own words leaving little for the doula to recognise it is possible that low trust results from the doula not being womancentred however it is also possible that some women find it hard to trust regardless of a doulas approach this again may be explained by attachment theory but this andor other new hypotheses would need to be tested no explanation was found for a womans decline in birth confidence it is possible that some women lose confidence after not knowing what to expect so start out feeling reasonably confident but then having this confidence shaken through giving birth or through participation in the program and developing a more informed judgement this judgment could then shape a womans memory of how she felt at the time of birth however it is important to acknowledge that there is a wide range of other contextual factors such as type of birth and medical intervention known to impact a womans retrospective feelings about her birth experience including confidence 5253 a strength of this study is that it mixed data from multiple sources data collection methods also enabled participation of women from diverse cultural backgroundsalbeit only women who could be interviewed in english or arabic results were found to be consistent between english speaking and arabic speaking interview participants which suggests methodological rigor and cultural safety for arabic speakers or possibly equal levels of socially desirable responding other language and cultural groups may reason differently social desirability bias may also explain why substantially larger proportions of women said their doulas helped with birth confidence than the proportions of women whose birth confidence had increased access to routinely collected data was a further strength of the study including social indicators at the time of referral we are cognisant with the use of program data that was not collected for research the social indicators may be underreported due to shame stigma and the absence of trust or variation in understandingdefinitions of terms such as trauma or poor mental health in the absence of a clinical diagnosis 54 alternatively the indicators may be overreported in attempts to strengthen eligibility for the program the absence of association between womens social factors and change in birth confidence may have been influenced by these issues future iterations of evaluation could build on the findings of this study by asking interview participants for permission to access their routinely collected data linking qualitative data on contexts and mechanisms with quantitative outcome data may enable stronger explanations of outcomes targeted recruitment for qualitative theory testing with women who do not have increased confidence and either continue in the program or withdraw and doulas who have left the program may also build on findings exploration of new hypotheses including different attachment styles of women as contexts enablingpreventing trust with doulas motherbaby attachment and other longterm outcomes would further refine the program theory exploration of the effects of other social supports as contexts affecting how doula support works may be valuable as well the quality of routinely collected data may also be strengthened by testing and improving the wording of pre and post confidence and other questions for example the question how confident did you feel about your birth could be framed as the babys birth and be more specific in relation to elements of the birth experience the most positive outcome of the programa sustained increase confidence capacity for agency and psychological wellbeing from doula support and knowledge of how and when this occurs has significant implications for women the program and for other like programs the clients of the birth for humankind doula support program are from socioeconomic groups known to face significant misrecognition and barriers to a good and healthy life that the doula support offers a turning point in some womens lives and they leave the program better emotionally and socially resourced than they were as women and as mothers is noteworthy knowledge of why and when this outcome occurs may enable it to be maximised and alternative negative outcomes minimised through strategic adaptations of the program in the future this knowledge may also inform other initiatives based on relational care that seek to improve the confidence and wellbeing of people living with socioeconomic adversity conclusion this first realist evaluation of a volunteer doula support program has found how and when a doulas recognition of a woman in a support relationship can increase the womans confidence in the shortterm in a sustained way with broader psychological wellbeing or not at all postpartum experiences and views of parents with a history of childhood maltreatment plos one 2019 14 the sources of data reported in this study cannot be shared openly out of respect for the privacy of participants stipulated in the human research and ethics committees data curation kerryn orourke jane yelland

how women are cared for while having a baby can have lasting effects on their lives women value relational care with continuitywhen caregivers get to know them as individuals despite evidence of benefit and global policy support few maternity care systems across the world routinely offer relational continuity women experiencing socioeconomic adversity have least access to good quality maternity care communitybased doula support programs offer complementary care for these women and are known to on average have positive outcomes less understood is how when and why these programs work a realist evaluation of an australian volunteer doula program explored these questions the program provides free social emotional and practical support by trained doulas during pregnancy birth and early parenting this paper reports the testing and refinement of one program theory from the larger study the theory previously developed from key informant interviews and rapid realist review of literature hypothesised that support increased a womans confidence via two possible pathwaysby being with her and enabling her to see her own strength and value and by praising her and her feeling validated as a mother this study aimed to test the theory in realist interviews with clients focus groups with doulas and with routinely collected prepost data seven englishspeaking and six arabicspeaking clients were interviewed and two focus groups with a total of eight doulas were conducted in januaryfebruary 2020 qualitative data were analysed in relation to the hypothesised program theory quantitative data were analysed for differential outcomes formal theories of recognition and relational reflexivity supported explanatory understanding the refined program theory recognition explains how and when a doulas recognition of a woman increases confidence or not five contextmechanismoutcome configurations lead to five outcomes that differ by nature and longevity including absence of felt confidence

introduction provisional data from the us centers for disease control and prevention indicate that there were over 100000 drug overdose deaths in the usa during the 12 months ending in april 2021 almost a 30 increase compared to the year before 1 the worsening of the overdose crisis has been linked to the profound societal and economic impacts of the covid19 pandemic and continuing proliferation of nonpharmaceutical fentanyl fentanyl analogs and other novel synthetic opioids 2 3 4 5 the continuing spread of npftype drugs shows new geographic patterns with greater increases in the western part of the country 6 including arizona 7 the new wave of npf spread is linked to the increased presence of counterfeit pills 89 counterfeit pharmaceuticals are fake pharmaceutical products that are manufactured illegally in clandestine laboratories using pill press machines that are easily accessible through online sources 10 they are designed to look like legitimate pharmaceuticals but may contain fentanyl other novel synthetic opioids andor other drugs 11 first reports about the counterfeit pills containing fentanyl emerged in the initial phases of the npf epidemic in 20142015 12 however their presence remained relatively restricted instead powdertype npf often sold as heroin or mixed with heroin became increasingly available gradually saturating illicit drug markets and in some regions nearly replacing heroin 2 12 13 14 since 2020 many states across the usa have registered notable shifts in the illicit market dynamics as npf is increasingly available in counterfeit pills not just in powder form andor as heroin 8911 increases in counterfeit pill presence have been especially dramatic in arizona located on important drug trafficking routes arizona is considered to be the ground zero of the evolving npf epidemic 15 according to the arizona criminal justice commission between 2019 and 2020 retaillevel seizures of counterfeit pharmaceutical pills that contain fentanyl increased 764 in arizona 7 concurrently npfpositive overdose fatality cases in arizona increased over 80 in 2020 compared to 2019 16 despite the substantial uptick in the opioid overdose mortality in the southwest most prior studies on the npfrelated experiences among people who use illicit opioids were conducted in the eastern or midwestern states 13 17 18 19 20 21 22 23 24 25 importantly currently available information on the use of npf in the form of counterfeit pills is largely limited to law enforcement statistics 8 clinical case studies and media stories 12 this qualitative study aims to detail and contextualize drug use practices motivations and experiences related to counterfeit npf pill use among pwuo in arizona methods individuals who use illicit opioids were recruited via social media posts craigslist ads referrals by a local harm reduction organization and from other participants to qualify individuals had to meet the following criteria at least 18 years of age currently residing in arizona and use of illicit opioids in the past 30 days and or participation in substance use treatment for oud in the past 12 months phonebased eligibility assessment was conducted first before scheduling an interview due to covid19 restrictions all interviews were conducted using the zoom platform the study was approved by the arizona state university institutional review board a total of 36 individuals contacted the research team and participated in a phonebased eligibility assessment out of a total of 36 callers 30 met eligibility requirements and were scheduled for a zoombased meeting six individuals were not eligible because they did not use opioids were in longterm recovery from opioid use or did not reside in arizona out of a total number of 30 who were scheduled for an interview seven did not keep their interview appointments one respondent who passed phonebased eligibility and completed the interview was removed from the final sample because of inconsistencies that were identified in the interview responses there was a final sample of 22 completed interviews between december 2020 and may 2021 interviews included both structured and semistructured sections that were informed by prior research 2425 the structured assessment collected sociodemographic and drug use history data semistructured interview questions focused on the motivations and pathways of npf and other opioid initiation patterns of npf heroin and other drug use perceived local availability of heroin npf and other drugs perceived benefits and risks associated with npf and other drug use and covid19 impacts on drug use experiences and behaviors participants were allowed to keep their cameras on or off depending on their personal preference all interview participants were compensated with a 40 egift card that was delivered via email through the tango rewards management system after completion of the interview session most interviews lasted about 5060 min all audiorecorded interviews were transcribed and analyzed thematically using nvivo 26 in the first stage of deductive coding the team developed a coding schema based on the broad topics that were included in the interview guide 27 in the next stage of inductive coding the interview segments related to the history and patterns of npf use were coded further by the first author to identify emerging codes and patterns for example second stage coding included the development of codes that capture reasons for the transition to npf pill use the first and second authors met to review compare and discuss the coding the coding process involved several rounds of labeling and reorganizing the data 27 after the coding was completed coded interview segments were queried using nvivo simultaneously brief interview summaries and interpretive notes were completed in separate excel sheets to compare key themes across all participants this approach is based on the key principles of iterative categorization described elsewhere 28 when writing the paper nvivobased queries that provide access to complete interview transcripts and summaries in excel were used simultaneously to ensure a consistent and systematic approach to the interpretation and presentation of qualitative data 27 all participant names used in this paper are pseudonyms results participant characteristics out of 22 participants 14 were male and eight were female in terms of ethnicracial background 12 were nonhispanic white seven were of hispanic latinx ethnic background one was of native american one africanamerican and one of mixed white and asian ethnic background age ranged from 25 to 51 years old with a mean of 339 years the majority of participants resided in maricopa county four individuals were from pima county and others were from mohave yuma pinal and yavapai counties eighteen participants were unemployed and four reported current homelessness the majority reported use of both heroin and npf pills in the past 30 days with 82 reporting use of heroin on at least one day in the past 30 days and the same percentage reporting use of npf pills in terms of frequency of use 14 individuals indicated that they used npf more frequently than heroin seven used heroin more frequently and one person indicated only using nonprescribed pharmaceutical opioids at the time of the interview eight individuals were enrolled in opioid use disorder treatment nonpharmaceutical fentanyl in arizona nonpharmaceutical fentanyl in pressed pills nearly all participants described recent dramatic increases in the availability of nonpharmaceutical fentanyl in the form of pressed pills mimicking 30 mg oxycodone most commonly referred to as blues dirty oxys or fentanyl pills amy a 31yearold woman from phoenix who had a history of illicit pharmaceutical opioid use before transitioning to heroin at the age of 21 and then eventually to npf pills at the age of 30 explained well they say its fentanyl but they honestly look like perc 30 s because…when i was doing perc 30 s they looked exactly the same and it says 30 on it alex a 43yearold man who recently moved from phoenix to his hometown in the northwestern part of arizona to attend a methadone treatment center also described the increased presence of npf pills okay so yeah it was just an ingenious thing to make money that they did making those counterfeit perc 30 s in phoenix they are absolutely everywhere the increasing availability of npf pills was associated with sharp declines in the prices of these pills ricky a 42yearold man from phoenix who started using npf pills amid the covid19 pandemic and in the context of personal losses and turmoil in his life explained the changes in prices between the summer 2020 and spring 2021 theres a mass amount of blues the fact that when i first bought my first pills it was 8 the way that it is now its 5 shows you that the supply is flooding and outdoing the demand theyre flooding the market so much that the pills are getting cheaper to buy similarly kai a 31yearold man from the tucson area explained his experiences cause before in the beginning it would be like 10 for one pill but now i would never wanna pay that much for one pill its more like 5 a pill or 6 increased street availability of npf pills was often compared to the declining availability of heroin sofia a 28yearold woman from tucson noted it heroin s been very difficult to find and blues are everywhere in the city i live in theyre everywhere thats all anybody wants to do anymore is fentanyl similarly jeff a 40yearold man from phoenix who used illicit opioids to manage fig 1 county of residence in arizona of 22 participants recruited and interviewed for the study his pain issues described his experiences like my roommate hes got to drive like eight miles to buy heroin when i could literally walk out in the apartment courtyard and find three or four people selling blues because the only reason i started doing it because it blues was cheaper and more accessible most participants noted that unlike the easy availability of counterfeit pills access to genuine pharmaceutical opioids has declined sharply johnny a 31yearold man from phoenix who used blues daily characterized genuine pain pill availability the real ones pain pills are extremely extremely hard to get you have to get those prescribed and i think only car accident and cancer patients can get prescribed real percocet you know what i mean especially 30 mg nonpharmaceutical fentanyl in heroin several participants discussed the increasing presence of npf in the local heroin supply powdertype heroin was viewed as being more prone to contamination with npf however some individuals also noted the increasing presence of npf in black tar heroin which is the most common form of heroin available in the region lucas a 26yearold man from mohave county described his experiences i mean any time i get powdered heroin then i know its fentanyl… even black tar heroin will have fentanyl in it but its not as much if its powdered heroin then its pretty much just fentanyl beth a 40yearold woman from phoenix also described prior experiences of obtaining heroin that was laced with fentanyl she avoided it though by limiting her dealings to established and trusted sources ive had heroin like that mixed with npf you can usually taste it a lot of dealers will let you know hey this has been laced with fentanyl because it gives you a better high… i stay away from that i have one particular dealer that i use that i have had for quite some time now hes pretty honest with me with what he knows is going into it and i stay away from it for the most part nonpharmaceutical fentanyl in powder form a few participants mentioned sporadic availability of powdertype npf in arizona although it was viewed as far less common than npf in counterfeit pill form jasmine a 26yearold woman from phoenix described her experiences of obtaining powderform fentanyl referred to as pure no its not very available in arizona its really expensive most of my people that sell the pills dont also have access to the pure but ive come across it quite several times and on it and then it is just kind of weird because some of the powder is white some is pink some is purple and youre not really sure what youre getting i guess or why its different colors but its great when you do find it some you can smoke it or shoot up and its just really strong antonio a 25yearold man from yuma who had a prior history of selling npf and other drugs explained why local availability of npf pills was greater than that of powderform npf here … for the most part the cartels are just pushing the pills they dont wanna sell the pure thing or obviously theyll be killin the client base for the most part you only find pills out here… initiation of counterfeit npf pill use nearly all individuals reported the first use of pressed npf pills in the past year and all of them had prior experiences of using other illicit opioids a few individuals noted that they first tried npf pills because of the social circumstances that facilitate their access to the drug and sparked their curiosity about its effects maria a 47yearold woman from mohave county transitioned to heroin use three years ago after many years of using prescribed and illicit pain pills she indicated that she first smoked npf pills just a few months prior to the interview unfortunately i had a family member that was um is probably still currently involved in the trade of it and like that through them socially you know here you want to try it more commonly the first use of npf pills occurred in the context of reduced access to heroin in most situations these initiation decisions were driven not by consumer preferences but by shifting market situations and circumstances for example scott a 30yearold man described his first use of npf pills i live in tucson now but i actually ended up going back homeback to scottsdale city northeast of phoenix where i grew upwhere my parents live i went back for christmas with my girlfriend at the time we both did heroin i got back to scottsdale we actually ran out of blackout of heroinand we were trying to get more i actually couldnt find heroin the people… that id known from growing up didnt have heroin they had actually these pills these fentanyl pills they were actually the only thing i was able to get at that time i ended up getting them i wasnt very happy about it i didnt really know about them i knew about them but in my opinion i didnt really care because i did heroin i didnt care to try anything else or try something different heroin worked for me i didnt really have a choice in the matter cause i was gonna get sick i actually ended up buying the fentanyl pills for a few individuals the first use of npf pills occurred through a pathway of reduced access to pharmaceutical opioids jeff a 40yearold man from phoenix explained how he was first introduced to npf pills in the context of reduced access to legitimate pain pills that were prescribed to him after a serious workrelated injury all the pain management places that you go to now theyre so afraid because of the opiate epidemic that they don t want to put you on what you need to be on… … i think after being out of the nursing home for a few months and they cut my pain pills down again and it just wasnt enough and i couldnt function i couldnt walk when you have two shattered legs and i think somebody ended up giving me one of those fentanyl pain pills and you know it helped… it was way better than what i was getting from my pain management switching over to npf pills or not although nearly all individuals had tried npf pills participants noted distinct patterns and trajectories of switching over to npf pills andor maintaining some levels of heroin use some individuals transitioned to npf use nearly immediately after trying them for the first time for example scott explained basically from that moment on is when i started seeking out the fentanyl pills and doing those on a daily then basically within a week i phased out heroin and was not shooting up anymore i was just smoking these pills in contrast others made a slower transition by initially supplementing and then eventually replacing heroin with npf pills over the course of several weeks or months johnny a 31yearold man who was smoking about 10 npf pills per day explained gradually i started picking a couple of them up along with some heroin here at a time and then after a while i just started to like the pills better others have maintained a varying pattern of dualuse relying on npf pills intermittently when heroin was more difficult to find while still using heroin when available some individuals had tried using npf pills but attempted to avoid them altogether and maintained a more or less consistent pattern of heroin use for instance beth a 40yearold woman who used heroin daily to help her with chronic pain noted the pills i wont even touch honestly unless i havent been able to find the heroin or im somehow in some type of withdrawal state is the only time that ill actually smoke one of those pills its really just to get better until i can find the heroin participant decisions and processes of switching over to npf pills or maintaining some levels of heroin use were shaped by a range of personal and contextual factors including availability trends personal experiences with npf effects views about the social acceptability as well as perceived benefits and risks of npf versus heroin use going with what is available for most participants their personal experiences with the availability and prices of npf pills relative to heroin were among the most important factors that determined their transition trajectories and patterns of npf pill use for example antonio noted that the covid19 pandemic shorted the market on a lotta drugs and opened up the way for fentanyl as a result these changes pushed many into npf pill use i didnt really start using npf pills until last year 2020 and just because it was cheaper i know a lotta people that never wouldve touched it npf pills touched it last year thats just because we were locked in and couldnt go anywhere the drugs got frozen pretty much south of the border and the only thing coming in were npf pills kai a 31yearold man from pinal county who smoked npf pills every day and heroin on about seven days in the past month also noted that drug availability was one of the key factors in his transition to more frequent use of npf pills then the pills they started just becoming more available there was more of them than there was of the heroin and they were cheaper in contrast alex a 43yearold man explained that he did try using npf pills on several occasions but maintained more frequent heroin use before starting methadone treatment one of the underlying reasons for his continued more frequent use of heroin i actually met somebody that would sell it heroin to me fairly reasonable and i could afford to be a heroin addict in phoenix i was doing it for 20 a gram there in phoenix similarly lucas a 26yearold man from mohave county had tried smoking npf pills but considered heroin his drug of choice and injected it daily in the past 30 days he reflected on the potential for him to eventually switch over to npf pill use if i cant find heroin then i definitely will switch to blues you know what i mean ill probably end up doing that factoring in the effects of fentanyl for many individuals subjective experiences of fentanyl high were often discussed as another key factor that influenced their decisions and preferences concerning more or less frequent npf pill use scott a 31yearold man explained that in addition to the shifting availability trends greater potency of npf pills was one of the key motivators for his rapid transition from heroin to npf pills me and my girlfriend at the time we smoked them and they worked amazing they got me higher than heroin did antonio a 25yearold man shared similar experiences fentanyl was just more powerful to me it calmed me down faster got me in a high zone a lot faster than heroin did in contrast maria a 47yearold woman smoked npf pills on a few occasions but was not impressed with their euphoric properties she preferred to inject heroin and continued to use it more frequently the fentanyl is to me i really didnt get a whole lot out of it personally then again i didnt do a lot of it… it was once or twice in a probably a 45day span and then that was it… im not continuing to use it at all because i really didnt get a lot out of it some individuals disliked the effects of npf pills even as they were gravitating toward more frequent use because of easier accessibility in comparison with heroin fentanyl was viewed as more overpowering and disruptive to their daily functioning and routines sofia a 28yearold woman who preferred heroin and to the extent possible sought to use it more frequently than npf pills explained her hesitancy to make a complete switch from heroin to npf pills everyone is doing blues it makes people nod out it puts people asleeplook like theyre sleeping all the time… i dont enjoy spending my entire day with my head sunk between my legs nodded out thats what fentanyl does to everybody at least that i see i dont enjoy that i believe that heroin is better for me to do if im gonna do it because i dont nod out on heroin similarly francisco a 51yearold man used npf pills more frequently than heroin because of easier access however he found fentanyl effects less attractive in comparison with heroin because of the shorter duration of action and the need to engage in more frequent use well because you only gotta do oneshot of heroin in the morning and youre good all day fentanyl is one of them things its like coke man … when you do smoke a fentanyl pill and youre good for a little while and then you gotta smoke another one youre good for a little while and then the times get shorter and shorter a sense of familiarity some individuals felt that npf pill resemblance to wellknown pharmaceutical drugs contributed to the increased social acceptability and a sense of familiarity which made the transition easier and more likely alex a 43yearold man described his initial reactions and experiences with increased npf pill availability well fentanyl was just a weird thing how that whole thing happened i told you i was familiar with perc 30 i took a lot of those pills from my pain management doctor when the cartels decided they were gonna start making bootleg perc 30s using fentanyl i liked it initially similarly antonio a 31yearold man explained how he and his peers viewed the introduction of npf pills to the illicit drug market naturally since the fentanyl is introduced as a percocet percocet 30 milligram of course people who already were keen with liking those kinda drugs took a keen interest to fake 30s… they were already comfortable with the idea of taking it cause it was familiar to them switching from injection to smoking npf pills in the form of pressed 30 mg oxycodone tablets were generally administered by smoking jaime a 31yearold man explained his first experiences with npf pills i remember thinking it was weird that you put this pill on some tin foil and you smoke… i didnt really care for the smell i was still kind of all about heroin but it did work … for individuals who had been using heroin by injection switching to npf pills also meant a transition from the injection route of opioid administration to smoking as a result some felt that their switch to npf pills was a saving grace because smoking was viewed as a less stigmatized and overall safer and more convenient alternative to the injection route of opioid administration johnny described his transition to npf pills it was like my saving grace from a worse evil i guess you could say surprisingly just one day… i put the needle and the heroin down and i just started smoking npf pills i guess i could say its a matter of opinion but i say its the lesser of the two evils when it comes to how youre doing it as i think smoking is obviously a lot better than injecting lucas had been using black tar heroin more frequently than npf pills but considered that switching the route of administration was one of the attractive aspects regarding his potential future switch to npf pills you know actually ive heard that a lot of people got off shootin heroin by doin blues they stopped shootin heroin by doing that so i dont know maybe its something ill get into… itd be nice to not have to shoot up heroin anymore… others have also felt that the smoking route of npf pill administration could help moderate their overdose risks although in some situations these risk perceptions were difficult to reconcile with the observed npfrelated overdose experiences in the community scott reflected from my heroin addiction people didnt overdose when they smoked it the only way to overdose was to do a huge shot of heroin … but now ive seen people overdose from smoking this fentanyl… i dont really know how to weigh the risk risks of overdose and difficult to quit several participants expressed their concerns about the increased overdose risks associated with npf use and these fears deterred some individuals from making a complete switch over to npf pills as alex who used heroin more frequently than npf pills explained most of those pills are stronger than a regular pharmaceutical perc 30 and i liked that i tended to stay more towards heroin i did smoke my share of those pills a lotta people die from em thats why it scared me others were also concerned that npf was more difficult to quit because of greater potency and more severe withdrawal symptomatology tahlia a 26yearold woman from phoenix discussed her concerns its very addictive its a lot stronger than heroin so its a lot harder to get off of than heroin and thats another thing that ive noticed ive had a lot of people tell me that its almost impossible to get off of thats what i heard discussion this is one of the first studies to describe pwuo experiences with increased availability and use of counterfeit npf pills in the usa similar to prior studies on the initiation of npf in powder form andor mixed with heroin 1329 counterfeit npf pill use was primarily driven by shifting illicit drug market conditions not by consumer demands however since pharmaceutical drugs are generally viewed as less risky and stigmatized than heroin 30 our qualitative findings indicate that repackaging npftype drugs into counterfeit pharmaceuticallike products may contribute to perceptions of familiarity and increased social acceptability importantly our participants emphasized that counterfeit npf pills in arizona were generally used by a smoking route of administration and for many changes in the route of administration were viewed as a positive aspect of npf transitions no prior studies on heroin to npf transitions conducted in the eastern part of the country have identified changes in the route of opioid administration that were described by our study participants a recent study conducted in san francisco california 31 was the first to characterize a pattern of replacing black tar heroin injection with a smoking method of npf use similar to our participants in arizona pwuo in san francisco viewed this transition as beneficial in terms of reduced stigma and health risks uniquely pwuo in arizona noted most commonly smoking npf in a counterfeit pill form while pwuo in san francisco used powder npf for smoking 31 our findings emphasize the need for ongoing tracking of unique adaptations and patterns of use that local communities of pwuo develop in response to the local specificities and situations of drug market conditions participant views and experiences with the transition to the noninjection route of drug administration have significant implications for the development of harm reduction services prior research has established that the injection route of drug use is linked to greater drugrelated harms than other routes of drug administration 32 33 34 35 most prior public health interventions had limited success in helping individuals who inject drugs to switch to noninjection routes of drug use 32 it is important to emphasize that smoking presents its healthrelated risks including exacerbation of respiratory problems and potential exposures to a range of toxins and pathogens 33 to respond to the changing drug use patterns in the community it is critical for the local harm reduction services to expand their reach to individuals who use noninjecting routes of drug administration and provide education about safer smoking practices along with sterile smoking paraphernalia 31 we acknowledge that these findings are based on the data derived from a small qualitative sample although we were able to recruit participants from distinct regions of the state and different ethnic minority groups more research is needed with larger samples of participants to identify regional differences and specific needs of ethnic minorities in arizona our findings are limited to selfreported data in future research it is critical to include urine toxicology analyses to identify specific fentanyl analogs and other novel synthetic drug exposures 1424 the interviews were conducted via zoom and this might have limited our access to individuals who have less confidence in using online resources on the other hand our experiences suggest that videoconferencing platforms provide a novel and efficient format to engage pwuo in research with a few exceptions most of our participants had current or prior histories of heroin use more research is needed to assess the use of other types of counterfeit pills and npf pill use among individuals without prior history of heroin use including schoolaged youth since there were increased npfrelated overdose fatality cases in this population in arizona 36 conclusions our findings indicate the rapid proliferation of npf in arizona primarily in counterfeit pill form and are consistent with the law enforcement statistics 15 and overdose mortality data 36 as heroin becomes less available and access to prescribed pharmaceutical opioids more restricted npf domination in the local drug markets has significant implications for policy modifications to allow the expanded use of drug checking technologies to identify the presence of npfs in street drugs 12 although there is growing use of fentanyl testing strips as a harm reduction tool to qualitatively identify fentanyl and some analogs to help individuals adopt safer drug use practices 37 38 39 there is a need for communitybased drug checking services and use of more advanced technologies that can be reliable and specific in identifying emerging fentanyl analogs and other novel drugs 4041 from a community and clinical practice standpoint there is an urgent need to address the structural and attitudinal barriers for patient access to lifesaving medications for opioid use disorder 42 our interviews suggest that participants may have even more pessimistic attitudes toward their prospects of quitting npf these findings are consistent with prior studies 25 and suggest a need to recalibrate existing buprenorphinebased and other opioid use disorder treatment protocols to address the unique needs of patients using npftype drugs 43 44 45 from a research standpoint it is imperative to continue examining the confounding influence of the covid19 pandemic on individuals who are at risks resulting from npf as the combined crisis could lead to increased health disparities over time 46 especially for ethnic minority populations 47 and those experiencing homelessness 48 lastly research efforts that seek to develop and test new means of communitywide surveillance will become critical 49 for the development of a more timely and geographically targeted delivery of harm reduction services and interventions abbreviations npf nonpharmaceutical fentanyl oud opioid use disorder pwuo people who use illicit opioids author contributions rd nm and bd collaborated on obtaining the funding and designing the overall study rd conducted interviews and data analyses reviewed the literature and wrote the first draft of the paper nm contributed to data interpretation and the first draft of discussion section sk and ks conduced preliminary qualitative coding and contributed to data presentation and interpretation bd contributed to data interpretation all authors reviewed commented and edited the manuscript competing interests all authors declare that there are no conflicts of interest • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m 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background worsening of the overdose crisis in the usa has been linked to the continuing proliferation of nonpharmaceutical fentanyl npf the recent wave of npf spread in the usa has been fueled by an increased presence of counterfeit pills that contain npf this qualitative study aims to characterize the motivation and practices of counterfeit npf pill initiation and use among individuals using illicit opioids in arizona methods between october 2020 and may 2021 semistructured interviews were conducted with 22 individuals meeting the following eligibility criteria 1 18 years or older 2 residence in arizona and 3 use of illicit opioids in the past 30 days andor opioid use disorder treatment in the past 12 months participants were recruited through referrals by a harm reduction organization craigslist ads and referrals by other participants interviews were conducted virtually via zoom qualitative interviews were transcribed and analyzed thematically using nvivo results out of 22 participants 64 were male and 45 were ethnic minorities age ranged between 25 and 51 years old participants noted significant recent increases in the availability of counterfeit npf pills blues dirty oxys that were most commonly used by smoking the majority indicated first trying npf pills in the past year and the first use often occurred in situations of reduced access to heroin or pharmaceutical opioids participant decisions to switch over to more frequent npf pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with npf effects they were also influenced by conflicting views of social acceptability of pharmaceuticallike drugs perceived harms of npf in terms of overdose risks and increased difficulty of quitting and perceived benefits of switching to the noninjection route of opioid administration eg from injecting heroin to smoking npf pills our findings highlight the need for the implementation of novel policy treatment and harm reduction approaches to address the growing unpredictability of drug supply and npf pillspecific risks attitudes and behaviors